The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments, potentially totaling some $27 billion over ten years, to clinicians and hospitals when they implement electronic health records in such a way as to achieve “meaningful use,” in terms of advances in health care processes and outcomes.
But, are EHRs really “meaningfully useful” or are they more likely to be costly and ineffective?
The latter seems to be one possible interpretation of a recent RAND study of EHR adoption in US hospitals.
The RAND study statistics are impressive: five study authors tallied 17 “quality measures” for three medical conditions against three possible levels of EHR capability (no EHR, basic EHR, advanced EHR) for more than two thousand hospitals for each of 2003 and 2007. They then related changes in quality over the four year timeframe against changes in EHR status (for example, from no EHR to an advanced EHR).
The reported results were disappointing to EHR proponents. Among the hospitals whose EHR capability remained unchanged over the four years, there was no statistically measurable difference in quality improvement between hospitals with EHR capability and those without. For hospitals which upgraded their EHR capability, the performance improvement was generally less than for those who didn’t change, including those with no EHR at all.
So, should we forget about EHRs? Maybe defund HITECH?
As the study’s authors point out, there are a several possible explanations for their results other than ineffectiveness of EHRs. Implementation of an EHR—a very demanding effort—might temporarily disrupt other quality improvement efforts. Hospitals with EHRs typically had higher quality measures to begin with, and—like trying to catch up with the speed of light—would likely find improving quality more challenging as 100 percent quality is approached. Results might have been different for other medical conditions. And the timeframe of the study may have been inadequate to measure the impact of new EHRs, some of which may have been implemented only just before the end of the time period.
It can also be argued that the measurement methodology was flawed. Using simplistic indicators of quality like whether or not aspirin was dispensed on arrival or discharge instructions were provided is a little like judging the quality of a meal by whether or not there was a caterpillar in the salad. Presence of a caterpillar definitely indicates a problem, but its absence says nothing about other aspects of the meal. The study authors indicate their awareness of this limitation in stating “we are concerned that the standard methods for measuring hospital quality will not be appropriate for measuring the clinical effects of EHR adoption.”
Perhaps most importantly, as with other IT systems, EHR success depends on the competence of the implementers and the willingness of the users to accept change, with poorly managed projects more likely to foul up existing processes than improve them. The RAND authors praise programs initiated by the Office of the National Coordinator for Health Information Technology to improve EHR implementation, and comment—in spite of the inconclusive results of their study—that “We believe that these programs are well conceived and anticipate that they will lead to more effective use of EHRs, which will in turn lead to improved quality in US hospitals.”
EHR systems are no panacea, and clearly there have been both successful and troubled EHR implementations. What is needed now is a closer look at what works and what doesn’t, how well EHRs perform over a longer timeframe than the RAND study, and a much less simplistic look at what is really happening to clinical quality as a result.
Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE.
The real bottom line is that some EHRs are ergonomic wastelands, and can only be used well with intelligence, dedication, and effort. Our hospital recently upgraded, and lost nursing notes (nurses are no longer asked or required to summarize the patient’s shift), med errors ballooned for various reasons having to do with the interface design, and physician and support staff time seems to have increased 20-50% for any given records interaction.
The things it does well are things that cannot be done without database and connectivity. But the things that it does not do well — almost entirely related to stupid ergonomic design — are magnifying effort and making inevitable procedural and medication errors that could not happen in a paper environment.
And these ill-designed tools are extraordinarily expensive — yet could be made much more efficient and less costly with (forced) consensus on database design and user interface commonalities. But of course that would require actual cooperation among users and vendors, neither of which are really interested in actual collaboration.
Interesting enough on the eve of a GOP takeover. We now have a
solution? During the year long squabble over Health Care reforms. The
GOP worked hard to destroy and weaken Those reforms. If not stop it
all together! Of Course ,They were doing the dirty work of the
insurance companies. If they had not abused the powers entrusted in
them and had not shown such malfeasance. This question could have been
resolved at the time it was debated. These power brokers wasted energy
and taxpayers dollars.
You are so consumed by your profits that human life is a abstract
concept of statistics. These are those people whom put their first
love above quality health care for all! Their love of Money!
Some of these concepts seem reasonable but in the end. We find the
concerns to be profit driven. I know of no one who doesn’t want access
to health care. So the only ones debating it are those who stand to
see a reduction in their stock portfolios.
Please, stop acting as if you care!
“EMR systems designed to eliminate redundant medical tests”
Haven’t come across that unicorn yet. Physicians are just as, if not more, capable of ordering unnecessary tests via EMR as via paper.
The medical establishments that will most effectively implement health information technology are those firms were Health IT is an integral part of their business model. For instance, retail clinics and telemedicine firms need EMR to operate. Retail clinics don’t have the space for paper records and telemedicine clinics need a patient’s medical history before ordering therapies. Yet, hospitals that make money performing redundant tests cannot be expected successfully install EMR systems designed to eliminate redundant medical tests.
I would go 180 degrees on this: As long as the government is funding implementation of health IT, it will have questionable consequences and poorly measured outcomes.
To achieve effective adoption, defund HITECH.
Vote on eMRs
Roger – Medicine may be the last industry to resist the digital revolution as many doctors still use paper medical records.
Framing the Debate
Privacy advocates worry that if the move to eMRs is rushed, patient privacy will suffer. Supporters, on the other hand, argue that health information technologies have advanced to the point that such concerns are vastly overblown. Any loss of privacy will, they insist, be more than offset by efficiency gains.
Who is right?
Ann Miller RN MHA
“It can also be argued that the measurement methodology was flawed. Using simplistic indicators of quality like whether or not aspirin was dispensed on arrival or discharge instructions were provided is a little like judging the quality of a meal by whether or not there was a caterpillar in the salad.”
Logically then, this argument should be extended to “measuring quality” in general. The same criteria, and even more simplistic ones for ambulatory care, are being used by CMS and Meaningful Use to measure hospitals and doctors. If these criteria are too simplistic to measure EHRs, aren’t they too simplistic to measure physicians and hospitals?
“It can also be argued that the measurement methodology was flawed.”
The final refuge of intellectual frauds.