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Failure, de-installation of EHRs abound: study

Failures of electronic medical-record systems are part of the lore of healthcare information technology.

Not surprisingly, a recently released survey of healthcare IT use conducted by the Boston-based Medical Records Institute found data to back up the legends.

The institute, which for 23 years has sponsored the annual Toward an Electronic Patient Record, or TEPR, trade show, has for the past nine years conducted an annual survey of attitudes and opinions about healthcare IT.

Nearly 19% of respondents to the survey this year indicated they either have in the past experienced the de-installation of an EMR system (12%) or are now going through a de-installation (7%).

Considering a number of EMR vendors have had products installed in ambulatory-care settings for more than a decade while some pioneering hospitals have been computerizing for several decades, the replacement rates should not be surprising.

Failures are another matter. Slightly more than 8% of those surveyed indicated they'd ripped out their EMRs and gone back to paper, with 6% indicating the uprooting occurred in the past, while another 2% responded that they were now experiencing the reversion to paper.

In addition, 30% of respondents indicated they either have had an EMR in the past (12%) that not all clinicians used because some refused to do so, or that they now have a system (18%) and are experiencing the same recalcitrance by some clinicians.

C. Peter Waegemann, chief executive officer of the Medical Records Institute, said the 19% rate of de-installations reported by respondents of his survey may be slightly higher than others conducted in the industry, but only by a couple of percentage points.

"This is a very consistent number through the industry, from what I have heard," Waegemann said. "We have been going after why this happens."

When it comes to switching systems, the trend more often has been to downgrade to less-expensive, less-complicated EMRs than to more-expensive, complicated ones, he said.

"It's not that someone goes from Amazing Charts for $1,000 to a NextGen for $40,000," he said. "The more sophisticated a system is, the more difficult it is to learn and maintain it and it changes the workflow and (yet) itís usually not sophisticated enough for the specialty needs."

That is a particular problem with medical specialties outside of primary care.

"If it's been designed for everyone, for every specialty, you could almost throw it out," Waegemann said, pointing to the annual EMR competition the institute hosts at the TEPR trade show, which this year included trials for systems in pediatrics. Out of an estimated 300 EMRs on the market, "we had 10 competing at the end," Waegemann said.

"It will be years" before there are top quality EMRs for all medical specialties, he said, because most medical specialty societies simply are not ready to "come up with the data" around which vendors can design specialized systems.

When it comes to removing an EMR system, there are myriad reasons given, he said.

"Usually, it's one colleague likes it and another one doesn't like it. Or a colleague who said 'I'm four years from retirementóI've had a practice manager with me for 20 years (who didn't like the change to an EMR) and she said I have to make a decision that either I go forward with her or without her.' Some found the templates were inadequate for their workflow."

Participants in the survey were solicited by e-mail between April and July and at the TEPR show in Dallas on May 19-23. There were 819 responses from providers that made up the database for the survey report, though not all answered every question.

Regarding respondent demographics, about 47% of the survey's participants work in ambulatory care, 25% in hospitals, 6% in integrated healthcare-delivery systems and 22% listed "other." Of them, nearly 29% were physicians and nurses, almost 41% were IT managers and professionals; 17% were nonmanagerial IT people; and 13% listed "other."

According to the survey, the two top priorities "for strategic decisions in IT" were a need to improve clinical processes and workflow efficiency, chosen by 52% of respondents, and the need to improve the quality of care, selected by 22%. The need to share data came in a distant third place, at just under 8%, and perhaps significantly, down from 14% in last year's survey.

Hospital-based respondents as well as those from integrated systems and managed-care organizations were asked what factors were driving their need for an electronic medical-record system in their organizations and "patient-safety considerations" topped the list with three out of four respondents making it a selection, followed by "efficiency and convenience, e.g., better networking to the medical community, and patients and remote access" at almost 73%, and "satisfaction of physicians and clinician employees" at nearly 61%.

When a similar question was asked of those working in ambulatory care, by far the top choice, at about 81%, was "improved patient documentation," followed by "efficiency and convenience to physicians through workflow benefits" at nearly 73% and "remote access to patient information" at 72%.

According to the survey, nearly 52% of respondents indicated they work where practitioners use e-mail to communicate with one another, but just 20% work where e-mail is used for communication between patients and clinicians.

Respondents also demonstrated a remarkable faith that EMRs would, at least sometime in the future, improve both the quality of care in general and, specifically, patient safety, though observations on the current impact of EMRs were more muted.

Asked, "How would you rate the effect of EMR systems on quality of patient care?" only about 6% indicated they have had a negative impact in their own organizations; either with care diminished somewhat, 4%, or greatly diminished, 2%. Meanwhile, 39% thought the EMR impact in their own shops was somewhat improved and 25% thought they were greatly improved. Meanwhile, 31% indicated an unenthusiastic "no effect."

Asked how they'd rate the effects of EMR systems on the quality of patient care throughout the healthcare industry in 10 years, less than 2% indicated there would be a negative impact, only 3% predicted it would be unchanged, 20% chose somewhat improved and 75% picked greatly improved.

One change, Waegemann noted in the survey this year, is that cost, while remaining a significant impediment to EMR adoption, was not as significant as in the past.

Asked, "What are the major barriers to your plans for implementing an EMR?" the most common answer: "lack of adequate funding or resources" led the list in the survey both this year and last, but it was selected by 40% of respondents this year, compared with 56% last year.

"In the past, funding was a big issue, but as prices are coming down, it still is an issue, but it is less of an issue," Waegemann said.

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