The EHR Has No Clothes

...However, now that I am experiencing the third such [EHR] system of my career, I have to say that I’ve been disappointed in virtually all of these hopes. As a former programmer, I have been appalled by the frequently abysmal quality of the programming of these systems, betraying both a lack of any central design and oversight of the user interface and an absence of understanding of the typical tasks and workflow in a primary care office...

The top-rated EHRs are almost all those targeted to small practices where the buyers are likely to be the users. There are two notable exceptions to this – VistA and EpicCare Ambulatory, the expensive system used by many of the nation’s largest integrated delivery systems such as Kaiser, which colleagues tell me has a steep learning curve but a lot of useful functionality once mastered. Medical students returning from rotations at Veterans’ Administration Hospitals often rave about how good VistA is – something I have never heard with any other EHR. While I have not used it in clinical care, I have examined the demonstration client available on the web and been impressed by the simple, clean interface – quite unlike most other EHRs I have used or seen.

There may still be time to change course from “pick an EHR, any EHR” to one more likely to yield better health and lower costs for Americans. It is probably too late simply to say “never mind” and remove the federal incentives to adopt EHRs. If one could guarantee achieving some of the potential benefits of EHRs, this would also be unwise. I believe that the greatest savings would likely accrue from standardizing on a single EHR, with VistA being obvious choice. It probably has the best evidence for both improving quality and lowering costs, it works in settings from small offices to large hospitals, and the software is open-source and free.

I do not believe that a mandate for the adoption of a national EHR, VistA or otherwise, will ever be politically feasible. However, there is no reason the government could not actively choose to facilitate the adoption of VistA. Each regional HIT Extension Center currently chooses which EHRs it will support. If, instead, they were all to support the adoption of VistA, organizations would still be free to adopt any EHR they wanted, but might be much more likely to give VistA serious consideration despite its suspect status as free software.

Having a large population of users of one EHR nationwide would not only simplify health information exchange (the proposed stage 2 meaningful use criteria related to exchange of information specifically exclude transfers between entities using the same EHR from the measurements – the barriers there are too low) and lower personnel training costs, it would create a tool for dramatically more powerful and inexpensive drug and device postmarketing surveillance, comparative effectiveness research, and identification of potential participants for clinical trials. With rising health care costs a major contributor to the nation’s fiscal crisis, choosing a policy that, by subsidizing the purchase of any “certified” EHR, locks in substantially higher costs for the foreseeable future in addition to the other adverse effects discussed above seems remarkably short-sighted and wrongheaded...