Trying to understand the relationship between Electronic Health Record (EHR) usage and health care quality can be confusing. Multiple reports show seemingly conflicting results. A recent study out of Harvard looking at EHRs in hospitals (not ambulatory settings) showed no significant benefit in health outcomes. This would seem to confirm older studies that showed minimal benefit from EHR-based clinical decision support when clinicians do not interact with the EHR during patient visits.
On the other hand, two studies by Kaiser showed significant benefit from EHR usage when combined with systematic care coordination – one study showing benefit for patients with chronic kidney disease, and another showing benefit for patients at risk for osteoporosis.
Another more recent study by the Group Health Cooperative, in the Seattle area, showed that implementation of the Patient-Centered Medical Home model of organizing health care delivery – which includes maximization of the use of e-health technologies – results in significant improvements in quality, satisfaction and cost. Investing in primary care physicians, physician assistants, and nurses resulted in breaking-even from a cost standpoint due to reduced downstream utilization costs (emergency room and urgent care visits were reduced 29%, and inpatient stays for patients with chronic conditions were down 11%). Quality improvement measures were 1.6 times greater across 22 measures than in controls. And satisfaction – both patient satisfaction and care-team work satisfaction – were improved in this coordinated-care setting.
Another study, focused on controlling utilization cost increases for ambulatory radiology services, showed that when Computerized Order Entry (CPOE) is combined with Integrated Decision Support, a significant “bending of the curve” was seen over a 7-year study period.
So how do we reconcile these seemingly contradictory findings? Firstly, it is clear that a tool by itself does not change much – it is how the tool is used that counts. A “power tool” (like an EHR) can be dramatically superior to “hand tools” (paper medical records) if put in the hands of a worker who knows how to use them – there is a learning curve and a cost involved (which is minimal with a free EHR such as Practice Fusion), but once implemented “meaningfully” the resulting improvement in the quality and consistency of the end-product advances to a whole new level.
All of the studies showing improvement in outcomes as a result of EHR use are in settings where e-technologies were used effectively in a coordinated health delivery system. Depending on the tool used, this sort of “systemness” can be made available to individual physicians – cloud-based EHRs can help physicians achieve some of the benefits otherwise only seen in more formally-structured settings, such as Kaiser or Patient-Centered Medical Home clinics.
Demonstrating quality improvement in hospital settings is more difficult to show. For one thing, a hospital setting focuses on an acute episode of care, whereas ambulatory care settings are more longitudinal. The benefits from EHR use are seen best in ambulatory settings, where hospital use is avoided by keeping populations healthier. Largely because of the highly complex nature of the inpatient setting, and the systems developed to address them, EHRs in inpatient settings will have difficulty showing benefit – this was the subject of a recent blog article of ours.
The Office of the National Coordinator (ONC) for Health IT is betting heavily on the use of EHRs, with the hopes that health outcomes will improve as a result of Meaningful Use. How this federal support and incentive for EHR usage by physicians becomes implemented is very important – the Medical Group Management Association (MGMA) recently warned that poor implementation of EHR incentives might squander the available resources and not achieve the goal. But, if EHRs are widely used (especially in an ambulatory setting), and become a tool that helps deliver care in a coordinated fashion (as shown by the studies referenced above), then the kinds of healthcare quality improvements that are hoped-for will actually become a reality – a future where we all look back and think, “I can’t imagine doing without an EHR.”
Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.
On the other hand, two studies by Kaiser showed significant benefit from EHR usage when combined with systematic care coordination – one study showing benefit for patients with chronic kidney disease, and another showing benefit for patients at risk for osteoporosis.Another more recent study by the Group Health Cooperative, in the Seattle area, showed that implementation of the Patient-Centered Medical Home model of organizing health care delivery – which includes maximization of the use of e-health technologies – results in significant improvements in quality, satisfaction and cost. Investing in primary care physicians, physician assistants, and nurses resulted in breaking-even from a cost standpoint due to reduced downstream utilization costs (emergency room and urgent care visits were reduced 29%, and inpatient stays for patients with chronic conditions were down 11%). Quality improvement measures were 1.6 times greater across 22 measures than in controls. And satisfaction – both patient satisfaction and care-team work satisfaction – were improved in this coordinated-care setting.
Another study, focused on controlling utilization cost increases for ambulatory radiology services, showed that when Computerized Order Entry (CPOE) is combined with Integrated Decision Support, a significant “bending of the curve” was seen over a 7-year study period.
So how do we reconcile these seemingly contradictory findings? Firstly, it is clear that a tool by itself does not change much – it is how the tool is used that counts. A “power tool” (like an EHR) can be dramatically superior to “hand tools” (paper medical records) if put in the hands of a worker who knows how to use them – there is a learning curve and a cost involved (which is minimal with a free EHR such as Practice Fusion), but once implemented “meaningfully” the resulting improvement in the quality and consistency of the end-product advances to a whole new level.
All of the studies showing improvement in outcomes as a result of EHR use are in settings where e-technologies were used effectively in a coordinated health delivery system. Depending on the tool used, this sort of “systemness” can be made available to individual physicians – cloud-based EHRs can help physicians achieve some of the benefits otherwise only seen in more formally-structured settings, such as Kaiser or Patient-Centered Medical Home clinics.
Demonstrating quality improvement in hospital settings is more difficult to show. For one thing, a hospital setting focuses on an acute episode of care, whereas ambulatory care settings are more longitudinal. The benefits from EHR use are seen best in ambulatory settings, where hospital use is avoided by keeping populations healthier. Largely because of the highly complex nature of the inpatient setting, and the systems developed to address them, EHRs in inpatient settings will have difficulty showing benefit – this was the subject of a recent blog article of ours.
The Office of the National Coordinator (ONC) for Health IT is betting heavily on the use of EHRs, with the hopes that health outcomes will improve as a result of Meaningful Use. How this federal support and incentive for EHR usage by physicians becomes implemented is very important – the Medical Group Management Association (MGMA) recently warned that poor implementation of EHR incentives might squander the available resources and not achieve the goal. But, if EHRs are widely used (especially in an ambulatory setting), and become a tool that helps deliver care in a coordinated fashion (as shown by the studies referenced above), then the kinds of healthcare quality improvements that are hoped-for will actually become a reality – a future where we all look back and think, “I can’t imagine doing without an EHR.”
Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.
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2 comments:
I appreciate your balanced statements. Earlier studies showing improved patient safety and quality were from institutions with long standing home-grown EHRs and a history of IT adoption. This translates poorly to small rural hospitals and/or clinics.
That being said, the transition from paper to electronic health records is inevitable for many, just like digital libraries and the move from typewriters to word processors. If we create very user friendly applications with clinician input we should be ok.
We are still in our infancy in terms of clinical decision support, so we can expect improvement as we get better with alerts and reminders. Also, as artificial intelligence gets smarter (no pun intended) clinicians in the trenches will likely find this useful.
The Chinese have a symbol that stands for both danger and opportunity. I believe I will post that on my laptop
Bob Hoyt MD
Federal funding may be encouraging a move toward EHR, but there's more to it than just installing systems. How can healthcare data pooling lead to a better system? More at http://www.healthcaretownhall.com/?p=1499
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