Quality Several studies call into question whether EHRs improve the quality of care. One 2011 study in diabetes care, published in the
New England Journal of Medicine, found evidence that practices with EHR provided better quality care. EMRs may eventually help improve care coordination. An article in a trade journal suggests that since anyone using an EMR can view the patient's full chart, it cuts down on guessing histories and seeing multiple specialists, smooths transitions between care settings, and may allow better care in emergency situations. EHRs may also improve prevention by providing doctors and patients better access to test results, identifying missing patient information, and offering evidence-based recommendations for preventive services.
Costs At one time, the steep price and provider uncertainty regarding the value they might derive from adoption (in terms of
return on investment) lead to significant resistance to EHR adoption. As late as 2010, doctors complained that such systems were too cumbersome, eating up time otherwise spent with patients. In a 2008 project initiated by the
Office of the National Coordinator for Health Information Technology, surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system. Doubts about cost saving from EHRs continued through the early 2000s, raised by researchers at
Harvard University, the
Wharton School of the University of Pennsylvania,
Stanford University, and others. At this time only around 10% of U.S. hospitals and 20% of private practices used EHR systems. By 2015, with the rise of cloud-based EHR platforms, this had changed drastically, with 96% of all hospitals and nearly 80% of office-based physicians implementing an EHR system. In 2022, the chief executive of
Guy's and St Thomas' NHS Foundation Trust, one of the biggest NHS organisations, said that the £450 million cost over 15 years to install the
Epic Systems electronic patient record across its six hospitals, reducing more than 100 different IT systems down to just a handful, was "chicken feed" when compared to the NHS's overall budget.
Time The implementation of EMR can potentially decrease the identification time of patients upon hospital admission. Research by the
Annals of Internal Medicine showed that since the adoption of EMR, a relative decrease in time by 65% has been recorded (from 130 to 46 hours).
Software quality and usability deficiencies The
Healthcare Information and Management Systems Society, a very large U.S. healthcare IT industry trade group, observed in 2009 that EHR adoption rates "have been slower than expected in the United States, especially compared to other industry sectors and other developed countries. Aside from initial costs and lost productivity during EMR implementation, one key reason is lack of efficiency and usability of EMRs currently available." The U.S.
National Institute of Standards and Technology of the
Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers. The U.S. military's EHR,
AHLTA, was reported to have significant usability issues. Furthermore, studies such as the one conducted in BMC Medical Informatics and Decision Making showed that although the implementation of electronic medical records systems has been a great assistance to
general practitioners, there is still much room for revision in the overall framework and the amount of training provided. It was observed that the efforts to improve EHR usability should be placed in the context of physician-patient communication. However, physicians are embracing mobile technologies such as smartphones and tablets at a rapid pace. According to a 2012 survey by
Physicians Practice, 62.6 percent of respondents (1,369 physicians, practice managers, and other healthcare providers) say they use mobile devices in the performance of their job. Mobile devices are increasingly able to sync up with electronic health record systems, allowing physicians to access patient records from remote locations. Most devices are extensions of desktop EHR systems, using a variety of software to communicate and access files remotely. The advantages of instant access to patient records at any time and place are clear, but raise security concerns. As mobile systems become more prevalent, practices will need comprehensive policies that govern security measures and patient privacy regulations. Other advanced computational techniques allow EHRs to be evaluated at a much quicker rate.
Natural language processing is increasingly used to search EMRs, especially through searching and analyzing notes and text that would otherwise be inaccessible for study when seeking to improve care. One study found that several machine learning methods could be used to predict the rate of a patient's mortality with moderate success, with the most successful approach including using a combination of a
convolutional neural network and a heterogenous graph model.
Hardware and workflow considerations When a health facility has documented its workflow and chosen its software solution, it must consider the hardware and supporting device infrastructure for the end users. Staff and patients must engage with various devices throughout a patient's stay and charting workflow. Computers, laptops, all-in-one computers, tablets, mouse, keyboards and monitors are all hardware devices that may be utilized. Other considerations include supporting work surfaces and equipment, wall desks or articulating arms for end users to work on. Another important factor is how all these devices will be physically secured and how they will be charged so that staff can always utilize them for EHR charting when needed. The success of eHealth interventions largely depends on the adopter's ability to fully understand workflow and anticipate potential clinical processes prior to implementations. Failure to do so can create costly and time-consuming interruptions to service delivery.
Unintended consequences Per empirical research in
social informatics,
information and communications technology (ICT) use can lead to both intended and
unintended consequences. A 2008 Sentinel Event Alert from the U.S.
Joint Commission, the organization that accredits American hospitals to provide healthcare services, states, "As health information technology (HIT) and 'converging technologies'—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate. Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission. These unintended adverse events typically stem from human-machine interfaces or organization/system design." The Joint Commission cites as an example the
United States Pharmacopeia MEDMARX database, where of 176,409 medication error records for 2006, approximately 25 percent (43,372) involved some aspect of computer technology as at least one cause of the error. The British
National Health Service (NHS) reports specific examples of potential and actual EHR-caused unintended consequences in its 2009 document on the management of clinical risk relating to the deployment and use of health software. In February 2010, an American
Food and Drug Administration (FDA) memorandum noted that EHR unintended consequences include EHR-related medical errors from (1) errors of commission (EOC), (2) errors of omission or transmission (EOT), (3) errors in data analysis (EDA), and (4) incompatibility between multi-vendor software applications or systems (ISMA), citing various examples. The FDA also noted that the "absence of mandatory reporting enforcement of H-IT safety issues limits the numbers of medical device reports (MDRs) and impedes a more comprehensive understanding of the actual problems and implications." A 2010 Board Position Paper by the
American Medical Informatics Association (AMIA) contains recommendations on EHR-related patient safety, transparency, ethics education for purchasers and users, adoption of best practices, and re-examination of regulation of electronic health applications. Beyond concrete issues such as conflicts of interest and privacy concerns, questions have been raised about how the physician-patient relationship would be affected by an electronic intermediary. During the implementation phase,
cognitive workload for healthcare professionals may be significantly increased as they familiarize themselves with a new system. EHRs are almost invariably detrimental to physician productivity, whether the data is entered during the encounter or sometime thereafter. It is possible for an EHR to increase physician productivity. It can provide a fast and intuitive interface for viewing and understanding patient clinical data and minimizing the number of clinically irrelevant questions. However, that is almost never the case. The other way to mitigate the detriment to physician productivity is to hire scribes to work alongside medical practitioners, which is almost never financially viable. As a result, many have conducted studies like the one discussed in the
Journal of the American Medical Informatics Association, "The Extent And Importance of Unintended Consequences Related To Computerized Provider Order Entry," which seeks to understand the degree and significance of unplanned adverse consequences related to computerized physician order entry and understand how to interpret adverse events and understand the importance of its management for the overall success of computer physician order entry. ==Governance, privacy, and legal issues==