How I Feel About Health Reform: The ACA and HITECH Acts

Recently I completed the Commonwealth Fund’s 2015 International Survey of Primary Care Doctors. They wanted to know what I thought about our health system, if fundamentally it worked or needed to be better. They asked questions about my satisfaction with practicing medicine, the quality of care my patients receive, and my experiences with electronic medical records. (You can click here to read through the 2012 survey, to get an idea of what it’s all about)

Their final question was about health care reform.

“Thinking about the healthcare law that was passed in 2010, also known as the Affordable Care Act (ACA) or Obamacare, would you say that you have a: very favorable opinion, somewhat favorable opinion, somewhat unfavorable opinion, very unfavorable opinion, or not sure.”

And I realized, as I answered this:

That I have a somewhat favorable opinion of the Affordable Care Act. It is good for patients to have access to health insurance, even though there are ongoing and severe issues with access to care.

I have a very unfavorable opinion of the much-less-talked about HITECH Act, that rolled out about the same time as the ACA, and which has profoundly shaped physician practice and patient access. The HITECH Act pays doctors to use electronic medical records in a meaningful way in order to spur the widespread adoption of EMRs. But it didn’t provide any oversight of the EMR market to ensure that the EMRs could provide meaningful functionality in an efficient way.

When we used paper charts, I used to be able to comfortably see 24 patients and finish charting by the end of the day. Now with the suboptimal EMR adopted by our health center, I can barely see twenty, and I have to spend extra hours on evenings and weekends finishing computer charting. Sadly, the EMR hasn’t added clinical functionality beyond what paper charts did–each system is still fragmented, I can’t access records from specialists’  offices or most hospitalizations, lab results may or may not be integrated into the system, radiology reports are scanned in–only now I have to slowly click through each separate screen, rather than riffling through a chart to find what I need. A colleague described the process: “Death by a thousand clicks.”

I am not alone in taking longer with EMRs. A 2014 study in JAMA Internal Medicine showed that, nationwide, physicians average an additional 48 minutes a day charting when using EMRs (you can check out the original results here, or read the NPR summary here). When it take physicians longer, we take, on average 2 hours longer each day. But there are outliers–two fifths of physicians are taking the same amount of time, or less. 2% even report being much more efficient! What I want to know are–what EMR products are the physicians using who find EMRs equal to or more efficient than paper charts? And can I use those too?

Not all EMRs are created equal. I have worked with three different systems since residency–one was awesome (integrating records across a county system), one was equivalent to paper (same amount of time to chart, but same challenges in accessing records from different systems adopted in the ED, inpatient, outpatient). This last EMR has been terrible. Of the hundreds of products on the market, some EMRs are more efficient than others, and deliver on the promise of improved functionality. Sadly, those are the minority. Some of the products on the market are so bad that doctors sued the companies that sold them the dysfunctional EMRs. There are health centers that have gone out of business while trying to implement inefficient EMRs. Primary care physicians have been pushed out of practice by EMRs, contributing to our primary care shortage.

So how do I feel about healthcare reform?

The Affordable Care Act was health insurance reform, and I like its provisions ensuring coverage.

The HITECH Act was health record reporting reform, replacing functional paper systems with what sadly, too frequently, have been dysfunctional electronic medical records.  I have a very disfavorable opinion of the impact of incentivizing the adoption of any old EMR, without requiring that EMRs meet basic functionality requirements.

Together, the ACA and HITECH Act created a destructive environment for primary care doctors, where we take longer to see fewer patients when there are more patients to be seen. The mismatch of time and need are burning us out.

But let’s not blame our healthcare woes on Obamacare. Let’s blame it on HITECH, and seek to improve the functionality and efficiency of our electronic health records. We don’t need to appeal the ACA. We need to improve the HITECH Act, and ensure all EMRs on the market meet minimum standards out of the package, and that all systems can talk to each other to facilitate information exchange and better clinical care. Then we’ll get a healthier America, with happier primary care doctors. And I have a very favorable opinion of that prospect!

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