In a study published on Monday in the Archives of Internal Medicine, Electronic Health Records (read EMR in Canada) failed to boost care delivered in routine doctor visits. The numbers of patient visits (1.8 billion) are hard to dispute and provide validity to the numbers. The conclusions from the study reveal that EHR alone is not sufficient independently to improve quality of care.
I am not surprised by the these findings. The EMR/EHR is simply a 'sharper pencil' and unless a change process designed to support quality improvements is implemented in parallel with EMRs, it is logical that the tool alone will not be sufficient. While EMRs make it easier to track disease and automate recall procedures, many of the efficiencies are related to improvements in business workflow in a practice. The ease of sharing data and providing remote access to information.
CHICAGO (Reuters) - Electronic health records -- touted by policymakers as a way to improve the quality of health care -- failed to boost care delivered in routine doctor visits, U.S. researchers said on Monday
Of 17 measures of quality assessed, electronic health records made no difference in 14 measures, according to a study published in the Archives of Internal Medicine. The study by researchers at Stanford and Harvard Universities was based on a survey of 1.8 billion physician visits in 2003 and 2004. Electronic health records were used in 18 percent of them. In two areas, better quality was associated with electronic records, while worse quality was found in one area, they said. Many experts believe electronic records can help prevent costly medical mistakes, but few studies have evaluated whether the records actually improve the level of care when compared with paper records. "Our findings were a bit of a surprise. We did expect practices (with electronic medical records) would have better quality of care," said Dr. Randall Stafford of Stanford University. "They really performed about the same," he said in a telephone interview.
The 14 quality indicators for which electronic records made no significant difference included such factors as prescribing recommended antibiotics; diet and exercise counseling for high-risk adults; screening tests; and avoiding potentially inappropriate prescriptions for elderly patients. The records seemed to help doctors treating patients with depression to avoid prescribing certain tranquilizers.
They also helped to avoid offering urinalysis during general medical exams. But when it came to prescribing statins for patients with high cholesterol, physicians using electronic systems did worse than their peers with paper records. Electronic health records promise to eliminate errors due to bad handwriting and make it easier for doctors to follow a patient's care over time. Some systems can also flag dangerous drug combinations, or offer advice about tests or drugs the doctor might prescribe. President George W. Bush has set a goal for all Americans to have electronic medical records by 2014. "I think they will be a very important tool, but I think they are not sufficient in and of themselves to improve quality a great deal," Stafford said.
Link: Electronic health records don't lift care: study - Yahoo! News
Click here to read the original abstract in the Archives of Internal Medicine. Conclusion: As implemented, EHRs were not associated with better quality ambulatory care
What are your thoughts? Do you agree with the findings in this article? Are there additional lessons learned that can be shared? Do you have examples or anecdotal evidence as to how your EMR/EHR has improved quality of care (or not)?
To add your thoughts, click on the 'Comments' link
To me, the quality measures used seem rather odd. Given those measures, I am not surprised the study did find a significant benefit associated with electronic health records.
If you wish to design a study to demonstrate the benefits of EMRs, perhaps better measures would be such outcomes as "prescribing errors" (due to drug allergies, drug interactions, inappropriate doses). Even better, perform the study where EMRs are tied into some form of e-prescribing system at local pharmacies, so handwriting error is another factor that can be measured.
Posted by: Allan Horii | July 11, 2007 at 01:34 PM
In the following article published in iHealthbeat, the claims of the above article are brought into question:
July 31, 2007 - EHRs, Media and Statistics: Misinterpreted Results Skew Understanding
by Jane Sarasohn-Kahn
"Electronic Health Records Didn't Improve Quality of Outpatient Care"
"Electronic Health Records Don't Lift Care"
"Electronic Records Don't Always Improve Care"
"No Quality Benefits Seen with Electronic Health Records"
"Electronic Medical Records May Not Live Up to Hype"
So said some of the newspaper headlines about the July 9 Archives of Internal Medicine paper, "Electronic Health Record Use and the Quality of Ambulatory Care in the United States."
When I read the news coverage emanating from the study, it caught me -- and I suppose many of you readers -- off guard. I'm not one to bash the mass media, but reporters got this latest study on electronic health records and outcomes wrong. Journalists need a quick course in statistics, and perhaps simple reading mastery, to know the difference between causality and simple association.
A highly credible and switched-on team from Harvard and Stanford universities wrote the study, which the Agency for Healthcare Research and Quality funded. For the study, researchers studied data from the 2003 and 2004 National Ambulatory Medical Care Survey published by CDC. The data set detailed EHR use coupled with 17 ambulatory care quality indicators. These indicators covered medical management of common diseases, antibiotic prescribing, preventive counseling, screening tests and other services. According to the analysis, physicians' performance on these quality indicators was not associated with the "use" of an EHR system.
All you have to do is read the second sentence in the paper abstract's background paragraph to realize that the researchers were assessing "the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey." Herein lies the nuance of the study: the authors did not seek to address whether the installation of an EHR would result in better outcomes, as newspapers incorrectly interpreted. They simply sought an association between EHRs and quality of care -- and that they did not find.
It's also important to closely look at the second half of that introductory sentence: the simple phrase, "EHR use, as implemented" (emphasis added). That is the point.
So, before you swallow the mass media line of reasoning that "EHRs don't work," take a few minutes to understand what's really in the study.
And Now, a Word From Our Researchers
Given the media's shallow coverage of this study, I thought it best to go right to two of its researchers, Jeffrey Linder and Blackford Middleton. Both are affiliated with Brigham and Women's Hospital and Harvard Medical School. Middleton also leads the Center for Information Technology Leadership, which has performed numerous studies examining various flavors of health IT and their return on investment.
"We were surprised by the kafuffle" among the media, Linder told me. "We would have thought that we would find an association between use of IT and outcomes. In some ways it was disappointing we found what we found," he acknowledged.
During the study period, many of the EHRs "were basically replacements for the paper chart," Linder added. Thus, a great number of the EHR systems implemented by the ambulatory practices did not re-engineer processes or incorporate important features for quality and safety and other applications.
Middleton noted that in 2003 and 2004, when the data from this study were collected, "in even the best EHRs, doctors hardly turn on the decision support function in the full complement of ways it can be turned on." He added, "Many doctors weren't using electronic prescribing" at the time when the study data were collected, which also could positively impact patient outcomes.
"Drawing any causations from this study would be wrong," Middleton said. The point, he noted, is that the study did not measure "effectiveness of use." He said, "If we could tell you these doctors were using these EHRs effectively, then we could draw" more exacting conclusions.
Absent measures of effective use, Middleton said, these data are, statistically speaking, simply association data.
Tools Still Need Incentives To Drive Use
As with the adoption of all medical technologies, good outcomes all depend on how you use them. "EHRs are nothing more than a tool," Linder explained. "A good analogy is that we're trying to build a better cockpit and need a pilot to fly the plane. Part of the cockpit would include registry functions, decision support for team care and other functionality. I do think that EHRs are part of a solution to improve quality of care in the U.S. But it also takes a cultural commitment to quality and safety," Linder added.
He also believes, rightly, that "reimbursement has to line up" with the adoption and use of EHRs. He added, "Until now, doctors have been paid for just providing more care, and we're entering an era where doctors will begin to get paid for quality of care."
Medical culture and the larger health system must be aligned toward providing safe and effective patient care. EHRs are part of the solution, but they are far from sufficient on their own to improve patient outcomes.
ROI is Tangible
Middleton's research team at CITL has generated several detailed studies into health IT's ROI. They've already assessed ambulatory computer order entry, which, if adopted on a national scale, could save our health system billions of dollars. The CITL team also has analyzed information exchange and interoperability, which could save us billions more.
If you wondered about David Brailer's consistent mantra of "interoperability," check out CITL's paper on Healthcare Information Exchange and Interoperability. It will wake you up to the importance of interoperability and the possible cost savings.
As Middleton explained, "The value of health care IT interoperability dwarfs savings accruing to decision support. If all the [EHRs] and relevant stakeholders in the land could talk to each other," the savings would be huge.
ROI in Rochester
The same week the Archives of Internal Medicine study appeared, another report looking at EHRs and ROI was published in the Journal of the American College of Surgeons. Intriguingly, this study got much less press.
In the study, a team of researchers at the University of Rochester Medical Center reported a favorable ROI from the center's EHR system. Comparing cost data from 2003 and 2005, the Rochester team calculated that the center recouped the initial cost of its EHR within 16 months of implementation. The researchers looked at ROI in five ambulatory practices comprising 28 providers. They found that the EHR reduced costs by about $394,000 per year, with two-thirds of the savings resulting from time saved by no longer manually pulling patients' charts. Ultimately, the EHR appears to be saving about $10,000 per health care provider in the center using the system.
If you wed the results of these two important studies, you can conclude that how an EHR is used in practice is a critical success factor in the deployment of EHRs. To derive the full abundance of positive patient outcomes, an organization must fully commit to implementing EHRs and the growing array of features they offer.
"Adoption" of EHRs in and of themselves is not sufficient. There must be full engagement. And that, unfortunately, appears to be in short supply -- especially among mainstream journalists reporting on this issue.
Link: EHRs, Media and Statistics: Misinterpreted Results Skew Understanding - iHealthBeat.
Posted by: Alan Brookstone | August 14, 2007 at 04:36 PM
The vast majority of clinicians are interested in using technology such as electronic medical records (EMRs) to better manage patient data and improve access to clinical information. But these technology-savvy clinicians still aren’t able to access a large amount of patient information, including EMRs from non-compatible facilities. Clinicians know that having access to this information when diagnosing or treating their patients would lead to improvements in care. However, while clinicians recognize the value of health information exchange (HIE), many do not know how to initiate a conversation about establishing a local health information network in their community.
Posted by: Jay Andrews | August 09, 2009 at 11:00 PM