America’s hospitals are a triumph of modernity, stocked as they are with PET scanners, ECMO machines, and ICUs bedecked in eye-popping gadgetry.
They are also the most complex organizations ever created by man. The seemingly simple process of delivering a drug from the pharmacy to the bedside for example, typically involves a 30-step process executed by a half-dozen people on 3 floors. There are hundreds of ways it can fail.
It often does, and that’s just half the story. Each hospitalized patient requires a unique combination of services including lab tests, physical therapy, a discharge plan and so forth. Since a complex process must be executed to produce each service, the hospital becomes a job shop.
By contrast, the processes used to produce cars and silicon chips are relatively unfettered. That is why piston rods can be produced in batches with every item meeting specs to the micron, while hospital processes often feature error rates of 10-20%.
This explains why hospitals have struggled for decades to improve quality. It also explains why a study by Ashish Jha and colleagues at Harvard has shown that hospitals using electronic health records (EHRs) don’t have better quality.
Jha’s team divided 3,000 US hospitals into 3 groups based on the extent to which they had adopted EHRs. One group had deployed “comprehensive” EHRs throughout the facility. A middle group had implemented “partial” EHRs. A third group did things the old-fashioned way.
The scientists compared the groups using federally approved quality measures for congestive heart failure, pneumonia and surgical infections, and found minimal differences.
In the heart failure patients for example, hospitals that had deployed full-blown EHRs met best-practice standards 87.8% of the time. Hospitals in the middle group did so 86.7% of the time and the EHR laggards clocked-in at 85.9%. Similarly trivial differences were noted for other conditions and length of stay, a measure of hospital efficiency.
These differences were “really, really marginal,” Jha told the New York Times. “The way electronic medical records are used now has not yet had a real impact on the quality or cost of health care.”
Jha and many others that have commented on his research have it all wrong.
EHRs aren’t intended to fix the complex care systems which cause quality problems in hospitals. In fact, operations researchers have told us for decades that automating error-prone processes will, perversely, produce more errors in the same amount of time.
Outpatient Settings are Different
Things are different in solo and small group practices. Although harried physicians and office staff in such venues might not believe it, the processes in which they work are less complex than those in hospitals.
For one thing, fewer people are involved. This means there are fewer information hand-offs and the errors that accompany them.
In addition, most people in solo and small group practices work within shouting distance of each other. This means process failures can be corrected in real time. And if that doesn’t work, the process can often be redesigned over lunch.
Furthermore, in solo or small group practices the key aspects of clinical quality usually do come down to decisions made by physicians. Did the doctor order the colonoscopy for the 61 year old male? Did she account for drug allergies when she wrote the prescription?
Anyone that has participated in a hospital-based effort to reduce length of stay will understand that physicians cannot be held accountable for quality in such complex systems.
It follows that in small outpatient settings (but not hospitals), EHRs can favorably impact the quality of care. The EHR can provide decision support to the physician at the time she needs it. The informed physician makes a better decision and quality improves.
Unfortunately, Jha’s study didn’t focus on outpatient settings. In part, this is because EHR penetration has been poor in those venues, with the major barriers being cost and the inability to accommodate office workflow.
The advent of inexpensive, easily modifiable Web-based EHRs ought to change all that.
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