This is a response to a recent post on LinkedIn by Col. (Dr) Surendra Ramamurthy (https://tinyurl.com/ppyw346z).
IMHO, he presents a simplistic and inadequate diagnosis for the failure of EHRs to take root and penetrate in India. This article, of course, is focused on India and this needs to be kept in mind as some of the statements below may not quite agree with contexts elsewhere in the world. The conclusion that lack of user friendliness is the cause for doctors to stay away from using EHRs is only partly true and describes only a secondary problem.
The Drivers of Deployments
The reasons hindering embrace, deployment, and use may be seen in four dimensions, all of which are equally necessary and in the order presented below:
1. Regulatory:
Government regulations mandating comprehensive and systemic use of EHRs is critical to success. When not mandated, the onus of responsibility vests with individual providers who make decisions based on other criteria.
2. Economic Value:
The "other" criteria referred above, in fact, is overwhelmingly an economic decision made by individual providers unless they are required by government regulations. Can value be appropriated from the deployment and maintenance of EHR? Enterprise-wide, not to speak of system wide, EHR deployment is expensive. Could the expense be monetized? Would this be subject to future regulatory impositions or requirements?
3. Clinical Value:
Would a provider find benefit in the EHR in the pursuit of superior clinical decisions and outcomes? Can a clinician be able to see patterns, search for similarities across cumulative patient records (in an anonymized setting) for contextual clinical decisions involving condition, co-morbidities, and observed outcomes for what works and what doesn't? Most patient-physician engagements at present are ad hoc and episodic with decisions made on the basis of temporal assessments of recent diagnostic test results, verbal patient complaints, and (where possible) review of past prescriptions that lead to subjective clinician conclusions and warranted changes. Objective clinical decisions would call for prior history review of all clinical symptoms and parameters with the possibility of system-generated evidence of connections, correlations, coincidental occurrences, and predictive direction of progression - exactly why EHRs hold the golden promise of evidence-based medical practice.
4. Ease of Use:
Finally, all systems have to aim for simplicity in everyday use. This matters both for clinician acceptance as well as for the higher productivity and customer satisfaction that results from smooth and comfortable patient-physician engagements.
At its root, EHR adoption is essentially a behavioral issue: of both individual clinicians and of provider organizations. There may be some overlap but the reasons why individuals may choose not to use EHRs (or at least attempt to avoid using it) are likely to be ones that are influenced by type of practice (individual or physician office versus consultants at large providers), number of patients seen every day, amount of time spent with patients, patient overflow and waiting times, ease of use of the system, cost of deployment and maintenance, support staff requirements, and finally the clinical benefits they see from it - assuming they are indeed motivated by investigating and improving care outcomes (in a large patient volume scenario where the physician is unlikely to see a patient ever again, focusing on future care outcome when they cannot see prognosis is relatively unimportant). For a large provider, it becomes an assessment of cost center versus profit center unless the law demands it.
There are more reasons that could accelerate or hinder universal digital health and I had elaborated on these in my post on LinkedIn on November 25, 2016 (reference below).
Reference
https://www.linkedin.com/pulse/neha-indias-proposed-digital-health-regulatory-jay-srinivasan/
The Logic of Deployments
In healthcare, many experts have noticed - and commented upon - a curious phenomenon: physicians are very comfortable with, and easily embrace, high technology for their clinical practice. Such things as MRI, CT, robotic surgery, endoscopic sonography and other such high tech aids that reduce complexity of clinical diagnosis and aid faster decisions are routinely invested in by tertiary care providers despite their high cost.
From a provider perspective, these technology aids have a profitability aspect in a private sector environment - ie, the investment is easily recoverable as they represent revenue enhancing and profitable modalities of care delivery. In other words, they are profit centers. Not so with productivity technologies such as office computerization, security, analytics, CRM/ERP, communication & collaboration, operations, data repositories for automated retrieval and processing, remote engagement, and myriad other tools that other industries have historically and routinely invested in to improve process and visibility into constraints and frictions that make the entire system inefficient. EHRs belong to this class of productivity tools and is inherently a cost center.
Financial services, technology, retail for example, invest in expensive IT that have productivity benefits. Often, other industries invest in these to increase efficiency and reduce costs.
In healthcare, cost reduction have not been top considerations: first, because the purpose is seen as saving lives, and second, for reasons resulting from the industry's complex connections to, and interactions with, other sub-sectors servicing the industry such as insurance, manufacturing, supply chain, and retail that often have high margin pricing, costs get passed on with downstream effects on consumers. This is particularly so as healthcare is generally considered inflation-proof and citizens will pay for one way or other for healthcare. Regardless of the cost, “they will continue to consume” is a basic, and unarticulated, premise.
In the US, for example, various studies suggest that almost 30% of the high healthcare expense is contributed by "administrative waste". It is telling that the healthcare industry spending in IT services is less than half of what the financial services industry does as a percent of revenues. Insurance pays for the waste and is in turn paid for by the consumer through higher premia. No magic.
Reference
https://deloitte.wsj.com/articles/it-spending-from-value-preservation-to-value-creation-1520830927
https://www.healthaffairs.org/do/10.1377/hpb20220909.830296/
The Evidence for Deployments
While the parameters that inform EHR deployment and penetration are reasonably clear, the practicalities in achieving universal availability and use still face considerable odds for reasons of complexity. And India is not alone, though we have come to the party relatively late. The EU is a good example.
Despite having a predominantly state-delivered healthcare delivery system where most providers are owned by the State, while EHR penetration is high, interoperability remains weak. This results in differing standards and lack of uniformity, curtailed data mobility across borders and even between regions within a single country, and "limited impact in overcoming barriers to access health data" according to one study. Clearly, it's not an India problem alone.
The US represents a different case study of how a structured government mandate, together with financial incentives, lead to rapid penetration of EHRs. The technology is the equivalent of ERP implementations in organizations and entails workflow disruptions owing to process redesign, endless troubleshooting, and high implementation costs. It is not surprising, therefore, that industry has generally balked at what is essentially a cost center. Minus the push from the government, status quo would have prevailed.
Fortunately, the HITECH Act of 2009 gave that push and came with both a carrot and a stick: the federal government put aside $27 billion for financial incentives to providers to encourage them to adopt EHRs (carrot) and the stick came in the form of a latent threat to shut the doors of Medicaid for patients covered by it. The latter was potent: one-third of an average physician's patient profile are covered by Medicaid and they were set to lose both this important clientele as also about $44,000 in total incentives if EHR implementations were not carried out by 2016. Guess what? Providers moved with rapidity - EHR penetration nationwide went up from less than 9% in 2008 to 95+% by 2014.
As in the EU, though, penetration does not equate to availability. While penetration is near comprehensive, data mobility across state lines is still an issue. My contacts tell me that a person moving from, say, the East Coast to take up a job on the West Coast does not see his or her health data following seamlessly. Still, the US is an illustration of how important incentives are in a largely private sector-led healthcare economy where different stakeholders have different stakes, agendas, constraints, and focus.
And this is an important lesson for India that has a very large private sector presence in healthcare.
Reference
https://www.uoc.edu/portal/en/news/actualitat/2022/096-electronic-health-record-europe.html
https://www.healtheuropa.com/digitalising-the-healthcare-ecosystem-in-the-european-union/100949/