Ideal Medical Practices

Electronic health records as path to improved outcomes and lower costs is more hype than reality

In short, the most rigorous studies to date contradict the widely broadcast claims that the national investment in health IT—some $1 trillion will be spent, by our estimate—will pay off in reducing medical costs. Those studies that do claim savings rarely include the full cost of installation, training and maintenance—a large chunk of that trillion dollars—for the nation's nearly 6,000 hospitals and more than 600,000 physicians.

But by the time these health-care providers find out that the promised cost savings are an illusion, it will be too late. Having spent hundreds of millions on the technology, they won't be able to afford to throw it out like a defective toaster. Link to WSJ article

 

Health information technology is held up as the means to improve health outcomes and reduced cost of care - we will be able to eliminate redundant tests, share information seamlessly from doctor's office to emergency room to hospital, and we will be able to order just the right tests and stop all this waste and inefficiency.

This message sells very well in Washington DC but fails to resonate with many in the front lines of health care.  Software developers and vendors want market share and have made their systems largely incompatible with others.  Success in this seamless environment appears possible only if one chooses a monopolistic vendor that locks you up in ancient legacy code requiring substantial and expensive work-arounds to achieve desired ends.

Sadly, this myth is translated into major national initiatives helping primary care step up to its role as the foundation of high performing health care.  Primary care has been systematically under-funded relative to its benefit to people and population outcomes.  Starved for resources to help their patients, struggling primary care providers grasp at "meaningful use" and "PCMH" dollars contingent on buying into the boondoggle.

The boondoggle is compounded by the idea that health information technology will somehow produce meaningful patient data for quality measurement and improvement - another point where they hype is far far ahead of the reality.  Producing meaningful quality data from electronic health records is proving a major headache and cost, eating up scarce resources that might have been applied to patient care.

Digitized records have great promise but the current crop woefully under-performs on key functions: true interoperability and ease of use in real patient care.  If our nation wants to improve population outcomes and the experience of care and hopes those improvements lead to reduce cost trends, then we ought to shift our focus to those things we know drive the outcomes:  give more people access to good primary care, support primary care as a career choice, make it easier for primary care clinicians to do the best job they can for their patients, and stop mandating tangential and ill informed mechanisms.

Typical Electronic Health Record Use in Primary Care Practices and the Quality of Diabetes Care: don't count your chickens

From the Annals of Family Medicine May/June 2012:

In this longitudinal observational study of primary care practices, we found that practices using an EHR for a 3-year period had a poorer quality of diabetes care at baseline, did not make more rapid quality improvements than practices using paper records, and had a poorer quality of diabetes care at the 2-year follow-up.  via www.annfammed.org

 

Count me among those hardly shocked. 

Many who advocate the expanded use of health IT appear to believe that health IT itself will catalyze improvements in care. While there may be a few narrow instances where this is the case, we believe that most current health IT systems have a long way to go before they encompass the functionality that would support robust ongoing improvement of care. Additionally, the success of health IT-enabled improvement depends critically on the skills of clinical and administrative staff in primary care settings to understand and use solid improvement methods—methods that need not rely solely on health IT to be effective. (Langley 2007)

 

Too many of the improvement plans I come across rely heavily on the oft-touted benefits of health information technologies.  "We'll use our electronic health record to find gaps in care and this will improve our chronic care outcomes."  or  "With electronic health records we will reduce duplication of services and unnecessary testing and reduce costs."

Maybe.

But the results to date are not as encouraging as some marketing materials would lead one to believe. 

In this controlled study, EMR use led to an increased number of HbA1c and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed. (O'Connor 2005)

 

As you consider interventions to improve outcomes for individuals and populations, consider carefully the strategies you will use to change work flow, who is doing what, and the very nature of the work being done.  To achieve meaningful results we must change the way we work, not merely create an electronic version of the way we have always worked.

There are some good strategies that truly support overstretched and under-resourced primary care practices and their patients, but too many intitiatives just pile on demands, drawing clinicians further away from the people who need their time. (Bodenheimer 2008)

 

L Gordon Moore

Bodenheimer T.  "Transforming Practice" N Engl J Med 2008; 359:2086-2089

Langley J, Beasley C. Health Information Technology for Improving Quality of Care in Primary Care Settings. Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016. AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2007.

O’Connor PJ. “Impact of an Electronic Medical Record on Diabetes Quality of Care,” The Annals of Family Medicine 3, no. 4 (July 1, 2005): 300–306.

Paging Dr Luddite: health information technology, the hype and the reality

My wife handed me the Atlantic article Paging Dr. Luddite.  I felt like I'd die if I had to read yet another article gushing over the wonders of electronic health records and all they are going to do to save health care. I grit my teeth and read it.

While the title imples that the main obstacle to better health care are those luddite doctors, the article is somewhat better rounded.  Sure, there are Luddite doctors resisting EMR adoption, but the real story is more complex.  Much of the current crop of health information technology falls woefully short of the functionality we need.

Everywhere we turn we're given glimpses of the promised land through the lens of those infatuated with technology:

• No matter where you show up, the health care system will have your totally secure records at hand.
• No more unnecessary or duplicate tests - every part of the system will be working off the same data set.
• Patients will be able to communicate their needs via email, secure messaging, video.
• We'll finally be able to roll out standards so that everyone gets the exactly the care they need.

Puh-leeeze!  Some people been drinking the PR koolaid. Time for a dose of reality:

• Most health information technology solutions do not communicate with other vendor solutions, so the silos are still in effect.
• In spite of their own hype, most elecronic health records are trumped up billing engines (as the Atlantic author correctly pointed out) and do not enable the kinds of chronic disease tracking the health delivery system desperately need to better help their patients (sure, they all say they do, but talk to the dissapointed and frustrated practices desperately trying to get reports out of most of them and you'll hear a very different story).
• The impediment to emailing and other virtual communication with doctors is not the electronics - it is a payment system that will not support this mode of communication.
• Guideline driven standards of care are mostly based on studies of people with single conditions and exclude the majority of people with chronic conditions, leaving open the question of best practice standards for the bulk of people who have more than just one diagnosis or condition.

I spent last week with a rural community health center network.  They are one year into implementing a whiz-bang EMR with a great national reputation. 

I listened with horror but not surprize to the woes of the senior clinical management team as they told me that their new and very expensive EMR forced them to run separate reports (from scratch) for each of their nine clinics, separate reports from scratch for each variation in the drug warfarin (there are many), and how the vendor "help desk" has crashed their system multiple times when they come in to "help."  A recent crash lost an entire week of laboratory data which must now be entered anew.

They are unable to get a clean and accurate list of women who are due for a Pap test.  This is due in part to the arcane and difficult workflow processes embedded in the EMR that makes it difficult to use in real time with patients, and in part due to the fact that (like almost every EMR creator) the makers are clueless about serving the real-world needs of practices that want to better manage population health.

And this is one of the "good" EMRs getting all sorts of accolades from folks in D.C. who think that EMRs are going to revolutionize care.

Electronic records hold immense promise.  We need good technology to help us manage oceans of data and help our patients get the care they want and need.  I want to have one that does the things described in this and all the other articles touting the benefits of technology in health care.  Too bad most of the current crop doesn't deliver on the hype.

How odd - the public doesn't necessarily believe that EMRs will improve their care

NPR / Kaiser / Harvard School of Public Health published a poll that shows that, for the most part, the public is on our side.  They believe that “their doctor” is the best to take care of them, make decisions and decide what is the best treatment,  and that  insurance companies and government should stay out of the decision making process.  The poll shows that the public believes that we are trying to keep cost down and that insurance should pay for all services asked for by their doctor.

The poll also shows that the public, as us, believes that just spending money on EMR’s is not going to improve their health or bring cost down; the most important part, it seems, is their relationship with their doctor.

Personally, I think that we should make sure that the government and all powers at be, understand this plain and simple reality.  This poll validates my point that we need to bring our patients into the fray; they should populate the barricades with us.

José E. Batlle, MD
Hoboken NJ