Electronic health records

The Office of the National Coordinator for Health Information Technology was born two decades ago, tasked with creating an interoperable health IT infrastructure and shifting the country away from paper medical records.

Much has changed since then. The vast majority of hospitals and physicians now use electronic health records. Nationwide health data exchange under the Trusted Exchange Framework and Common Agreement, or TEFCA, went live in December 2023, after years of work. 

And now, artificial intelligence-enabled tools — including products that aim to cut down on providers’ administrative tasks — signal more change ahead for the industry. In late 2023 the ONC finalized a sweeping rule that included transparency requirements for certified clinical decision support and predictive tools.

Micky Tripathi, head of the ONC, sat down with Healthcare Dive to discuss the past 20 years and how the agency’s work aims to create the foundation for the next generation of healthcare technology.

HEALTHCARE DIVE: When you look back at 20 years of ONC, what do you see as some of the agency’s biggest accomplishments?

MICKY TRIPATHI: The transformation that the healthcare delivery system, particularly hospitals and physician offices, have gone through in being largely paper-based to what I would argue is starting to closely approximate digital native. It’s pretty hard for any of us to find a paper record on ourselves. I don’t think there are many being recorded.

I think we’ve played a significant role, obviously working in partnership with our colleagues at the CMS, who did a lot to create the incentive structure for providers to adopt electronic health records. And then we certified those systems to be able to create sort of a digital floor or digital foundation on which we can now start to build the 21st century digital healthcare system that all of us are eagerly anticipating. 

What are some of your next big goals and priorities for ONC?

We want to continue to fill in the gaps. We’re certainly not pretending that the entire system is digital. There are large parts that didn’t get the benefit of those incentive programs and associated ONC support, like long-term, post-acute care, behavioral health. We didn’t even include human services and social services, which are a very important part of people’s overall health status, even though they’re not what we think of as healthcare in the U.S. 

But increasingly, it is building on that digital foundation that we’ve all worked so hard to put in place. What are the higher ambitions that we all have for these kinds of technologies? There is an adage out there, which is that we in technology tend to overestimate the benefits that we’re going to get in five years. And we totally underestimate the benefits in 10 years. 

And I think that’s true for electronic health records. There was a lot of anticipation that, once these are in place, they’re going to solve all of healthcare. And of course, we saw that it’s very difficult to adopt these systems, and a lot of contribution to what people call clinician burden.

But now as we look ahead to 10 years, we would not be able to have the anticipated benefits that we’re going to get from AI if we didn’t have these electronic health records in place. We would be so far behind at that point. We’d all be struggling to say, “Wow, AI is really cool. Too bad we can’t use it in the U.S.” Or, “Too bad only the Mayo Clinics and the Mass Generals of the world can use it, but not the federally qualified health centers, not the inner city hospitals.”

EHRs are widely used, but providers still have plenty of complaints about usability, the time it takes to document care and the number of alerts they’re managing. These aren’t new challenges, but what do you think ONC’s role will be to ameliorate these issues moving forward?

There’s a bunch of stuff that people blame on the EHR, but are really about piling onto the EHR. This isn’t to say that the providers’ concerns aren’t real. But there’s a lot of stuff that got added onto the EHR, like extra documentation practices and prior authorization and quality measurements. If you add all of those things onto it, then yeah, it’s going to become a very complicated, unwieldy process for some organizations. 

So a part of what we required in the 21st Century Cures Act regulation that we put into place on April 5, 2021, requires that all electronic health information be made available in a machine-readable format. And part of that was the hope that technologies are going to come on the scene that are going to be able to process that data and make it usable for people. And then of course, ChatGPT erupts onto the scene.

Now I’m not suggesting you should do this on public ChatGPT, because there are lots of privacy issues. But you do have the technological ability now to literally take those records, run them through ChatGPT or Llama or whichever one is your choice and it will actually give you a synthesis and a summary of what’s in those records, which is pretty phenomenal. 

Now, we still have work to do to assure you as a patient that that’s safe to do. It’s not going to make the serious mistakes that could actually cause you harm. And, as I was describing, we have work to do on the privacy side. You need to be assured that when you use a tool like that, you know what you’re getting into. It either does or doesn’t have privacy protections, but you need to be aware of whether it does or doesn’t, so that you can make a choice of whether you're willing to take that risk.

This is a good segue into AI. There are plenty of concerns that it’s coming too fast, and we’re not really sure how safe it is or how well it works. As the co-chair of the government’s health AI task force, do you think those concerns are warranted?

It is definitely warranted. We, as a department, are concerned. We, as the U.S. government, are concerned. But we also don’t want to lose sight of the opportunity. We’re big AI optimists. And we do believe, on net, that there’s huge opportunities for patients and for the industry at large. 

We need to be able to create the avenues to spur innovation in this area, and take best advantage of these great technologies that are coming into place. But we also want to make sure that patients feel protected. The basic mantra is that we want to make sure that these technologies are used for patients, and not on patients. 

I think that for the most part, they will see that provider organizations are being judicious in this because they have safety and quality at heart too. 

In almost all cases that I’m aware of, AI-enabled tools are being used, but to help to augment physician decision making, not to replace physician decision-making, which I think is what all of us want. We expect that our doctors are going to use the best possible tools available to them to give us the best possible care. And we want to make sure that these tools fall into that category, or the best possible tools that they trust. 

But we also recognize that it’s moving really fast and people are going to adopt it really fast. Without any rules of the road, you will get inadvertent and maybe even malicious outcomes that all of us want to prevent.

The Department of Veterans Affairs Office of Inspector General released three reports in March 2024 detailing scheduling and pharmacy issues with the agency’s new Oracle electronic health record, including a problem that may have contributed to a patient’s death.

The latest reports come as the VA and technology giant Oracle try to get their joint EHR project back on track, after years of controversy and patient safety concerns. Cerner first won the multi-billion dollar contract to update the VA’s EHR in 2018, and was acquired by Oracle about four years later.

Only six medical centers are currently using the new EHR. The agency halted deployments of the record in April 2023, except for a recent rollout to a site jointly run by the VA and the Department of Defense in North Chicago, Illinois.

The VA also renegotiated a tougher contract with the tech firm in 2023 that includes stronger performance expectations and larger financial credits to the VA if Oracle doesn’t meet requirements.

Scheduling error contributes to patient death

The OIG found a rescheduling error with Oracle’s EHR may have contributed to the death of a patient who accidentally overdosed.

The veteran, who had history of substance use disorder and suicidal ideation, overdosed after missing a scheduled follow-up appointment at the VA Central Ohio Healthcare System in Columbus in Spring 2022. 

In the new EHR, schedulers are supposed to update appointments with a no-show status, which routes the patient’s information to a request queue so staff know to begin outreach. The watchdog determined the patient’s appointment status was updated, but the case wasn’t routed to the queue — so schedulers weren’t prompted to complete three telephone calls on separate days as required.

The patient overdosed about seven weeks after the missed appointment. 

“The OIG concluded that the lack of contact efforts may have contributed to the patient’s disengagement from mental health treatment and ultimately the patient’s substance use relapse and death,” the report said.

The report also found that the Veterans Health Administration had put in place new EHR minimum scheduling effort procedures that required fewer contact attempts in May 2022.

The new record didn’t readily track contacts for specific appointments, and the scheduling efforts were cut down “to make this workable,” a director with the VHA Office of Integrated Veteran Care told the OIG. The watchdog argued the different scheduling procedures could create disparities in access to care depending on whether a medical center used the new or legacy EHR.

Pharmacy-related issues pose ‘high risk’ to patient safety

Months after the first VA medical center went live with the new EHR, the VHA was aware of pharmacy-related safety and EHR usability issues, but continued to deploy the system at new sites, according to the OIG. 

Previously identified problems included patient records not matching pharmacy software, pharmacy technicians being unable to initiate prescription refills and errors that could allow providers to order unavailable medications. 

After the new EHR was rolled out at at the VA Central Ohio Healthcare System in April 2022, some previously identified problems were still an issue, adding strain and increasing burnout among pharmacy staff, according to the OIG.

The report also cited national pharmacy-related patient safety issues relating to the new EHR that could affect hundreds of thousands of patients.

An issue in Oracle’s code caused the “widespread transmission” of incorrect medication identifiers from new to legacy EHR sites. That could throw off system safety checks that monitor whether new prescriptions are compatible with previous medications or patient allergies. 

The tech giant applied a patch a year ago, but the OIG said incorrect identifiers stored as far back as 2020 weren’t fixed because the prescription data would expire in April 2024.

As of September 2023, the transmission errors could affect about 250,000 patients at new EHR sites who had also received services at a legacy facility, according to the OIG. The unresolved issues present a “high risk” to patient safety, the watchdog said.

“Further, the responsibility to protect patients from harm rests on legacy site providers’ ability to accurately perform a series of manual, complex, time consuming, and unmonitored mitigations of which they may or may not be aware,” the authors wrote.

More complex care sites could exacerbate scheduling problems

Another OIG report highlights scheduling problems with the new EHR that could become more challenging as the agency moves to deploy the EHR at larger, more complex medical centers.

The VA had previously rolled out the new EHR to five medical centers before the expansion was put on hold in 2023. Those facilities are all “low or medium complexity,” serving about 200,000 veterans combined, according to the OIG.

The agency recently deployed the new EHR at the Captain James A. Lovell Federal Health Care Center — a more complex joint center run by the VA and the DoD that provides care to about 75,000 patients each year. 

The report noted problems that hadn’t been resolved, like inaccurate patient demographic information, difficulties changing the type of appointment (like switching from telehealth to in person) and an inability to automatically mail appointment reminder letters.

“The impact of these limitations will continue at future deployment sites unless they are resolved,” the report said. “They will also only become more pronounced at larger, more complex facilities that provide more services and care for more patients.”

The OIG report also documented other issues. In one example, scheduling staff can place a block on a provider’s availability if they need to take time off, which should push currently scheduled visits onto a displaced appointment queue for rescheduling.

But schedulers said appointments sometimes disappeared from the queue or weren’t routed there at all — so they couldn’t depend on the system to tell them which appointments needed to be rescheduled. The VA’s Electronic Health Record Modernization Integration Office said it was aware of the issues, and updates were scheduled for February 2024 and April 2024 to fix the problem.

The OIG also noted issues with sharing patient information, as medical facility staff were given access to different EHR applications based on their roles. Providers sometimes couldn’t see schedulers’ notes, like the reason an appointment was canceled. 

Oracle did not respond to a request for comment.

Nearly three-quarters of healthcare professionals say the time or effort needed to complete clinical documentation hampers patient care, according to a survey published in June 2024 by the American Medical Informatics Association.

Documentation tasks follow healthcare workers home too. More than 77% of respondents reported finishing work later than desired or working after hours due to excessive documentation.

The survey comes as a number of technology companies are touting generative artificial intelligence tools that aim to cut down the amount of work needed to document care in medical records.

Documentation burden is a long-term problem in the healthcare industry. Clinicians say they spend hours on note-taking and other administrative tasks in electronic health records — sometimes after work hours — contributing to burnout and siphoning time away from direct patient care. 

The latest survey by the AMIA, which surveyed more than 1,200 healthcare workers across the country, found many clinicians still report spending excessive time and effort recording patient care.

Clinicians also noted EHR usability problems, another long-reported challenge in the sector. More than 44% disagreed that it was easy to document patient care in the EHR and greater than 66% of respondents said they had not seen a recent decrease in the time or effort needed to complete documentation tasks.

The survey comes as the healthcare sector has shown increased interest in generative AI note-taking products, which technology companies say will alleviate documentation burden and burnout.

Companies like Oracle, Amazon, NextGen Healthcare, Google and Microsoft-owned Nuance Communications have developed tools that listen to conversations between clinicians and patients and draft clinical notes. HCA Healthcare, one of the largest hospital chains in the country, said it would roll out its Augmedix AI scribe to more emergency departments.

Other healthcare organizations say they’re interested in implementing generative AI products soon. A survey published in late 2023 by Klas Research found more than half of organizations are looking to put the tools in place within the next year, and a number of executives with a strategy said they’d use it for documentation at their companies.

But there are still concerns about generative AI products, with leaders citing worries about accuracy and reliability. Other experts have argued a too-rapid deployment could replicate biases and widen health inequities.

Nearly one-third of nurses experiencing symptoms of burnout in 2023 said their electronic health records were a contributor, according to a report by healthcare IT research firm Klas.

Of those nurses, 40% said they were likely to leave their organization within the next two years. 

Many nurses don’t think they have a say in governance over the EHR at their organizations. Sixty-five percent of survey respondents didn’t agree that they have a voice in EHR changes, while 39% said they don’t feel they can ask for fixes.

One long-term frustration for clinicians is the amount of time and effort it takes to document care or perform other administrative work in EHRs, which can contribute to burnout.

Thirty-three percent of nurses reported symptoms of burnout in the Klas survey, which included feedback from roughly 75,000 respondents.

For example, nurses argue they face technological challenges, like slow loading times or unplanned system downtime. Forty percent of nurses reported their EHR doesn’t have the expected response time, while nearly a quarter said the record isn’t reliable. 

Stress and burnout among nurses is a significant challenge for the healthcare workforce. Some research has found a large chunk of nurses are considering changing jobs or leaving the profession entirely due to burnout — a major problem for health systems who are still recovering from the workforce shortages and heightened labor costs they faced during the COVID-19 pandemic. 

Even though nurse satisfaction with their health records has increased from 2021 to 2024, they still report insufficient training and system reliability problems that could contribute to burnout, according to the Klas report.

Training is also key to nurse satisfaction with their EHRs, but many nurses say their education was lacking —  nearly 40% reported their ongoing EHR education wasn’t sufficient, according to Klas. Forty-two percent of respondents reported their initial training wasn’t up to snuff, while 32% said it wasn’t specific to their workflow.

Improvements and upgrades aren’t always helpful to nurses either, according to the survey. Sixty-seven percent of respondents didn’t agree that upgrades improved the EHR. More than 70% said EHR optimizations weren’t delivered quickly enough, and 60% felt fixes weren’t timely. Half said changes to the EHR weren’t well communicated to them.

Lawmakers raised concerns about resuming deployments of the Oracle electronic health record at Department of Veterans Affairs medical facilities during a House subcommittee hearing in July 2024. 

The recent launch of the new EHR at the Captain James A. Lovell Federal Health Care Center, a joint VA and Department of Defense facility in Illinois, went well, VA and Oracle officials testified. New deployments of the EHR have largely been on hold for more than a year to improve the system’s reliability and performance. 

However, legislators argued the rollout at Lovell required additional staff, and some problems haven’t been fixed. “I think we are far from ready to endorse further go-live activities,” said Rep. Sheila Cherfilus-McCormick, D-Fla. “The two departments threw more resources at this go-live than will ever be available at any future VA facility.”

The deployment of the new EHR has been a yearslong challenge, plagued with technical issues and patient safety concerns.

EHR vendor Cerner — later acquired by technology giant Oracle — scored the contract to modernize the VA’s health record system in 2018. But only six VA medical centers have deployed the new EHR so far, as users grappled with system reliability problems and errors that could result in patient harm. 

Legislators have also raised concerns about the project’s cost, as the VA faces a historic budget shortfall of nearly $15 billion for the remainder of the 2024 and 2025 fiscal years.

“The Oracle Cerner EHR is simply not good enough today to enable a bare minimum of efficiency at the VA, let alone the high quality care our veterans deserve, without a huge influx of extra staff and money,” Rep. Matt Rosendale, R-Mont., said during the House Committee on Veterans’ Affairs subcommittee hearing. 

New rollouts of the EHR were largely put on hold in April 2023, except for the planned deployment at Lovell in North Chicago that took place in early March 2024. In April 2024, VA Secretary Denis McDonough said the agency plans to resume the Oracle EHR rollout by the end of the 2025 fiscal year. 

The pause aimed to address problems at facilities where the new EHR was already live, invest in enterprise work necessary for long-term success and prepare for the deployment at Lovell, Neil Evans, acting program executive director of the VA’s Electronic Health Record Modernization Integration Office, told the subcommittee.

It’s still too early to declare the latest rollout a clear success, but results at Lovell have been “promising,” Evans said. 

The medical center maintained 100% capacity for its emergency room and inpatient bed census for mental health throughout the deployment. Inpatient census for acute medical and intensive care has returned to baseline after a 50% reduction when the EHR went live, he testified.

“I’m going to say it’s going very well,” said Lovell Director Robert Buckley. “I’m going to say it’s going better than anyone expected.”

That outcome is in part due to new training and change management programs, leading to faster adoption rates and less time spent in the EHR compared with previous live sites, said Seema Verma, executive vice president and general manager of Oracle Health and Life Sciences. Verma was the CMS administrator under President Donald Trump.

The Lovell deployment and improvements at the other five facilities using the EHR offer proof they can implement the health record at new medical centers, she said. 

“In parallel to ongoing enhancement efforts, pre-deployment work at future sites should restart this fall, and new deployments at those sites should be planned for next year,” Verma said. “Oracle’s ready to get restarted and to bring the benefits of this new EHR to more veterans across the country.”

Epic was the only electronic health record vendor to see a net increase in acute care market share in 2023, as the company continues to pull ahead of competing technology providers, according to a recent Klas Research report. 

The vendor covered more than half of all acute care multispecialty beds and 39% of hospitals in the U.S. 

In contrast, Oracle Health saw its largest net hospital loss on record. Several large multispecialty systems switched vendors, and growth among small standalone hospitals stagnated. 

Acute care EHR purchasing was high in 2023, driven by large healthcare organizations that made the bulk of purchasing decisions, according to the Klas report.

Nearly 80% of hospitals that were affected by an EHR purchase decision in 2023 were part of a health system, and more than half were part of large health systems.

Large organizations are interested in partnering with Epic because they see the vendor as a consistently high performer, according to the report. They also chose Epic to consolidate their IT systems —  a key priority for many providers looking to cut down on the number of vendors they manage.

Meanwhile, Oracle faced challenges as growth among small hospitals with 200 beds or less stalled — previously an area where the vendor had notched market share successes, according to Klas. In 2023, Oracle covered nearly 24% of acute care beds and about 23% of hospitals. 

Facing financial pressure, small standalone hospitals focused on improving existing technology last year, and made just 41 purchasing decisions compared to 73 in 2022.

Oracle’s Millennium EHR platform also received a low customer experience grade, according to Klas.

“Further, Oracle Health’s decline in performance and persistent revenue cycle challenges have resulted in some customers leaving Millennium and prospective small standalone hospitals being deterred from choosing Oracle Health,” the report’s authors wrote.

The technology giant, which acquired EHR vendor Cerner for more than $28 billion nearly in 2022, has faced headwinds. Oracle is shifting customers to the cloud from licensed purchases, which means less revenue upfront and more cash rolling in over time. Leaders have said the segment will return to growth in 2025. 

Another major EHR competitor, Meditech, also lost market share in 2023. The vendor covered 16% of U.S. acute care hospitals and 13% of beds in 2023. 

Meditech also saw its retention rate dip to its lowest on record in 2023, with about a quarter of its legacy losses linked to mergers and acquisitions. Several customers moved to Epic to consolidate systems and improve data exchange with other Epic users, according to Klas. 

Particle Health filed an antitrust lawsuit against Epic in September 2024, alleging the electronic health record giant wielded control over patient information to damage the health data startup’s business.

The suit argued Epic used its position as a “monopolist in the EHR software market” to deny health data access to Particle’s customers and squash competition for payer platforms, or tools that help insurers obtain and analyze medical records.

The litigation comes months after a dispute in Spring 2024 when Epic cut off data requests from some Particle customers, citing unauthorized uses of patient information and privacy risks. An Epic spokesperson called the lawsuit “baseless.”

Up to 94% of patients in the U.S. have at least one medical record stored in Epic’s EHR, typically giving the company control over where that data is distributed, according to the lawsuit, filed in the Southern District of New York. 

Meanwhile, Particle is a relatively new venture-backed startup that aims to help healthcare organizations share and analyze data. The company was founded in 2018 and just entered the payer platform market in 2023, according to the complaint.

Vendors like Epic are required to share records for treatment purposes, which historically excluded payers, according to the lawsuit. But as more insurers have moved into healthcare delivery, they can access patient data and use it for other tasks, like population health management or processing claims — opening the door for new entrants. 

Particle alleged that Epic tried to shut the startup out of the payer market.

“Epic therefore set out to eliminate any whiff of competition in this relatively new market, so it could continue to extend its dominance and erect an impregnable moat around payer platforms,” the lawsuit said. “Epic accordingly began a multi-pronged campaign to destroy Particle and actively snuff out competition, which only meaningfully showed up once Particle began its recent, swift growth.”

Particle said the EHR vendor began to “suddenly and arbitrarily” deny dozens of customers access to Epic’s records in March 2024, telling users they could resume access if they stopped using Particle’s platform.

Epic also launched a dispute process with interoperability framework Carequality, which supports the exchange of millions of health documents each month, arguing Particle might be inaccurately representing why it was requesting records.

Particle said the dispute resolution process lasted for more than five months, and Epic used its “power and influence” over the information exchange to require the startup to implement a corrective action plan.

Particle alleged Epic’s comments about data security and privacy risks were false, but they destroyed public trust in the company. The startup also argued Epic slowed the onboarding process for new Particle customers, with the time to connect sometimes taking more than a month when it previously took about two days, according to the lawsuit. 

Particle argued its revenue growth has since declined significantly. The startup is seeking monetary damages and wants Epic to “cease its anticompetitive conduct,” according to a press release. 

In a statement to Healthcare Dive, Epic said the lawsuit aims to divert attention away from Particle’s “unlawful actions” on the Carequality exchange that violated HIPAA privacy protections. 

“Epic’s software is open and interoperable, allowing healthcare organizations to easily share data under HIPAA and all relevant regulations,” an Epic spokesperson said. “Epic will continue to protect patient privacy and vigorously defend itself against Particle’s meritless claims.”