The pros and cons of implementing EHR

When considering the pros and cons of electronic health records it is important to understand that what is considered a pro or con for EHR adoption will depend on the setting. Restated not every pro or con of implementing EHR will apply to every circumstance, rather the pros and cons relevant to an organization’s situation will depend on a practice’s size, the type of services it delivers, its operation and structure and its patient population, among other factors.  

With the caveat in mind that context dictates the pros and cons of implementing EHR, one can still arrive at a list of pros and cons that, for the most part, are applicable to most practices. 

The pros and cons presented below cover a range of factors that touch on the following areas:

1. Financial factors 
2. Care delivery
3. Care coordination 
4. User-centered factors

With the following discussion of the broad issues surrounding the pros and cons of EHRs in mind, what are some specific and concrete examples practices should consider? 

Pros of implementing EHR

When legislation crafted to encourage EHR adoption was being put in place by the Obama administration, as part of the American Recovery and Reinvestment Act, one of the main legislative goals involved encouraging meaningful use of EHRs. In the context of the discussion of the pros and cons of EHRs what EHR-related regulations contemplated as meaningful use can be used as a proxy for the pros of EHR use. These benefits as stated, in part, by the American Recovery and Reinvestment Act are:

Improvements in quality of care

An organization who selects the right system and when used properly can expect to see improvements in the quality of care. The Institute of Medicine defines quality of care as "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Gains in quality of care can be achieved by implementing an EHR that offers clinical decision-making tools; seamless information sharing among providers within an organization and in other care settings; and the ability to examine and analyze quality of care metrics, among others.  

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Improvements in efficiency and other financial metrics

An EHR can also assist a practice to, overall, operate more efficiently. These gains in efficiency can be in an organization’s administrative processes and in its care delivery function. Several studies point to the potential for these gains. For example, a Health Affairs study that practices can operate more efficiently and generate more revenue when an EHR is used to improve its billing functions. In this capacity, an EHR can allow an organization to be more accurate in coding for services and save time and resources in carrying out this task. 

Another study on the topic notes that in a five-physician pediatrics practice increased efficiency resulted from reduced reliance third party transcribing and from the gains achieved by the integration of practice management software with its EHR.  In addition to the evidence presented above, a 2014 study published in the Journal of the American Medical Informatics Association showed that reimbursements significantly increased after EHR implementation despite a decline in the number of patient visits over a 2-year observation period. 

Improvements in safety

Like quality of care, EHR users can also see improvements in patient safety when using an EHR with the right set of features. Patient safety improvements are driven primarily by the fact that the risk of communication errors between staff and outside providers can be reduced through using electronic clinical data and communications. Also, patient safety-oriented features common in EHRs have also reduced the risk of medical errors by providing EHR users with alerts that are triggered when a patient safety risk is present. 

Improvements in patient engagement 

Patient engagement is vital to improving clinical outcomes and operating more efficiently. The foundation of patient engagement rests removing barriers to communication and information access between patient and providers. When patients more easily contact their provider through a patient portal and access their own records and other useful information relevant to their care it has been documented that clinical outcomes improve.  

Improvements in care coordination

A large portion of providing healthcare services involves coordinating with other providers. When dealing with patients who may be suffering from comorbid conditions or are under the care of multiple providers for a nonchronic condition providing quality, safe care depends on making certain all providers are on the same page. 

Improvements in population and public health

Given the high incidence of chronic disease among Americans, healthcare providers need to concern themselves with improving overall population health and the health of their own patient populations. EHR play a vital role in improving both these areas. EHRs that contain features such as analytical tools to monitor, in the aggregate, the health of their patients, and share information with stakeholders in the public health community which can offer significant benefits related to improving overall population health and the health of their patient populations.   

Cons of implementing EHR

Documenting the cons of EHR-use has been a fruitful area of discussion over the last decade. Before looking at the specifics of this topic it is important to note that a driver of some so-called cons or disadvantages of EHR use is the product of push back against legislative efforts to drive EHR adoption. The motivations for this push back derive from several factors, some based on credible evidence, whereas other factors driving these perceptions that EHRs are, overall, not beneficial to the delivery of healthcare services are based faulty information or personal biases against government-led efforts to stimulate EHR use.  

Even though the pros and cons of EHR use represent a complex topic, one can point to several cons related to implementing EHR that are grounded in solid evidence. These cons center on user-based and financial factors such as:

Hindering patient-clinician engagement 

One of the common complaints expressed by clinicians related to EHR use relates to the fact that when seeing a patient, they must turn to their computer station and enter information causing an important aspect of forming and maintaining patient-provider relationships to be disrupted. Survey data indicate this is a genuine concern among clinicians. For example,  a study conducted by Stanford University indicates that during a 20-minute primary care appointment, a provider usually spends about 12 minutes interacting with the patient and eight minutes documenting on the EHR. When asked if this was a problem, sixty-nine percent of respondents said the EHR takes away valuable time from patients. The same number of respondents said the EHR has not strengthened their patient-provider relationships.

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EHR-related clinician burnout

Among clinicians, EHR-related burnout is a real and serious concern. EHR-related burnout among clinicians arises from increased demands for data entry into an EHR system. As a result, studies indicate that decreases in job satisfaction and burnout can be linked to increased EHR-related data entry demands.  

In the Stanford study referenced above, fifty-four percent of providers noted that using their EHR has detracted from their professional satisfaction and 71 percent said the technology has contributed to provider burnout. Another study conducted by a team led by the Mayo Clinic Division of Hematology's Tait Shanafelt, MD, found EHR use was tied to lower physician satisfaction as a result of the time spent on clerical tasks as well as higher rates of physician burnout. A study published in the Annals of Internal Medicine shows, “for every hour physicians provide direct clinical face time to patients, nearly 2 additional hours are spent on EHR and desk work within the clinic day.”  Further, outside office hours, “physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.” A remedy for this problem can be found in adopting hands-free dictation or selecting an EHR with more intuitive data entry features. 

Poor ROI

Early in the push by the government to encourage EHR adoption, the claim was made that the efficiency and revenue-generating potential for EHR use, when coupled with incentive payments and other reimbursement related “carrots or sticks,” would offset investment costs related to adopting an EHR. As time has shown the clear ROI gains promised by many government and non-government affiliated observers did not materialize.  As such, many practices who overestimated the benefits to be gained or underestimated investment costs were caught in a difficult situation. As evidenced in a Medical Economics study the financial risk from EHR investment is well noted. When doctors were asked if their EHR investment was worth the effort, resources and cost, “no” was the reply given by nearly 79% of respondents in practices with more than 10 physicians. As a counter to this practice can mitigate this risk by selecting a system that meets their financial needs and accurately modeling all costs and benefits. 

Deciding if EHR is right for you

For practices adopting an EHR for the first time or switching to a new product, it's important to look at the pros and cons of implementing an EHR. The process of considering these factors is not simply a rhetorical exercise, but rather a functional strategy that can be used during the selection process or after deployment. By weighing the pros and cons of EHR your organization can better position itself to make more informed choices when selecting an EHR or adapting how an existing EHR is presently used.