Can the use of Electronic Health Records (EHRs) actually affect health outcomes? That is the hope of the Office of the National Coordinator for Health IT (ONC), who has developed Meaningful Use criteria as part of the ARRA’s HITECH section, which creates incentives for physicians to use EHRs. The Meaningful Use criteria are designed to achieve 3 progressive sets of goals, targeted for 2011, 2013 and 2015. The first set of goals might be thought of as “structural” goals – simply make sure that physicians have “certified” EHRs and are starting to use them. The second set of goals are sometimes referred to as “process” goals – now that you’re using the EHR, show that process improvements are occurring (e.g. doing lab tests or screenings that should affect outcomes). The third set of goals (for 2015) are sometimes referred to as “outcomes” goals – now that you are using EHRs, and are doing the recommended processes, show that all of this makes a difference in health quality outcomes.
But what evidence is there that widespread EHR use can affect outcomes? Some studies in the past have shown that there is not much change in healthcare delivery quality with EHR use, but this results from clinicians not using decision support features of their EHR and not interacting with the EHR during patient encounters. More recently, Kaiser has shown that EHR use, when combined with pro-active Care Coordination, can improve outcomes of patients with chronic kidney disease. This study, however, is hard to reproduce outside the Kaiser system, since the main intervention was to “push” nephrology referrals and intervention onto primary care physicians, prompted only by data rendered by their EHR system that identified at-risk patients. This kind of “referral without asking” is possible in a closed staff-model system like Kaiser, but won’t work in a disparate private-practicing environment elsewhere. So, one might ask, how much of the benefit seen in the study is the result of EHR use and how much is simply the integrated Kaiser system?
A more recent study from Kaiser is more easily extrapolated to the outside world – Kaiser studied osteoporosis screening and intervention for patients who were identified as being at-risk and needing attention. The result was a 38% reduction in hip fractures in 2007, which is very significant. This positive outcome was the result of increased “process” usage, which resulted from their EHR use – there was an increase in annual bone density screenings of 263% from 2002 to 2007, and the number of people on anti-osteoporosis medications increased by 153% during that time frame.
How can these outcomes be realized in a more disaggregated system outside Kaiser? An EHR can generate a list of patients at risk for osteoporosis – not everyone is a candidate for bone mineral density (BMD) screening, but those who are at risk (and who have not had a BMD or are not on anti-osteoporosis treatment) can be identified using a Simple Calculated Osteoporosis Risk Estimation (SCORE). The SCORE test, a simple 6-question test, has been shown to have a 99% sensitivity, and a reasonably good (50%) specificity, in predicting patients with low bone density on BMD analysis – in short, those with SCORE values >6 should have a BMD test done, and treatment would be determined by the BMD result.
SCORE tests can be placed on Personal Health Record (PHR) web sites for patients to self-administer and report to their physicians. These values can also be automatically calculated from existing EHR data (if all the needed data elements exist for the screen), and displayed to physicians in either a report format, or as a prompt on a patient dashboard.
The Practice Fusion platform, which offers hosted, web-based and free EHRs to physicians in all different practice configurations, can create reports such as these – calculating SCORE values on patients in the system (all across the country) and report these to the attending physician (similar to how Practice Fusion made available H1N1 flu vaccination candidate reports in October 2009). In addition, by having a connected PHR/EHR platform, Practice Fusion could offer a SCORE calculator on the PHR side, and thus have any patient-entered results immediately flow to the attending physician.
Such capabilities of EHRs, where process-improvement steps (resulting from central, automated prompting to physicians and patients) can result in measurable outcomes improvement, is in line with the ONC’s vision of EHR deployment across the country over the next several years. Widespread adoption of low-cost (or free) web-based EHRs, when put into practice and used meaningfully, can be the key to truly making a difference.
Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.
But what evidence is there that widespread EHR use can affect outcomes? Some studies in the past have shown that there is not much change in healthcare delivery quality with EHR use, but this results from clinicians not using decision support features of their EHR and not interacting with the EHR during patient encounters. More recently, Kaiser has shown that EHR use, when combined with pro-active Care Coordination, can improve outcomes of patients with chronic kidney disease. This study, however, is hard to reproduce outside the Kaiser system, since the main intervention was to “push” nephrology referrals and intervention onto primary care physicians, prompted only by data rendered by their EHR system that identified at-risk patients. This kind of “referral without asking” is possible in a closed staff-model system like Kaiser, but won’t work in a disparate private-practicing environment elsewhere. So, one might ask, how much of the benefit seen in the study is the result of EHR use and how much is simply the integrated Kaiser system?A more recent study from Kaiser is more easily extrapolated to the outside world – Kaiser studied osteoporosis screening and intervention for patients who were identified as being at-risk and needing attention. The result was a 38% reduction in hip fractures in 2007, which is very significant. This positive outcome was the result of increased “process” usage, which resulted from their EHR use – there was an increase in annual bone density screenings of 263% from 2002 to 2007, and the number of people on anti-osteoporosis medications increased by 153% during that time frame.
How can these outcomes be realized in a more disaggregated system outside Kaiser? An EHR can generate a list of patients at risk for osteoporosis – not everyone is a candidate for bone mineral density (BMD) screening, but those who are at risk (and who have not had a BMD or are not on anti-osteoporosis treatment) can be identified using a Simple Calculated Osteoporosis Risk Estimation (SCORE). The SCORE test, a simple 6-question test, has been shown to have a 99% sensitivity, and a reasonably good (50%) specificity, in predicting patients with low bone density on BMD analysis – in short, those with SCORE values >6 should have a BMD test done, and treatment would be determined by the BMD result.
SCORE tests can be placed on Personal Health Record (PHR) web sites for patients to self-administer and report to their physicians. These values can also be automatically calculated from existing EHR data (if all the needed data elements exist for the screen), and displayed to physicians in either a report format, or as a prompt on a patient dashboard.
The Practice Fusion platform, which offers hosted, web-based and free EHRs to physicians in all different practice configurations, can create reports such as these – calculating SCORE values on patients in the system (all across the country) and report these to the attending physician (similar to how Practice Fusion made available H1N1 flu vaccination candidate reports in October 2009). In addition, by having a connected PHR/EHR platform, Practice Fusion could offer a SCORE calculator on the PHR side, and thus have any patient-entered results immediately flow to the attending physician.
Such capabilities of EHRs, where process-improvement steps (resulting from central, automated prompting to physicians and patients) can result in measurable outcomes improvement, is in line with the ONC’s vision of EHR deployment across the country over the next several years. Widespread adoption of low-cost (or free) web-based EHRs, when put into practice and used meaningfully, can be the key to truly making a difference.
Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.
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