A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don’t improve outpatient quality. The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and “doubt [the] argument that the use of EHRs is a “magic bullet” for health care quality improvement, as some advocates imply.”
This should surprise no one. Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes? Does simply installing computers in our classrooms improve educational test scores?
Of course not.
The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn’t seem to improve outcomes on 20 quality indicators. First, it isn’t clear that the CDS implemented across the various doctors’ offices and emergency rooms actually addressed the indicators studied. Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007). The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality. Whether this can be scaled to the national level is the question.
In other words, it isn’t just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections. As most people know already, there is not typically an appropriate antibiotic to use for a virus. It’s a virus. It does, however, take good bedside manner to inform and educate an ill patient!
As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I’m incredibly lucky. In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to. CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time. It is a safety net. Understandably some EHRs aren’t that good, the CDS is clunky, and certainly the one I use is good, but not perfect.
The real issue isn’t finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done. Indeed, to get into medical school, one has to be self-motivated, persistent, and determined. Why on earth would we need a computer to help us?
Frankly, because it makes us better doctors. CDS frees up time and mental energy. I don’t have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia. Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen.
Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don’t fit any protocol (cognitive medicine) because science hasn’t evolved to that level of understanding. I’m a big believer in the history and physical exam and how the use of HIT can make care more personal. Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen. Instead of hunting for lab work in a paper chart or trying to find a specialist’s consultation, I can access the information I need rapidly and focus on the patient in front of me.
Sadly, however, many doctors don’t feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate. It might also be, however, our training and tradition which limits us from improving. If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better. We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande’s New Yorker piece, the Checklist. Because, really, CDS is essentially a checklist.
In the situation where a patient doesn’t fit CDS, then we get to do what we do best and that is use all of our training to get a patient better. HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before. In the end, that is what patients really want.
This is why I love my EHR so much.
Davis Liu, M.D., is a practicing board-certified family physician and author of the book, Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System. He graduated summa cum laude and Phi Beta Kappa from the Wharton School of Business at the University of Pennsylvania. He received his medical degree from the University of Connecticut School of Medicine. Follow him at his blog, Saving Money and Surviving the Healthcare Crisis or on Twitter, davisliumd.
All excellent comments. Appreciate the feedback.
Davis Liu, MD
Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
(available in hardcover, Kindle, and iPad / iBooks)
Exactly. When I first saw that WSJ article and then saw the time frame of the original (and equivocal) study, my reaction was that “2005-2007? Might as well have been 20 years ago.”
Please get us one that works for inpatients, especially in the OR.
I agree with you on the fact that the data set is dated and therefore can’t possibly correctly measure the change in quality of care. With meaningful use incentives coming up very soon, more and more doctors are switching to EMRs than back in 2005. Overall, EMR systems
and EMR/EHR features
save doctors save and create a more efficient workflow for doctors. Thousands of people die each year due to mistakes made by paper records, we can;t dispute the fact that electronic medical records are a much more secure way of treating patient information versus a paper record.
The first step in regard to EHR is it sets a base line for measurement. If you don’t measure how would you know whether you are improving? Over the long term, I believe EHR will help clinical decision support even though progress will take time.
Once the baseline is set, you can work to improve on the key aspects. It is good to know there are doctors that love their EHR system.
Yes, there are many reasons to love EHRs and your reasons are compelling. However, for the vast majority of private practice physicians, they do not have the access to those resources which you do, especially access to your affiliated hopital’s EHR system. In addition, they are faced with a myriad of choices of EHR systems which may or may not have a “robust” CDS component. Few physicians have the technical knowledge or interest to discern specific details necessary to select the best system and at best can only hope to choose a system that appears to best fit their needs and can potentially grow with them.
As to the cultural issues, certainly there are some older physicians in practice who are reluctant to change, or elect to spend the amount of money necessary to purchase an EHR system if they are looking at retirement in a few years. However, it is more of the culture surrounding “being a doctor” that seems to me to throw up more skepticism and reluctance to change. Your example of Dr. Gawande’s checklist is an excellent example and I heartily agree. And I agree that too many see CDS as an intrusion rather than an aid. Depending on the system that they purchase, it can go either way to the point that it is so intrusive that it becomes ignored completely. Part of being a good doctor is the art of medicine, a practitioner’s experience, in addition to “just the facts.” I think that is the road many practitioners are going down at this point in time, while Washington uses the carrot and stick approach to make EHRs a force by a deadline that is doubtful they can keep since they keep making the rules, changing them and granting exemptions. On the other hand, if dates and money were not involved, there would likely be little progress at all sadly.