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Where’s the magic with electronic medical records?

Last week a new article from The American Journal of Medicine entitled, “Hospital Computing and the Costs and Quality of Care: A National Study” by Himmelstein, et al. appeared in my Twitter stream. In fact, Brian Ahier (@ahier), whom I and about 3300 other tweeps like me follow, sent me a DM asking for thoughts. In that article the authors sort of breathlessly conclude that current hospital computing has minimal impact on quality and no impact on cost. Shocking. Actually, it’s the kind of gotcha article that really grates—the kind that isn’t particularly helpful to anyone as the authors seem intent on drawing sweeping conclusions from pretty limited data.

For starters, how can we draw any conclusions about the impact of widely adopted, meaningfully used electronic records until they’re, well, widely adopted? As research by Ashish Jha et al. highlighted in Chapter One of the recently released 2009 RWJF HIT Adoption report (results from that research also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system. I’m not sure how one can draw important conclusions about national hospital computing given such an unbelievably low national rate of adoption.

More importantly, though, most do not think that simply adopting, even widely, a technology would ever magically on its own improve quality or lower costs. I’m not sure why these authors seemed to say otherwise. The point as many have noted over and over again is for health professionals to adopt and then USE (remember our year long discussion regarding meaningful use?) the technology FOR improved quality, including improved efficiency. As I discuss extensively in Chapter Five of the 2009 HIT Adoption Report, one important use of the technology will be, for instance, automation of performance measurement and public reporting. The automation enabled by widely adopted, meaningfully used EHRs will hopefully accelerate the creation of results oriented information—information that will facilitate payment reforms as well as improvement. We absolutely cannot do the kind of payment reforms that the nation needs without creating measures from the automated collection and aggregation of clinical data. Bundled payment reforms, like the Prometheus model for example, will not work without this kind of automation—and to get to that automation we need widespread adoption and meaningful use of the technology. But the adopted technology is only an important step.

We are still nowhere near that kind of use in an environment of ubiquitous electronic records. Given that small fact, to conclude that there is “evidence” that hospital EHRs “don’t” improve quality or lower costs seems pretty silly. That’s like saying a stethoscope should, but shockingly doesn’t, improve the quality and cost of care just because an intern buys one and hangs it around her neck.

The authors end their article asserting that predictions about cost and efficiency improvements from widely adopted EHRs “are premature, at best”. To me that statement is pretty disingenuous, at best. What’s premature is expecting magic transformation when folks are just getting the tools out of the box—and trumpeting the lack of that magic transformation as if it’s evidence.

Michael W. Painter, J.D., M.D., is a physician, attorney, health care policy advocate, and 2003-2004 Robert Wood Johnson Health Policy Fellow. He is currently senior program officer and a senior member of the RWJF Quality/Equality Team.

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15 replies »

  1. It is an ideal thing to have electronic medical records. But then, this is somewhat tricky, especially for those people who are not tech-savvy. It will be helpful to always have some sort of back-up filing system done the traditional manner.

  2. I agree they are not widely adopted enough to draw meaningful conclusions as to improved care and decreased costs. One of the large drawbacks to use is huge cost of implementation and maintenance. I really enjoy this article.
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  3. Paperless healthcare records relieves the burden of maintaining sheaf’s of paper for endless number of years, the doctors have instant access to health records at any time any place. The EMRs provide doctors the option of interacting with fellow doctors through a computer, without referencing hard copies of patient records.

  4. EMRs are in their infancy. I agree they are not widely adopted enough to draw meaningful conclusions as to improved care and decreased costs. One of the large drawbacks to use is huge cost of implementation and maintenance. Intensive training is also required, as those of you who use EPIC know. (EPIC has a large portion of the hospital market.) I think we will have to wait for more data, and hope that more intuitive, simpler to use systems emerge as EMRs move forward. I also believe that no one piece of technology will “revolutionize” health care. To expect an EMR to do just that is misplaced.

  5. To say my hospital’s EMR was a “boat ancher” would imply it actually was good for something. In fact it is good for NOTHING!
    The problem with every system is and will be they are designed to serve someone else’s agenda. They are not to help the doc. They are not to help the nurse. They are not to help the patient.
    They are to help the government.

  6. I’ll accept the premise that legacy EHRs can’t easily be shown to have improved the quality and cost-effectiveness of care, but please let me offer an alternative explanation for this observation.
    It’s only with the recent advent of SaaS-based EHRs, which are far less expensive and offer unprecedented opportunities for continuous, rapid improvement of the end product, can this technology reach the aspirations we all have for it.
    We release updates to our EHR over the Web twice monthly based on direct feedback from physician-users, who get a tremendous rush when they see their suggestions to improve workflow, and for new features, added with only a short delay. The updates go out to all users instantly, and in our case, for free.
    The legacy EHR vendors are hopelessly saddled with poor initial design and glacial update cycles. This is the root cause of end-user frustration and their apparent failure to show improvements in quality and cost.
    Thanks,
    Glenn Laffel, MD, PhD
    Sr. Vice President, Clinical Affairs
    <a href=”PracticeFusion“>http://www.practicefusion.com”>PracticeFusion
    Free, Web-based EHR

  7. Actually they admit that electronic records have been a big success at the VA. The reason the VA system is effective is that it was developed in a decentralized, opensource manner, in close cooperation with doctors and interns. They got exactly what they needed, at low cost, and they’ve been developing it for decades.
    The software is freely available to anyone, there are commercial and opensource communities dedicated to helping people use it, and it is in use in several other countries.
    Which brings up another point: this is a “national” study, which means they’ve excluded the very successful electronic records systems in France, Germany, and Japan. None of these countries have single-payer healthcare.
    The core of the problem is, as they say, “Coding and other reimbursement-driven documentation might take precedence over efficiency and the encouragement of clinical parsimony,” or to put it another way, hospitals have little incentive to develop systems that help them to be clinically successful. This is a problem much larger in scope than computerization.

  8. Brad,
    Thank you for your comment. You are absolutely right, Mr. Painter’s representation of the article (which I encourage everyone here to access via the link and to read at least the discussion) is dishonest; he builds a strawman in order to knock him down.
    It is interesting that, according to Painter, EMR now all of a sudden are not helpful by themselves (against all common wisdom), but just the beginning of the road to fundamental changes in health care reimbursement that “hopefully” (Painter) will materialize as we will go along.
    As I said here numerous times, by my own experience over a decade with 3 different EMR in 4 different settings, EMR seem to improve quality of care (at least of complex patients in larger hospitals and MSGs). Whether they are worth the enormous efforts necessary for their implementation and use remains to be seen, as the study authors carefully concluded.
    Catron, I do not know whether the same group has “been debunked left, right and center” with their claim that many (actually rather 60%) of personal bankruptcies are related to medical illness and health care bills. They did not just “tell” us that, they published a peer reviewed article/study … if there is reason to seriously doubt their findings, please provide a link. Or better three, one from left, one from right and one from center.

  9. FYI—The authors of the AJM piece (Himmelstein, Woolhandler, et al) are founding members of PNHP, a single-payer advocacy group notorious for drawing wild conclusions from limited data.
    For example, they are the folks who told us that half of U.S. bankruptcies are due to medical bills, a claim that has since been debunked left, right and center.

  10. I disagree. Read the conclusions and their language. They did the analysis and stated the results. They were careful to say IT “in its current form in 2000s.”
    I walked away from paper not thinking that EMRs are “ineffective,” but pragmatism and course corrections are necessary, and my take–this is a work in progress.
    At no point did they say abandon ship.

  11. These authors obviously must have a CPOE system in their hospital that they hate. (:

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