There have been a number of research studies published that question the value of Electronic Health Records (EHRs), particularly as it pertains to improving quality of care and ultimately outcomes. Chilmark has always viewed these reports with a certain amount of skepticism. Simple logic leads us to conclude that a properly installed (including attention to workflow and thorough training) of an enterprise software system such as an EHR will lead to a certain level of standardization in overall process flow, contribute to efficiencies and quality in care delivery and ultimately lead to better outcomes. But to date, there has been a dearth of evidence to support this logic, that is until this week.
Yesterday evening the New England Journal of Medicine published the research paper: Electronic Health Records and Quality of Diabetes Care, which provides clear evidence, albeit a little fuzzy around the edges, that physician use of an EHR significantly improves quality metrics over physicians who rely on paper-based medical record keeping processes.
The research effort took place in Cleveland as part of Better Health Greater Cleveland from July 2009 till June 2010 and included 46 practices representing some 569 providers and over 27K adults with diabetes who visited their physician at least twice during the study period. Several common quality and outcome measures were used to assess and compare EHR-based care to paper-based. On composite standards of quality, EHR-based practices performed a whooping 35% better than their paper-based counterparts. On outcome measures, which are arguably more difficult for physicians as patients’ actions or lack thereof are more integral to final outcomes, EHR-based practices still outperformed their paper-based peers by some 15%. The Table below gives a more detailed breakout.
While the authors claim that insurance coverage has little bearing on the final analysis (i.e., Medicare, commercial and Medicaid patient metrics are similar) there is a surprisingly high percentage of patients in paper-based practices who do not have any insurance which makes one wonder: Will future Health Insurance Exchanges (HIX) and the individual mandate, should it survive the Supreme Court, have some bearing on what physician a patient may chose in the future? Will patients migrate to those doctors that use more advanced technologies (EHRs)? Also, there was an abnormally high percentage of patients in paper-based practices that were “Nonwhite” which raises another question: Could those practices that still rely on paper-based processes be in more disadvantaged neighborhoods? If that is indeed the case, will HITECH and its incentives trickle down to this strata of the healthcare sector? All in all though, these are relatively minor points in relation to the broader implications of this paper.
This research paper could become a seminal piece in support of the current administration’s efforts to reform the healthcare sector as it not only supports efforts to digitize the healthcare sector via EHR adoption, but may also provide an added incentive that goes beyond HITECH Act incentive payments.
Throughout the healthcare sector reimbursement models are changing from fee for service to value-based contracts. Such value-based contracts, be they ACOs, PCMHs, P4P, or whatever other acronym you want to throw at it, are accelerating coming not only from the government but also commercial payers. A key component of these value-based contracts is achieving certain quality metrics and moving from episodic care to continuous care models. This research paper is one of the first and most comprehensive that has come across our desks here at Chilmark Research that clearly shows the use of an EHR has a significant impact on key quality measures, in this case diabetes care. While virtually all hospitals are on the HITECH bandwagon, it is less clear just how many private physician practices are jumping in and adopting EHRs for their practices. For many such practices, the HITECH incentive payments may not be enough of a reward for the numerous Meaningful Use hurdles that a physician needs to jump through. But if you hit these physicians directly in their wallet with value-based contracts and they see that EHRs provided demonstrably better quality care metrics, then we may see broader EHR adoption in the ambulatory sector. Bit of a crystal ball forecast, but the logic is there.
Ultimately, what we are seeing happen in the healthcare sector is not dissimilar to what we saw occur in the manufacturing sector. In manufacturing the lag between adoption of enterprise software systems and subsequent increases in productivity has a special term: the “Productivity Paradox,” wherein it was some ten years after wide spread adoption and deployment of these enterprise systems that improvements in productivity metrics could be measured.
Might the healthcare sector have its own paradox? We think so and from this point forward will refer to it as the Quality Paradox.
This study bears out what many observers have said, that there is discernible value in EHR’s.
A key question will be how specialists such as radiologists can take advantage of EHR’s and qualify for meaningful use bonuses (and avoid the penalties). Radiologists have special challenges because many rads practice at multiple sites –making it much harder to prove their meaningful use through one PACS or RIS.
A new article in the Journal of the American College of Radiology, by Murray Reicher, M.D., says a cloud-based ambulatory EHR is probably best for radiologists. Abstract of the paper here: http://www.jacr.org/article/S1546-1440%2811%2900168-2/abstract
Agreed Gregory. This study looks at by and large primary care practices and not specialists and it remains to be seen what improvements in quality may be derived among specialists via EHR use. THere are probably studies now underway, or at least under development that will look at this as well and we’ll have to collectively wait for the release of their results. Thanks for the link to the article on radiologists and we at Chilmark believe that radiologists will not be the only specialty looking to the cloud.
Here’s a bit more detail on the JACR article about radiologists, meaningful use, and cloud-based solutions. Press release from Dr. Reicher’s outfit: http://bit.ly/pwOJEL
I’ll post a link to the article if/when I have it.
The quality paradox will be hard to measure, because in 10 years we’ll have a whole new breed of physician that takes over the reigns of many clinics and can’t imagine a clinic without an EHR (costs, quality or otherwise). I’m sure many of these now young doctors will utilize studies like this to make their case for EHR, but I expect that the new generation will want an EHR regardless.
When was the last time that I wrote a paper instead of typed it? This is the perspective that many of them will take. Of course they want to type it. They don’t want to look at their own handwriting.
Even a new breed of physician John that is more amendable to using IT may still be reluctant to use some of the EHRs out there in the market unless there is value that exceeds risk (or in the case of many a physician, pain in the a**). Therefore, still believe a significant portion of the physician populace, especially in the ambulatory sector will not run out and buy an EHR if it cannot deliver the goods and those goods are improvements in quality metrics which these physicians pay will be increasingly tied to.
[…] Article John Moore, Chilmark Research, 1 September 2011 Article (Cebul 2011) […]
EHRS and Diabetes Care
As regards your excellent post EHRS Delivers the Goods, or at Least the Quality, I’d like to make some comments.
EHRS-Do they serve patients?
There is an Industrial-EHRS Buyer Complex that effectively ‘Feeds the Pig’. I do not use the term in a pejorative way, but rather to characterize how I view the relationships between healthcare providers and organizations that buy HIT systems to do their work and who decide what they want and need- and the EMRS industry that need to give them what they want. It is as simple as ‘Serve the customer what it wants’, a good and necessary business principle.
But, is it good for patients? I think not as though patients are the ultimate beneficiaries of EHRS and providers being only intermediaries, patient’s needs are not fully taken into consideration. When was the last time you received at the end of an EHRS visit a take-home ‘clinical’ summary of your health-facts and disease state in terms you can understand? And I don’t mean an ‘exercise’ or ‘eating healthy in diabetes’ print-out.
We have no healthcare ‘system’. We do have a collage of geographically, and functionally, distributed ‘healthcare deliverers’ with diverse skills and qualifications that work under varying incentives with essentially zero oversight (there is no entity that oversees what any doctor actually does) in highly diverse fields-neurosurgery, internal medicine, etc.
What typically governs provider behaviors are 1) first, do no harm, and 2) don’t get sued and 3) bill to the max After that it’s let me see what I can do for this patient.
I think the industry surrounding HCIT, and the life-of-its-own that HCIT has developed, gets in the way of our recognizing that the written patient record, whether ink on paper-starting with the first notes recorded by a doctor about a patient or bytes in memory, now massive, distributed, and protected, is, individually and collectively all there is that defines and documents a person’s state of health. A person who ‘feels well’ is not necessarily well but a careful analysis of a properly constructed, honest, and complete record could reveal that. Don’t count on doctors to create that record with EHRS systems.
It is the integrity of the record that is paramount, its ‘wholeness’, honesty, and accuracy. EHRS do little to provide that. What is missing from the record is often more important than what is in it. EHRS do little to help that, too.
“For all practical purposes the record is the patient and the patient is the record.”
EHRS contribute to the chaos and disparity of the written record of care and most always create a poor record of care. For example most EHRS enable a provider to generate the most wonderful record of a complete physical that never happened. It just takes a CPE template and a few clicks. It’s often largely boilerplate.
I’ve personally seen letters of consultation from orthopedists obviously armed with modern EHRS that record complete exams that even I as an internist wouldn’t do for a patient presenting with a painful knee. I mean including a complete neurological exam including counting backwards by sevens starting with one hundred? This is a classic example of ‘feeding the pig’ and I do not believe it is an isolated example.
Do we really, really want these EHRS, these bearers of misinformation, talking to each other? Is that productive HIE or cyberclutter?
Modern IT has taken on a life of its own, independent of the patient helping to synthesize records and soon provide the means to scatter the patient record of dysinformation all over providervile.
DIABETES and EHRS
The use of the EHRS in diabetes care is the epitome of the disintegration tool for diabetes care. By providing endless varieties of ‘diabetes’ templates, built-in or provider created, EHRS drive disparity of care by facilitating departure from well accepted standards of medical care, for example the ADA SMCD.
It doesn’t have to be that way, however, but giving doctors control over their practice methodologies is what they want so that is what they get. To give maximum control EHRS provide maximum diversity and become universal care tools serving both acute and chronic disease encounters. Turns out they are poor for chronic diseases like diabetes. Is that good for patients?
Here is what the ADA says about diabetes care in our country. ADA Standards of Medical Care in Diabetes—2011, IX. STRATEGIES FOR IMPROVING DIABETES CARE
“Only 57.1% of adults with diagnosed diabetes achieved an A1C of <7%, only 45.5% had a blood pressure <130/80 mmHg, and just 46.5% had a total cholesterol <200 mg/dl, with only 12.2% of people with diabetes achieving all three treatment goals (381). Moreover, there is persistent variation in quality of diabetes care across providers and across practice settings even after adjusting for patient factors that indicates the potential for substantial further improvements in diabetes care.”
Only 12.2% of diabetics meet just three ADA goals and part of the reason is the variation in quality of care! And now we are going to arm these providers with EHRS that will empower diversity even more.
Why not build into all EHRS chronic disease apps that guide, without forcing, care to core, care standards of medical care? Because, good for patients, not so good for sales.
Finally, the ADA goes on to say:
“While numerous interventions to improve adherence to the recommended standards have been implemented, a major contributor to suboptimal care is a delivery system that too often is fragmented, lacks clinical information capabilities, often duplicates services, and is poorly good for designed for the delivery of chronic care.”
Surely, EHRS industry can address, and solve, the above critical issues by de-fragmenting diabetes care and standardizing, without constraining, diabetes care processes.
I do see the numbers in your Table indicating statistical improvement of the core care diabetes variables. I don’t know if they are real or not, or why they are so.
EHRS are at the DOS stage of software development. We need better GUIs, and chronic disease apps on EHRS screen that implement already existing chronic care algorithms. This can be done without constraining individual provider care decision making but without giving providers the means to treat diabetes any way they wish.
Louis Siegel, M.D., President
'thinking software for patient care'
Lakewood Ranch, FL 34202
We’ve seen the same pattern with the introduction of automation and IT in the legal field. It takes years for newer, younger practitioners to make the use of the technology routine and then for the practice and the technology to be effectively integrated with each other.