Healthcare Own Goals: Electronic Health Records
A series on how well-intentioned decisions in medicine backfired — and what we can learn from them.
April 30th, 1986 — Game 7 of the Conference Final between Wayne Gretzky’s Edmonton Oilers and their Alberta rivals, the Calgary Flames. With the game tied 2-2 in the third period, 23-year-old Oiler defenseman Steve Smith turned an innocuous play into one of the most famous gaffes in sports history.
Attempting to clear the puck from his own end, Smith hit Oilers’ goalie Grant Fuhr in the skates. The puck banked into the Edmonton net, giving Calgary a 3-2 lead and eventual series-clinching Game 7 win. It became known as the “Own Goal”—an enduring example of good intentions gone bad.
Healthcare, with all its complexities, has its share of own goals too. We constantly find new ways to make things unnecessarily difficult. There’s no process we can’t render more convoluted, no policy too regressive, no common-sense solution too obvious. In short, we’re medical masters of healthcare own goals.
This series explores those self-inflicted wounds, one topic at a time.
Up first: Electronic Health Records.
HITECH, Low Yield
Delayed OR starts. Prescriptions sent to the wrong pharmacy. Discharges delayed by random button clicks. A deluge of clinically irrelevant inbox messages. Patient areas congested with workstations-on-wheels. All self-inflicted EMR wounds—and all experienced by clinicians daily.
The HITECH Act, enacted under the American Recovery and Reinvestment Act of 2009, ushered in the age of electronic health records (EHRs). Called “the foundation of healthcare reform,” the legislation aimed to spur adoption of EHR use and ensure meaningful improvements in patient care.
There are many potential benefits of EHRs—improved care coordination, fewer errors, cost savings, ease of order entry, and more. There’s no question healthcare lags other industries in adopting technological advancements. Prior to 2009, electronic health information technology included the VA’s well-regarded system and early versions of Computerized Physician Order Entry (CPOE). These systems were lightweight, customizable, and easy to use.
What happened?
First, the legislation created federal incentives for EHR adoption and meaningful use with the government investing billions to modernize healthcare IT. But this push—and the significant dollars that came with it—created unintended consequences. Hospitals and health systems scrambled to adopt electronic medical records and capture federal funds. Research suggests that HITECH accelerated EHR adoption by 8-14% per year.
Unfortunately, HITECH also created an ecosystem dominated by a few EHR vendors—Epic, Cerner, and MEDITECH—and complex, expensive implementation processes. As a result, EHRs became billing engines, data entry terminals, and compliance machines instead of useful clinical tools. Instead of making things more efficient, EHRs have created barriers to care. They are frequently cited as a top cause of healthcare worker burnout. What’s worse, they may not be fulfilling their promise of improving outcomes and reducing costs.
How did HITECH turn electronic health records into one of healthcare’s most infamous “own goals?”
Shooting Wide: Cost and Efficiency Impact
Results are mixed, but studies suggest less than impressive ROI on EHRs. Having a fully electronic record system may not improve outcomes or significantly reduce inpatient mortality, readmissions, or complications when adjusting for other factors. EHRs may make care worse by perpetuating errors, fostering “sloppy-and-paste” clinical notes, and causing alert fatigue. Overdocumentation or misidentification of medication side effects as allergies leads to substandard care. Large-scale studies have failed to demonstrate significant reductions in mortality or major adverse events attributable to EHRs alone.
EHRs were expected to lower costs through improved efficiency, less care duplication, and fewer complications. An oft-cited 2005 RAND study projected over $80 billion/yr in savings from full adoption of health IT. Eight years later, RAND was forced to admit that such savings did not materialize. EHR implementations can cost $15-800 million per instance, depending on the size of the hospital or health system. Partners HealthCare (now Mass General Brigham) saw its cost of implementation double from $600 million to a staggering $1.2 billion.
Large hospitals and health systems are better positioned to absorb these outsized financial and efficiency costs than smaller, independent practices. Managing EHR workload often means seeing fewer patients or, more commonly, working longer hours. Most physicians lose money on EHR rollouts, and only 27% experience a positive ROI (by either seeing more patients or improving billing processes).
If EHRs aren’t demonstrably reducing costs, improving outcomes, or driving efficiency, then surely they’re making clinicians’ and patients’ lives better. Right?
Literal and Figurative Barriers to Care
Following the implementation of a modern EHR system, clinical areas become clogged with workstations-on-wheels (WOWs)—computers on large, mobile stands. Simply getting to the bedside requires slithering past these monstrosities. EHRs create both figurative and literal barriers to care.
EHRs have dramatically changed clinicians’ daily work, contributing to burnout and frustration. Doctors spend as much or more time on a computer than with patients—49% of their time devoted to EHR and deskwork versus only 27% spent on face-to-face interactions. Furthermore, physicians can’t keep up with documentation requirements, spending an average of 2.8h on the EHR per “unscheduled” day (holidays and weekends).
This phenomenon, known as “Pajama Time,” is a major contributor to burnout. In fact, EHR-era burnout rates skyrocketed to a record 62.8% in 2021, thanks in part to excessive documentation requirements and poor EHR usability. Instead of technology working for clinicians, clinicians feel they’re working for technology, reduced to glorified data-entry clerks. The result is a flagging sense of professional fulfillment, early retirements, and career changes.
If technology improves the day-to-day of our personal lives, why can’t the same be true for our professional medical lives? Are EHRs a lost cause?
OK, Computer
Let me be clear, I’m not suggesting we abandon electronic medical records and return to using paper. EHRs have clear benefits—improved patient safety, data accessibility, and adherence to evidence-based guidelines. The EHR “own goal” is an execution problem, not a technological one. Incumbent EHR systems are so entrenched in traditional healthcare that unwinding from them would be prohibitively expensive and disruptive.
But potential fixes are coming.
Ambient AI scribes are a growing area of focus and investment in health tech. Evidence regarding their impact on productivity and finances is mixed. Time savings may be small, and the technology is expensive. ROI remains to be seen, and it’s unfortunate that our solution to an expensive technology problem is…more expensive technology. But, AI scribes do show promise in reducing clinician documentation burden and burnout.
Perhaps the best way to prevent the EHR own goal is to treat the cause of the problem instead of its symptoms. EHRs shouldn’t function as billing instruments, prior authorization buzzword collectors, and compliance enablers. These use-cases are a byproduct of the system in which they exist. Resolving the symptoms means curing the disease.
Care models should uncouple reimbursement from arbitrary documentation rules and requirements. Data portability is improving, but the EHR ecosystem could benefit from more of a plug-and-play approach. Patients move, data should too. Involving frontline clinicians early in the design and implementation of electronic health records ensures that they work for us, not against us. User experience and user interface should be paramount.
The HITECH Act came out in 2009—there’s no reason EHR technology should be stuck there.
Epilogue
Painful as it was, the “Own Goal” did not derail Steve Smith’s career. The following season, he won his first Stanley Cup, adding two more with Edmonton before playing for the Chicago Blackhawks and (ironically) finishing his career with the Calgary Flames. In all, Smith played 15 seasons in the NHL and later became a coach. His son was drafted by the Toronto Maple Leafs in 2009—the same year HITECH was enacted.
We can overcome “own goals” in healthcare, too. Doing so requires an honest assessment of why we continually turn good ideas into unintended consequences. Too often, instead of getting to the root of our problems, healthcare fixes exacerbate them.
We keep scoring on ourselves because we try to change the rules of the game instead of changing the game itself.
Thanks for reading this first edition of The Healthcare Own Goals Special Series. Future articles will tackle issues such as regressive regulations, reimbursement inequalities, the Joint Commission, and other examples of good intentions gone bad. In the meantime, we’d love to hear reader examples of other healthcare “own goals” to add to our list!
Ben Schwartz, MD, MBA
Editor-in-Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
We bring a lot of this on ourselves--filling notes with info that doesn't need to be there, copying forward irrelevant info, perpetuating myths about what has to be documented (ex. a Review of Systems), etc. This all served to turn the chart into a bloating pile of low quality information.