THCB

Asking the Wrong Questions About the Electronic Health Record

The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be.  Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question.  An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs).  This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.

While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it.  The problem is that the WSJ piece, and the studies it points to, are asking the wrong question.  The right question is:  How do we ensure that EHRs help improve quality and reduce healthcare costs?

The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate.  Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available.  Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment.  I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.

The problem is that some Health IT boosters over-hyped EHRs.  They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace.  We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.

Most EHR vendors today sell their products to doctors promising increased “revenue capture” (that is, improved billing resulting in greater payments to physicians and higher costs to the health care system).  In a fee-for-service world, the EHR, which is nothing but a tool, helps you get more “fee” for your “service”.  It’s not surprising that we aren’t seeing huge savings.

To understand how to best leverage the potential of EHRs to help the US improve care and save money, we will have to answer a series of other related questions:  how do we create incentives in the marketplace that reward physicians who are high quality?  How do we allow physicians to capture efficiency gains?  Today, if a physician becomes more efficient, he/she will likely lose revenue to insurance companies or to government payers.  When Kaiser Permanente installed an EHR and gave patients the ability to use the electronic system to message their physicians, they saw their ambulatory care visit rate fall by 20%.  This is a disaster in a fee-for-service world.  Sure, Kaiser was able to see real financial gains from their EHR – but how do we help the thousands of other physicians and hospitals that are not Kaiser gain efficiencies from their EHR?  That’s the question I’d like to see answered.

Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world.  I am sure that the healthcare industry single-handedly keeps the fax machine industry alive.  We need to stop. Period.  Every other part of our lives has become electronic and the benefits are clear.  Our lives are better because we bank online, communicate online, shop online.

The debate over whether we should have EHRs is over.  Can we fix our broken healthcare system without a robust electronic health information infrastructure?  We can’t.  Instead of re-litigating that, we need to spend the next five years figuring out how to use EHRs to help us solve the big problems in healthcare.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence.

Livongo’s Post Ad Banner 728*90

Categories: THCB

Tagged as: , , ,

35
Leave a Reply

17 Comment threads
18 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
14 Comment authors
RonnieSarah IngersollEricLynn in SCBobbyG Recent comment authors
newest oldest most voted
Ronnie
Guest

There’s definately a lot to learn about this subject. I love all the points you made.

Here is my blog :: Ronnie

southern doc
Guest
southern doc

Watching the AAFP fight with NPs for the crumbs from the health care table is better than Saturday night WWW. That they’re reduced to this indicates that they’ve already lost.

southern doc
Guest
southern doc

Wrong thread. Sorry.

Eric
Guest
Eric

Yes, Kaiser has reported some impressive outcomes associated with its EHR, including a sharp drop in their ambulatory care visit rate with no apparent ill effects. But it is also worth noting that it had several failed attempts at EHR installation it got it right, including a write off of more than a billion dollars after one of its earlier attempts ended in a fiasco. The benefits of EHRs get lots of publicity, but the costs and failures tend to be airbrushed out of the literature on EHRs. Which is a shame, because the health care industry could learn a… Read more »

BobbyG
Guest

I apologize for my tone.

Lynn in SC
Guest
Lynn in SC

Perhaps world peace or at least peace in the Middle East is easier. This process is paralleling the introduction of electronic billing in the late 1970s. Remember when claim forms were written by hand, bundled, and mailed to BCBS? And there a clerk keyed the data to be crunched by a big IBM computer and then print a check and remittance form back to the doctor? It took about 20 years and multiple coding updates for that to be “perfected” to the point checks appeared quickly. It suspect it will take about as long for providers, payers, and patients to… Read more »

southern doc
Guest
southern doc

EMRs prevent some errors, and cause new ones. I don’t think we have any good data yet that shows EMRs leading to better quality care.

The reason the US lags behind the rest of the industrialized world in quality of care measures is not due to the fact that we lack EMRs. It’s because a significant part of our population has no or limited access to needed care. We’d get far more return on our investment by addressing that elephant in the room, and let HIT develop as needed.

rbaer
Guest
rbaer

I agree with all you write in your last post, but I still stand by what I said above … there is no empiric evidence for the upsides, but strong “common sense” and anecdotal evidence supporting the advantages above. But even if I was right about the upsides, the question remains whether 1. it’s worth the effort or not (that in part a hard to impossible to research empirical and in part a judgment question) 2. whether EMR could be made cheaper and userfriendly (=less costly) 3. whether we can weed out a lot of the downsides (as discussed). For… Read more »

rbaer
Guest
rbaer

@midwest and southern docs, A reasonable bare bones EMR/PACS should provide availability of legible data, to everyone involved as soon as they are generated. That’s a huge achievement: no lost parts of the MR, no illegible scribble in docs’ notes, no mystery patients showing up at the ER and the MR or latest CT scan is not accessible, no lab slips falling behind the file cabinet … if we abolish the use of idiotic templates and excessive cutting and pasting resulting in note bloat, the EMR is a blessing, esp. in large institutions (IMO, very little benefit in stand alone… Read more »

Midwest doc
Guest
Midwest doc

You sound a little angry.

Midwest doc
Guest
Midwest doc

southern doc you are correct. See 8 to 10 patients a day and do the NY times crossword puzzle. What a great day. I worked at a VA and great gov. job. Do nothing , be home by 5. Get a check. “Our lives are better because we bank online, communicate online, shop online”. Very funny. For look at all the potential for fraud, I.D. theft ect..Bobby is rolling over as a REC REP. Any of you pups remember going to your local bookshop and greeting a smile. Having a beautiful bound book to hold. The local coffee shop owned… Read more »

BobbyG
Guest

Bobby is rolling over as a REC REP. [bleep] you. I shill for nothing. In fact, I have taken substantive shit at work over my REC blog (“exceeding your scope”). I am the Resident Curmudgeon. My REC job is done effective end of Q12013 anyway. “The problem with the EMRs I have evaluated is that they do not understand how humans think , work and solve problems.” “I have evaluated…” And, that would be precisely how many? Total, and as a pct of market? Remember (per ScienceBasedMedicine.org), “the 3 most dangerous words in Medicine are ‘In My Experience’.” apropos, see… Read more »

Dr. Mike
Guest
Dr. Mike

Although it was only implied by your comment, if the implied statement is true then it is also true that It is the height of arrogance to think that the fact that you may have evaluated dozens of EHRs means anything at all. Unless I missed it somewhere and you are in fact a provider of clinical services. I’ll say it for you – (bleep) me too.

BobbyG
Guest

You read too much into it. We work with about 40 systems here, about 2.5% of the 1,578 currently “Certified complete” EHR systems (ambulatory and inpatient). So, I would never claim to know how well ALL systems work. Oh, and, yeah, I know; since I’m not a physician, I have nothing but worthless views in this space. Heard that one many, many times. __ “A culture of denial subverts the health care system from its foundation. The foundation— the basis for deciding what care each patient individually needs— is connecting patient data to medical knowledge. That foundation, and the processes… Read more »

Dr. Mike
Guest
Dr. Mike

Your views are anything but worthless – it’s just that you have never used an EHR. Period. You have played with them, studied them, analysed them, but you have never used one. Ever. But the real point was that Midwest doc’s views are not worthless either, despite him/her having not evaluated the number of EHRs that would impress you.
So answer this question – which of the 40 systems you are familiar with are able to understand how humans think, work, and solve problems? If there are none, then you owe Midwest doc an apology.

steve
Guest
steve

OT, but related. I am reading Goodmans book. Anyone familiar with the eHealth EHR? Do they have a usable EHR that could be adapted into clinical practice?

Back on topic, bring me an EMR that works and I will use it.

Steve

rbaer
Guest
rbaer

“When Kaiser Permanente installed an EHR and gave patients the ability to use the electronic system to message their physicians, they saw their ambulatory care visit rate fall by 20%. ” There must be a reference documenting this impressive achievement – could you please provide it? ” How do we ensure that EHRs help improve quality and reduce healthcare costs?” Uhhm, not sure whether this is the appropriate question. Steven Colbert used to ask: “George W Bush – a great or the greatest president?” I actually do favor EMR and have been using them since my residency more than a… Read more »

southern doc
Guest
southern doc

“How do we ensure that EHRs help improve quality and reduce healthcare costs”

A perfect example of the fallacy referred to as “begging the question”

The VA EMR works because it’s a closed system where the docs see 8-10 patients a day and don’t have to deal with multiple insurers, not because the EMR is all that superior to what else is on the market.

rbaer
Guest
rbaer

Not sure about this argument. The number of visits may be lower (the VA where I trained prior to the VA EMR was a teaching hospitaI, so numbers are usually lower), but I heard the VA system is much simpler and user friendly … and I am not sure about reimbursement/billing/coding issue. We are working with Epic here and we still have lots of (wo)manpower doing billing and coding, and I would not be surprised if they use their own additional software. IMHO, a MR should be a MEDICAL record anyway, not primarily a billing tool.

southern doc
Guest
southern doc

“IMHO, a MR should be a MEDICAL record anyway, not primarily a billing tool.”

Every practicing doc would agree with that, but no one is interested in what we think.

Sherry Reynolds @Cascadia
Guest
Sherry Reynolds @Cascadia

Group Health Cooperative – a sister org to Kaiser with 1000 doctors and 620,000 members has seen even larger drops in primary care office visits 30% to 40% .. They wrote it up back in 2010 in Health Affairs http://content.healthaffairs.org/content/29/5/844.short and in a Commonwealth fund report in 2009 http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Jul/1283_McCarthy_Group%20Health_case_study_72_rev.pdf

MFreeman
Guest
MFreeman

Look at your premise of HOW DO WE ENSURE THAT EHT WORKS? That’s the point. It won’t work. We are distracting ourselves from the real problem which is cost. Computers will NOT help this.

BobbyG
Guest

Yes. Similarly, it’d be MUCH better if banking returned to the days of 9-3 M-F hours and double-entry paper bookkeeping.

southern doc
Guest
southern doc

The correct analogy would be that EHRs are as likely to solve problems of expense and quality as ATMs are to prevent another financial meltdown.

BobbyG
Guest

Well, i smell wafts of false dilemma — implication of “other overlooked causal factors” — in that analogy.

MFreeman — “It won’t work.”

Well, I guess we can all just go home now.

southern doc
Guest
southern doc

But the OP insists on asking the most bass-ackwards wrong question: “How do we ensure that EHRs help improve quality and reduce healthcare costs?” Who cares? The question we need to answer, of course, is “How do we improve quality and reduce costs?” And we all know what has to be done, and it doesn’t require EHRs: universal access to improve quality, cut RVUs for procedures and diagnostics by 50-75%. But nobody is pushing those. EHRs can put a little icing on the cake, but to present them as the necessary and sufficient first step is a tremendous distraction from… Read more »

Dr. Mike
Guest
Dr. Mike

The other point that needs to be made is that I can focus on any number of limited aspects of the system and make them better. I can do this with paper charts or with EHRs. It is the FOCUS that makes the improvement, not the particular tool choosen to do the job. Thus we have a multitude of studies purported to show the benefits of EHRs that actually only show the benefit of focusing on a particular aspect of the system.

Dr. Mike
Guest
Dr. Mike

You are still asking the wrong question. Without realising it, you are in essence asking, “How can we continue to live with our broken system but make it a little more tolerable through the use of technology.”
The parts of our system that are broken have very little to do with paper charts versus EHRs, and thus the reasons that even the more muted hype surrounding EHRs continues to lead to disappointment when the reality of their limitations sinks in.

southern doc
Guest
southern doc

“The parts of our system that are broken have very little to do with paper charts versus EHRs”

Exactly. That’s what I was trying to say.

Jon Cooper @RepoocNoj
Guest

Great post. Your point about fee-for-service specifically, and misaligned incentives generally, as the central problem is right on. Nonetheless, there still are systematic issues with our EHR infrastructure which we must address to optimize the potential efficiencies as healthcare migrates from fee-for-service to fee-for-value, namely that of cross-compatibility across the closed-standards of the major EHR players. While RHIOs and HIEs demonstrate that we recognize compatibility as a key problem, today HIEs and RHIOs are not adequately addressing the problem, and adding additional cost to the system. While I am not generally in favor of additional regulation or mandates, it seems… Read more »