A Look Back -- and Ahead -- at EHRs in the U.S. Health Care System

Q&A With Health IT Expert Jeffery Belden, M.D.

April 01, 2011 05:05 pm Sheri Porter

The health information technology movement in the United States, which has struggled to move medicine in the same direction as the rest of business and industry, started long before President George W. Bush's Jan. 20, 2004, State of the Union address. That night, Bush told Americans that computerized health records would help avoid "dangerous medical mistakes, reduce costs and improve care." The President's comments likely were the first time the average health care consumer heard the phrase "computerized health records," but they've probably heard those words many times since then.

[Photo of family physician and health IT expert Jeffery Belden, M.D.]

FP and health IT expert Jeffery Belden, M.D.

AAFP News Now recently turned to Jeffery Belden, M.D., of Columbia, Mo., to provide an overview on the rise in popularity of electronic health records, or EHRs, in the United States. Belden currently serves on the faculty at the University of Missouri School of Medicine Department of Family and Community Medicine in Columbia, where he works with teams of personnel on software design, usability testing, training and implementation. He also is the founder and past chair of the EHR Usability Task Force for the Health Information Management Systems Society, or HIMSS. After 25 years in private practice in Columbia, Belden continues to see patients at the university's family medicine residency program.

Q: Why has it been so difficult to make EHRs an efficient and integral part of America's health care system?
A: Computer software engineers have to relate to the people who are going to be using their software. So if engineers are making banking software, they have to talk to the bankers to know what they need. But bankers are easy because they just deal in numbers. Doctors and patients are hard because they are humans -- sloppy, complicated, messy humans. Humans are so darned variable, and that means their data needs are complicated, too. Add to that the fact that every medical practice, every institution, every academic health center is a little bit different. Software that works well for one may not work well at all for another.

Q: Can you identify the tipping point at which EHRs became more prominent in hospitals, clinics, physician offices and other health care settings?
A: I'm not so sure that you can point to one. It's a confluence of factors, maturity for one. I sometimes say that all EHRs are adolescents, meaning they're not responsible yet. They're shaving and menstruating, and you can tell they're going to be grownups one day, even though they're not yet. Five years ago, a lot of EHRs were early adolescents. Now, some are late adolescents, and you can almost be proud of them. But most EHRs are not completely off the family payroll. You're still paying for their education (i.e., upgrades and staff training) and their parking tickets (i.e., system crashes). They're still on the company dole.

Q: Have we crested the implementation wave to the point where we now can coast along comfortably?
A: I like to believe we have. I think we're looking at a higher rate of EHR adoption for a variety of reasons. One is that the software is a lot more mature. Another is that there are all these big financial incentives with the HITECH Act (Health Information Technology for Economic and Clinical Health Act). Are those going to actually pay for the cost of getting the job done? I'm not convinced they will, but at least the incentives lower the financial barrier to adoption. So if it was a giant hurdle before, now it's just a step up, and that makes a difference.

Q: Is life with EHRs going to get easier in the future?
A: I went to the HIMSS (conference) last week. I like to visit the software booths and talk to the vendors and see their latest software. In particular, I've been having them show me their mobile apps. There's a lot more attention to usability with the various vendors. I think they're having more conversations with their users. With the vendors we partner with here locally, absolutely, I've seen huge increased attention to the user experience.

Q: When will we know that we've arrived at the point where EHRs are seamlessly doing their job?
A: When it's as easy as picking up an iPad, and it just works. If you talk to anybody who's used an iPad, they just figure it out. You don't have to teach them. Of course it will be a little bit more complicated than that, but physicians already know how to manage data and they already use computers, so if you give them something easy and intuitive, they'll figure out how to make it work for them.

Q: When we reach that point where EHRs are the foundation of a medical practice -- as automated teller machines, or ATMs, are to banks -- will physicians look back and say it was worth the struggle?
A: If you go to doctors' offices right now that use electronic records, the physicians and staff members will tell you they'd never go back to paper. Now, don't ask me that question during the first two weeks of a new software implementation because everybody is exhausted and emotionally beat up. That's what change is like when it's big and disruptive and changes everything we do.

But there is no turning around; we're soon to leave the paper world behind. Physicians who don't come along won't be able to cross-communicate with other physicians. Their patients will say, "You're really nice and I like you as a person, but my daughter and son-in-law are making me change doctors."

All of the new physicians coming out of training are going to be trained using EHRs. If they're looking at five job opportunities -- four of which have electronic records and one of which is using paper -- who's going to go to a paper-based practice? Nobody. A practice that relies on paper will be a practice that doesn't have much breath left in it.