Despite the growing literature and case evident basis on the benefits of various Electronic Health Records (EHR) functionalities, yet I think it has its disadvantages that are remediable by other digital health solutions.

EHR is adopted at a large scale not only in North America but Europe as well as the rest of the world majorly on Multilingual basis.

Whilst Software as a service (SaaS) is largely used in Solo and Single Specialty group practices yet large and particularly old Solo and Single specialty group practices in addition to Multispecialty groups, Hospitals and institutions yet heavily rely on Software inhabiting hardware and privately-owned servers. It is in the latter group, which is hosted or on-premises software where the imperfections are most notable. These present themselves in these forms: financial issues, changes in workflow, temporary loss of productivity associated with EHR adoption, privacy and security concerns, and several unintended consequences.

EHR adoption and implementation costs include purchasing and installing hardware and software, converting paper charts to electronic formats, and training end-users whether physicians, Nurses, Technicians, Physical therapists and Ancillary service providers. Many studies have documented these costs in both the inpatient and outpatient settings. Evidence indicates that the cost for Inpatient adoption is immensely higher than for its outpatient use which is understandable.

However, as EHR technologies have become more commonplace over the past few years, the initial cost of systems has come down dramatically that is largely in terms of software acquisition yet the maintenance cost of an EHR remains comparatively costly. Hardware must be replaced and updated with new operating systems, newer processors and computer parts, and software must be upgraded on a regular basis to keep up with new features and clinical as well as administrative demands. In addition, providers must have ongoing training and support for the end-users of an EHR. According to one study conducted on 14 solo or small-group primary care practices, the estimated ongoing EHR maintenance costs averaged US$8412 per provider per year. A total of 91% of this cost was related to hardware replacement, vendor software maintenance and support fees, and payments for information systems staff or external contractors. Other estimates of ongoing maintenance costs for the first year after implementation was about US$17,100 per physician in a medical group of five. Not considering here to cost of hiring on-site dedicated IT Personnel! I have yet to find a study with that cost inclusion.

The costs of EHR adoption, implementation, and ongoing maintenance are compounded by the fact that many financial benefits of an EHR generally do not amass to the provider (who is required to make the initial and upfront investment) but rather to the third-party payers in the form of errors averted and improved efficiencies who is by default the Insurance Companies !, which end result is reduced claims payments. This mismanagement of incentives for health care organizations, along with the high upfront costs, creates a barrier to adoption and implementation of an EHR, especially for smaller practices. In fact, physicians frequently cite upfront costs and ongoing maintenance costs as the largest barriers to adoption and implementation of an EHR. Not that other solutions have no cost but it is a well-known fact that EHR costs the nost among Digital Health Products.

I can remember very well the Medicare and Medicaid EHR adoption incentives in the form of Bonus Payments established during President Obama Era although sounding Promising on paper but in reality only a small minority of eligible and participating practices were paid for more than the initial applicable incentive program year all of which due to the restrictive nature of eligibility criteria for these bonuses in addition to significant functional limitation of EHR when it came to analytics and data aggregation per established standards of care protocols.

Quite notable for medical staff and providers especially in long-established practices that have gotten used to paper charts, onsite and off-site dictation and Faxes. These preconceived best office practices that are quasi obsolete in my opinion and remain a huge hurdle that further contributes to dissatisfaction with EHR enactment. These factors lead to losses in productivity which in the best instances are not only temporary but hopefully short-lived too. This loss of productivity stems from end-users learning the new system and may potentially lead to losses in revenue. One study involving several internal medicine clinics estimated a productivity loss of 20% in the first month, 10% in the second month, and 5% in the third month, with productivity subsequently returning to its original levels. In that study, the loss in productivity resulted in lost revenue of US$11,200 per provider in the first year. In a study of solo and small-group primary care practices of one to six providers, revenue losses from reduced visits during the initial stages of an EHR averaged approximately US$7500 per provider. There is a variance depending on whether physicians worked longer hours during this stage or reduced patient visits. Lastly, researchers have estimated that EHR end-users spent 134.2 hours on implementation activities associated with getting and learning a new system. These hours spent on nonclinical responsibilities had an estimated cost of US$10,325 per physician.

Other declines in revenue are possible following EHR implementation. Because EHRs are often associated with fewer redundancies, fewer errors, and shorter lengths of stay, it is conceivable that a given provider may avert certain billable transactions that, could be considered expendable , may have generated reimbursements from third-party payers, especially in a fee-for-service payment system. Although reimbursement rates may differ for each organization, these declines could be offset by increased revenue that is generated as a result of efficiencies achieved with the help of an EHR system.

Another potential drawback of EHRs is the risk of patient privacy violations and this is the least discussed, which is an increasing concern for patients due to the increasing amount of health information exchanged electronically. To relieve some of these concerns, policymakers have taken measures to ensure the safety and privacy of patient data. For example, recent legislation has imposed regulations specifically relating to the electronic exchange of health information that strengthens existing Health Insurance Portability and Accountability Act (HIPPA) privacy and security policies. Although there is no electronic data that is 100% secure, the rigorous requirements set forth by the new legislation making it much more difficult for electronic data to be accessed inappropriately. For example, all EHR systems are required to have an audit function that allows system operators to identify each and every individual who accessed every aspect of a given medical record. Many hospitals and physicians are implementing strict, no tolerance and enforceable penalties for employees who access files inappropriately. I remember reading about, a hospital in Arizona terminated several employees after they inappropriately accessed the records of victims who were hospitalized after the January 2011 shooting involving a US Congresswoman. Although privacy will likely continue to be a concern for patients, many steps are being taken by policymakers and individual organizations to ensure that EHRs comply with the strict laws and regulations intended to ensure the privacy of clinical information that is in compliance with HIPPA and the European Union General data Protection Regulation (GDPR) rules . The advent of Blockchain and its use in software would ameliorate these concerns.

EHRs may cause several unintended consequences, such as increased medical errors, negative emotions, decision making and hierarchy structure, and the wrongly perceived overdependence on technology! It is to be noted that researchers have found an association between the use of CPOE (Computerized Physician Order Entry) and increased medical errors due to poorly designed system interfaces or lack of end-user training. Additionally, end-users of an EHR may experience strong emotional responses as they struggle to adapt to new technology and disruptions in their workflow. Changes in the power structure of an organization may also occur due to the implementation of an EHR. For example, a physician may lose his or her autonomy in making patient decisions because an EHR blocks the ordering of certain tests or medications that is less covered by insurance plan, not considered a first Tier or requires Prior Authorization. Overdependence on technology may also become an issue for providers as they become more reliant upon it and in that, I look at it from an angle that Technology is ever-evolving there will be always something new around the corner that can serve as a powerful tool for the better. Over-Reliance on technology here is what is seen as more credence on unrequired testing and Investigations without adequate attention to standards of care and specific workup pathways in differential diagnosis and overlapping treatment protocols. There must be an allowance and plan B in place to enabling optimal care in case of Malfunction or downtime of EHR systems so that care is not brought to a standstill.

Although EHR has been a groundbreaking development and had largely replaced paper charts in a good percentage of Healthcare clinics and facilities yet the shortcomings discussed above need to be bridged for the betterment of care with improved outcomes for consumers as well as all the stakeholders in health care. We will discuss that in future articles. Final word although there are many unintended consequences of EHRs, when balancing the advantages and disadvantages of these systems, they are beneficial, especially at the society level.