Stranded on Paper Islands: Consequences of Not Having EHR

While the use of Electronic Health Records (EHR) in the healthcare industry has skyrocketed over the last decade, there are some who still prefer to continue using purely paper based records in their practices. Most of these holdouts tend to view EHRs negatively, as unreliable, too expensive, or too complicated, and so have chosen to stick with outdated technology, and by doing so, risk stranding themselves on “paper islands.”

This article has been updated since its original publish date of March 23, 2015.

As seems to happen often when I’m writing these blog articles, I find myself reminded of a terrible joke:

For months, a man is stranded on a deserted island. One day, he notices a small object washed up on the shore—a corked bottle with a rolled up piece of paper inside. Curious, he opens the bottle and unfurls the paper to read, “Due to your recent lack of activity, we regret to inform you that we have canceled your email account."

And now, I beg you to forgive me for exposing your minds to that joke.

Hopefully, the rest of this article will make up for it.

In recent years, a trend has been noted by those who track and study the industrywide spread of EHR systems. As of 2021, nearly 4 in 5 office-based physicians (78%) had adopted a certified EHR, according to the Office of the National Coordinator for Health Information Technology. This compares to 34% of physicians back in 2011 — a 44% increase in 10 years.

However, a 2011 Medical Economics survey found that out of the 27% of PCPs who did not have EMR, 32% stated that they had no plans to purchase an EMR system in the future. That group rose to 48% in 2012 and 49% in 2013. Things haven't changed much in recent years. A 2020 study published in the peer-reviewed journal Life noted persistent barriers to ERH adoption and use. And a 2020 article from the American Medical Association noted seven factors that contribute to some physicians' refusal to embrace EHRs.

The above statistics tell us a number of things.

First of all, they tell us that EHR usage is now on track to become a nearly universal practice within a matter of only a few more years, and that the number of healthcare providers without an EHR continues to consistently and sharply shrink. However, these numbers also show us that the percentage of remaining EHR holdouts who have no plans whatsoever to adopt it continues to rise. This is due to the fact that, as time goes by, those who have not yet been persuaded to adopt an EHR are more vehemently opposed to it. 

This raises some interesting questions: Who are these seemingly hardcore holdouts? Why are they so opposed to an EHR? And, ultimately, what will happen to these holdouts in the (possibly very near) future, and what could the consequences be for those who do not have EHR in a world where it has become the standard?

The Paper Island of EHR Holdouts

For the most part, EHR holdouts tend to be near retirement age. While age is certainly not the only factor, studies support the fact that it is a primary one.  The previously mentioned survey found that 81% of physicians under the age of 50 had adopted some form of EMR/EHR, while only 70% of physicians over the age of 50 had done so. The reason for age being such a big indicator of EHR adoption can be summed up in one word — retirement.

Healthcare providers who see their retirement days on the horizon — within one to five years — found themselves in a difficult position a few years ago. Not only were they feeling increased pressure to implement EHR systems in their practices (which many of them already saw as problematic and expensive), many had no choice but to adopt an EHR to be compliant with ICD-10 for procedures, diagnoses, and billing. This left many older healthcare professionals feeling cornered, and some were so overwhelmed that they viewed retirement as their only option. 

Those healthcare professionals who were going to retire within a year or two tended to view it from more of a financial standpoint. They saw it as a waste to invest revenue in a new technology when they will not be practicing long enough to benefit from a return on it.

EHR Holdouts Nearing Retirement Need to Consider A Number of Things

What many of these “near retirement” holdouts failed to realize is that retirement rarely, if ever, provides an immediate clean break from patient records. There are a number of things all healthcare providers need to consider as they near retirement. For example, what will they do to maintain patient records once they retire? How will future records requests be handled? Having an EHR database that allows you to search for and send electronic records quickly and easily is a far more convenient method than rifling through boxes of paper files (instead of enjoying retirement) and finding a HIPAA-compliant way of transporting them. 

By the ends of their careers, many healthcare providers have spent decades accumulating patient information and working hard to build valuable private practices. What happens when it’s time to sell that practice to a new physician? Most young doctors coming out of residency these days have already become accustomed to using an EHR, and any practice that does not have it will likely not be considered a desirable enterprise to take over. An EHR also makes it far easier for the incoming physician to pick up a practice after the previous physician retires, allowing the entire transition to go far more smoothly.

EHR Holdouts Are Often Smaller Practices

Some holdouts have reasons other than a nearing retirement for why they refuse to adopt an EHR system. Probably the second most common reason has to do with the size and revenue of a practice. Many smaller practices also take in lower amounts of income, which makes it difficult for them to see an immediate return on their investments. However, there are various types of EHR available, and many can accommodate the budgets of smaller practices. There are also financial incentives, such as Meaningful Use, available from the government that can offset most EHR costs.

As the statistics we covered earlier in this article seem to predict, eventually the only ones who will not have an EHR will be those who have no intention of ever adopting it. Sadly, in a matter of years, those without an EHR will likely find themselves isolated from the rest of the industry. The next generation of physicians coming out of residency will view paper records as inconvenient, inefficient, and outdated, meaning they will prefer to do business and trade referrals with those who have an EHR. 

Isolation from other healthcare providers is not the only potential future consequence awaiting those who do not adopt an EHR. Patient retention is another reason. Every year, the number of patients who prefer to see physicians with an EHR continues to rise. A survey of both physicians and their patients, conducted by Hello Health back in 2012, found that 75% of patients stated they were willing to go online to view their medical records. They also found that 62% of the patients surveyed wanted the ability to go online to discuss health matters with their primary physicians, but that only 46% of their physicians had EHR systems that could accommodate that kind of patient communication.

There is further evidence to support patients' interest in services EHRs can provide. A 2014 study published in the Journal of the American Association of Nurse Practitioners found patients prefer when practices use EHRs for several reasons, including increased personal time with the provider, reduced incidence of being asked repeat questions, enhanced communication, improved patient education, and more.

This means that, over the next few years, more and more patients will migrate to healthcare providers who can offer them these kinds of electronic services.

Paper Charting is Coming to an End

The days of paper patient records, no matter the reasons for keeping them, are rapidly coming to a close. Doctors who cannot (or refuse to) adapt to the new world of EHRs may soon see their patient numbers dwindling as they are increasingly isolated from the rest of the healthcare industry … one day, they may find themselves stuck with obsolete practices that no longer have enough patients to maintain a satisfactory level of revenue …

They may end up like the guy in that terrible joke …

Stranded on an island … with a piece of paper and a canceled email account.