As we continue to see EHR hailed as the mechanism by which American health care will be transformed from an inefficient, anachronistic cottage industry into a sophisticated, statistically relevant expression of cutting edge, evidence based perfection we must resolve the cognitive dissonance that follows from comparing the Brent James disciples' argument that the EHRs should facilitate and amplify the innate desire of clinicians to do good to the actual EHR adoption and failure rate.

If EHRs offer a new paradigm of improved clinical outcomes via more efficient case finding for focused efforts, reminders for complete care and evidenced based care at the point of care then why is the failure rate so high? Chronic clinician EHR critics frequently site the lack of usability, the dearth of clinician input into design, bizarre business rules that drive inefficient EHR functionality and the tension between IT leaders and clinical informaticists that leads to marginalization of the clinicians due to lack of respect and/or lack of project management experience. It is hard to argue with the 2006 Annals HIT review that warned us that the benefits of EHR have been extrapolated from only a few long term self-developed clinical information systems from a remarkably short list of organizations that developed those systems over many years and thousands of Plan-Do-Check-Act iterations and that only with appropriate cynicism should we assume that commercial EHRs are capable of delivering similar results.

However it is entirely appropriate to recognize that at least a few of these market offerings are quite robust - certainly good enough to allow population management, case finding and reasonable decision support at the point of decision making. Why then the continuous criticism, the 'down sizing' of some aspects of Meaningful Use to something more akin to 'not quite significant use'?

I believe the principle reason is that we have yet to transform most of the health care system from paying for quantity of care to quality of care. If we accept that transformation of the health care system means we will more reasonably utilize resources based on best evidence and best practice then most would agree that primary care has a very important role to play in terms of appropriately matching the consumption of resources to the needs of the patient both individually for acute care and on a population basis for primary and secondary prevention. Yet most primary care physicians continue to practice in small groups organized around maximizing revenue (visits) with a focus on managing acute problems (or acute manifestations of chronic problems). We are all aware of the low utilization of preventative and evidenced-based care in both the clinic and in the hospital at discharge despite the tremendous benefits that would accrue to the country from preventing complications that lead to ER visits, admissions to the hospital, lengthened LOS, not to mention conversion to long term care, disability and death. The current payment system is perfectly designed to deliver the care we find so inadequate today - care that is fragmented, incomplete and at times inappropriate. Is it so surprising then, that physicians view EHRs as impediments to efficiency, when that efficiency is based on providing the minimum required care in the shortest time possible? Is it so surprising that the current care environment which encourages and rewards egregiously irrelevant documentation (re the failed E/M pay for bullets scheme) is equally inefficient when interpreted into EHR functionality? I believe that in 10 years we will look back upon this very fact as one of the great tragedies of the HITECH stimulus dollars; we will have successfully stimulated the purchase and implementation of EHRs but those EHRs will be crippled by designs that forced the worst of the existing incentives into their fundamental architecture.

In conclusion:

1. Currently available EHR systems are available and have been deployed that offer a level of sophistication that can help motivated clinicians achieve remarkably improved results. Kaiser, Cleveland Clinic, Mayo, Geisinger, Group Health and others have demonstrated the value of integrated information systems using existing technology.
2. The current failure rate of EHRs cannot be attributed to poor or inadequate design alone
3. The failure rate is directly related to the current set of incentives, tradition and lack of transformation change management that  prevents  clinicians, particularly those in low valued roles like primary care, from being able to afford the costs of redesigning the way they deliver care to focus on patient outcomes.

If we 'design with the end in mind' what would the American health care system look like? Would it change the way we pay for care? Have we had that debate? What successful Accountable Care Organizations exist that provide for significant participation of independent small groups? Should everyone be in a Mayo clinic?

I'd be very interested in your thoughts on the matter.

1.Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. http://www.annals.org/content/144/10/742.full

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