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Failure to Translate: Why Have Evidence-Based EHR Interventions Not Generalized?

The adoption of electronic health records (EHRs) has increased substantially in hospitals and clinician offices in large part due to the “meaningful use” program of the Health Information Technology for Clinical and Economic Health (HITECH) Act. The motivation for increasing EHR use in the HITECH Act was supported by evidence-based interventions for known significant problems in healthcare.

In spite of widespread adoption, EHRs have become a significant burden to physicians in terms of time and dissatisfaction with practice. This raises a question as to why EHR interventions have been difficult to generalize across the health care system, despite evidence that they contribute to addressing major challenges in health care.

Problems Motivating Use

EHR interventions address known problems in health care of patient safety, quality of care, cost, and accessibility of information. These problems were identified a decade or two ago but still persist. Patient safety problems due to medical errors were brought to light with the publication of the Institute of Medicine report, To Err is Human, with recent analyses indicating medical errors are still a problem and may be underestimated. Deficiencies in the quality of medical care delivered was identified about a decade and a half ago and continues to be a problem. The excess cost of care in the US has been a persistent challenge and continues to the present. A final problem motivating the use of EHRs has been access to patient information that is known to exist but is inaccessible, with access stymied more recently by “information blocking”.

Evidence Base

These problems motivated initial research on the value of EHRs. One early study found that display of charges during order entry resulted in a 12.7% decrease in total charges and 0.9 days shorter length of stay. Another study found that computerized provider order entry (CPOE) led to nonintercepted serious medication errors decreasing by 55%, from 10.7 events per 1000 patient-days to 4.86 events, with preventable ADEs reduced by 17%. Additional studies of CPOE showed a reduction in redundant laboratory tests and improved prescribing behavior of equally efficacious but less costly medications. Another analysis found that CPOE increased the use of important “corollary orders” by 25%. Additional studies followed from many institutions that were collated in systematic reviews published first in 2006 and then updated in 2009, 2011, and 2014 that built the evidence-based case for EHRs. There were some caveats about the evidence base, such as publication bias and the benefits mostly emanating from “health IT leader” institutions that made investments both in EHRs and the personnel and leadership to use them successfully.

Failure to Translate

Despite the robust evidence base, why have the benefits of EHR adoption failed to generalize now that we have their widespread adoption? There are several reasons, some of which emanate from well-intentioned circumvention of the EHR for other purposes. For example, both institutions and payers (including the US government) view the EHR as a tool and modify prioritization of functions for cost reduction. There is also a desire to use the EHR to collect data for quality measurement – which should be done – but not in ways that add substantial burden to the clinician. Additionally, there are the meaningful use regulations, which were implemented to insure that the substantive government investment in EHRs led to their use in clinically important ways but are now criticized as being a distraction for clinicians and vendors.

There are also some less nobly intentioned reasons why the value of EHRs has not generalized. One is “volume-based billing,” or the connection of billing to the volume of documentation, which leads to pernicious documentation practices. Another is financial motivation for revenues of EHR vendors, who may be selling systems that are burdensome to use or not ready for widespread adoption. Much of the early evidence for the benefits of EHRs came from “home grown” systems, most of which have been replaced by commercial EHRs. These commercial EHRs do more than just provide clinical functionality; they redesign the delivery of care, sometimes beneficial but other times not. It thus can take a large expenditure on an EHR infrastructure before any marginal benefit from a particular clinical benefit can be achieved, even if the rationale for that function is evidence-based.

Nonetheless, a number of “health IT leader” institutions have sustained successful EHR use and quality of care, such as Kaiser-Permanente, Geisinger, and the Veteran’s Health Administration. These institutions are not only integrated delivery systems but also have substantial expertise in clinical informatics. These qualities enable them to prioritize use of IT in the context of patients and practitioners as well as incorporate known best practices from clinical informatics focused on standards, interoperability, usability, workflow, and user engagement.

Moving Forward

How, then, do we move forward? We can start by building on the technology foundation, albeit imperfect, that has come about from the HITECH Act. We must focus on translation, aiming to understand how to diversely implement functionality that is highly supported by the evidence while carrying out further research in areas where the evidence is less clear. As with any clinical intervention, we must pay attention to both beneficial and adverse effects, learning from the growing body of knowledge on safe use of EHRs. We must also train and deploy clinician informatics leaders who provide expertise at the intersection of health care and IT.

Finally, we also must reflect on the perspective of the larger value of IT in health care settings. Approaches to cost containment, quality measurement, and billing via documentation must be reformulated to leverage the EHR and reduce burden on clinicians. We should focus on issues such as practice and IT system redesign, best practices for the patient-practitioner-computer triad, and practitioner well-being. We must build on value from other uses of EHRs and IT, including patient engagement and support for clinical research. Leadership for these changes must come from leading health care systems, professional associations, academia, and government.

William Hersh, MD is Professor and Chair of the Department of Medical Informatics & Clinical Epidemiology at Oregon Health & Science University. Dr. Hersh also maintains the Informatics Professor blog.

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meltootsWilliam HershAdrian Gropper, MDRes Morgan M.D.John Irvine Recent comment authors
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Adrian Gropper, MD
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Adrian Gropper, MD

This post and most of the comments are about a health records architecture that’s over 50 years old. It’s beyond obsolete. Expensive, insecure, proprietary. Because neither physicians or patients have any purchasing power in this architecture, it’s an obvious market failure. But it’s not regulated as a market failure because a decade of politics and regulatory capture insists that that we’re just about to turn the corner: The regulators have a ten year plan. Look around. Machine intelligence is beginning to provide decision support. It will provide this advice to physicians and patients directly, regardless, or in spite of, the… Read more »

William Hersh
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William Hersh

Adrian,

I don’t disagree with you that our health records architecture is archaic and that there are systemic reasons why it is not becoming more modern. But that is somewhat tangential to the real improvements in patient outcomes and healthcare delivery that we see in places where EHRs are used in ways supported by the research evidence.

Bill

Niran Al-Agba
Member

You lost me at “physician-patient-computer triad.” What a ridiculous notion. I am absolutely thrilled you went on to further specialize in informatics and suspect you know a lot about computers. Clearly, you like your computer so much you now think it belongs in the physician-patient relationship. I disagree. According to your bibliography, despite getting an MD in 1984 (back when I was 10 and only dreaming of becoming a pediatrician), you have put in exactly 3 years at an urgent care center. I have 16 years of clinical practice under my belt, and I have had 100’s of patients for… Read more »

Allan
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Allan

“You lost me at “physician-patient-computer triad. … Clearly, you like your computer so much you now think it belongs in the physician-patient relationship. ”

Niran, I’m glad you focused on the triad mentioned in the above blog posting.

I am now wondering if that triad shouldn’t be invloved in all relationships. Think of the husband-wife-computer triad. I wonder what bedside complaints we would get from that relationship? 🙂

Res Morgan M.D.
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Res Morgan M.D.

“physician-patient-computer triad”

Similar to the driver-traffic-computer triad – aka texting while driving. I’m sure Dr. Hersh highly approves.

William Hersh
Member
William Hersh

Niran, Your attitude that the facts and opinions of no one who is not a full-time physician matter perfectly exemplifies why medicine is so screwed up in this country, and one of the reasons why we achieve the worst outcomes at the highest costs. I am not sure you even read my piece above, because I am hardly defending the current state of the EHR environment. But your attitude clearly shows that our real problems in medicine in the US will never be solved with physician attitudes like yours that are an embarrassment to our profession. I am happy to… Read more »

Allan
Member
Allan

As a retired physican I object to the way you mischaracterize Niran who has stood up for patients and the appropriate practice of medicine. Thank goodness we have physicians like Niran that still recognize who we are treating, patients, not numbers, not EHR’s and not political processes. You owe her an appology. From your tone it sounds like your beliefs are what has made healthcare a mess. As an M.D. you ought to recognize that an M.D.’s concerns at the bedside should be the patient, not other concerns. You seem to have the desire to place some between the physician… Read more »

William Hersh
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William Hersh

I am not going to apologize for someone’s baseless attack on my professional activities. Niran knows nothing of what I do, including how much medicine I have practiced in my career. But she (and many of the rest you) also are not really reading my posting. I am hardly defending the current status quo of the EHRs most physicians are stuck using in their practices. I am trying to make the point that EHRs have been used successfully in many healthcare settings, and have been shown in the studies I cite to improve care delivered. My posting seems to be… Read more »

Niran Al-Agba
Member

No one was attacking you. Rather, I put your opinion into context based upon your experience in longitudinal clinical practice. I am making a valid point. This is what physicians are trained to do; assimilate the information and evaluate where bias exists to interpret someone’s assertions. Three practicing physicians disagree with your opinion EHR’s improve clinical practice in a small primary care setting over what we already have and we “have an axe to grind?” That opinion speaks volumes as to how one has learned to collaborate, compromise, and successfully resolve differences as a professional. We are not computers; we… Read more »

Allan
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Allan

“I am not going to apologize for someone’s baseless attack on my professional activities … But she (and many of the rest you) also are not really reading my posting..” You don’t have to apologize, you have choice, something that is being taken away from physicians practicing at the bedside. I read your piece and was only commenting on your response to Niran which was horrible. I think you should be listening a bit more and stop being so defensive. EHR’s need to develop more organically. If they do then gradually they will be accepted by the physician community, but… Read more »

meltoots
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meltoots

So Big Bill…how many patients do you see a week? This past week? Did you ever see any, for how many years, 1? 3? Do you (yourself) use an EHR to care for your patients currently? Do you get consulting fees from any EHR vendors, HIT companies? Or does you institution get money due to your involvement? Do you have a COI? Your pitiful studies are VERY old, like 1998 to 2000 old, WAY prior to current EHRs. Kaiser cannot seem to replicate itself out of California (IT fairly easy when all providers are on same IT/IDS, they just pulled… Read more »

William Hersh
Member
William Hersh

I do not receive a penny from EHR vendors. I work for an academic medical center, which is the largest healthcare provider in our state, and my work is mostly in academic clinical informatics. Call that a conflict of interest if you like. Again, I am not uncritical of current EHR vendors. Anyone who in any way reads that into my posting is not reading my words. This is getting frustrating. But there is plenty of evidence that *some* EHR systems work quite effectively. To denigrate the early groundbreaking work of David Bates and colleagues is an insult to Dr.… Read more »

Allan
Member
Allan

Dr. Hersh, what is your objection to organic growth of EHR’s, meaning physicians voluntarily use the EHR’s they find of value and when they find it important in their practice of medicine? When fax machines first arrived physicians didn’t run to buy them until the fax machine proved itself valuable.

William Hersh
Member
William Hersh

Read my posting. You may not agree with my answers, but I did answer your questions in my original posting above. To wit, medicine has known safety, cost, and information access problems. There is a line of research from the 1990s showing that EHRs (home-grown, developed by informatics experts, and with focused clinical decision support) can improve on these problems. But this research has failed to translate, in part due to the reasons I described. So the answer is not to give up on trying to fix the safety, cost, and information access problems, but instead to figure out how… Read more »

Allan
Member
Allan

Simplicity would lead one to respond directly to the question asked, but you didn’t respond seemingly preferring your answer to be cloaked in rhetoric. In other words you have unnamed disagreements with the organic growth of EHR’s and prefer them to be imposed from above. That is a problem.

Niran Al-Agba
Member

I am not certain you read my comment either. My position on EHR (you termed it attitude) is that no one should be able to “force” me to change to a inefficient documentation format in order to practice my profession. I did not say your opinion that a “physician-computer-patient” triad does not matter. I disagree with you and do not think you understand the first thing about clinical practice. I understood clearly you are not defending the current clunky, archaic systems used now, however there really is not a “usuable” alternative as of yet. Your deafness to the plight of… Read more »

Res Morgan M.D.
Member
Res Morgan M.D.

Somebody got his fee-fees hurt.

Dr. Niran’s attitude, if you bothered to check her out, is one of complete dedication to her patients, regardless of ability to pay. It speaks volumes that you consider that an embarrassment.

Shame on you.

William Palmer MD
Member
William Palmer MD

Why would we expect something that was not designed for doctors and patients to be particularly useful? After all, its real utility function was to help other stakeholders: cleaning up billing problems, studying costs, making prescriptions easier for the pharmacist to read, helping with inventories, studying public health and population health….essentially helping insurers and health plans and government. The proof is by asking ” were we complaining to one another about our old method of record keeping?” The EHR also obliterates the deeply intimate and personal value of physician note-taking. These styles had much meaning for us. There was great… Read more »

William Hersh
Member
William Hersh

Dr. Palmer,

You are missing my point. In the places where EHRs have been designed with the physician and improving care of patients in mind, they have been highly successful. My whole point is that these best approaches have not been adopted by other institutions, and this is why we have not achieved that translation. We must also not forget the downsides the paper records that I certainly experienced in my career, of records being lost, illegible, or otherwise not available.

Bill Hersh

pjnelson
Member
pjnelson

Increasingly, healthcare reform has focused on the cost and quality issues of the @16 million citizens who represent 70-80% of our nation’s healthcare spending. Meanwhile, we have no means to nationally focus on the equitable availability and ecologic accessibility of each citizen to Primary Healthcare. This process should be community driven to acknowledge the local over-riding social determinants of HEALTH. The actual problem-solving process should be community planned including all of its significant stakeholders and implemented by its institutions already existing. The rate-limited process of the cost and quality problems of healthcare are related to its responsive accessibility. . Remember… Read more »

techydoc
Member

I am not going to address the conspiracy theory presented in the comment, as I think there are more fundamental theories as to why we have not been able to reap the potential benefit of health IT. The two most prominent being: Mal-alignment of business (financial, etc.) incentives and the focus on local optimization (i.e. it is not just a technology solution). Bill touches on the first issue of mal-alignment of business incentives by discussing about volume based payments and its consequence of payment for documentation. While I believe this is the most important mal-alignment, it is not the only… Read more »

pjnelson
Member
pjnelson

The Academy of Medicine, previously known as the Institute of Medicine, substantially funded its TO ERROR IS HUMAN study by donations from General Electric and Cerner. It was done by the Rand Corporation. Ironically, it is the errors of the study that now continues to plague the poorly directed strategy for the reform of our nation’s healthcare industry. . The root cause of root causes for the main problems with our nation’s healthcare reform is that is has no means to fix the turmoil existing between the scientific and the humanitarian realms of knowledge underlying each person’s HEALTH, community by… Read more »