EHRs, Media and Statistics: Misinterpreted Results Skew Understanding

by Jane Sarasohn-Kahn

 

“Electronic Health Records Didn’t Improve Quality of Outpatient Care”

“Electronic Health Records Don’t Lift Care”

“Electronic Records Don’t Always Improve Care”

“No Quality Benefits Seen with Electronic Health Records”

“Electronic Medical Records May Not Live Up to Hype”

So said some of the newspaper headlines about the July 9 Archives of Internal Medicine paper, “Electronic Health Record Use and the Quality of Ambulatory Care in the United States.”

When I read the news coverage emanating from the study, it caught me — and I suppose many of you readers — off guard. I’m not one to bash the mass media, but reporters got this latest study on electronic health records and outcomes wrong. Journalists need a quick course in statistics, and perhaps simple reading mastery, to know the difference between causality and simple association.

A highly credible and switched-on team from Harvard and Stanford universities wrote the study, which the Agency for Healthcare Research and Quality funded. For the study, researchers studied data from the 2003 and 2004 National Ambulatory Medical Care Survey published by CDC. The data set detailed EHR use coupled with 17 ambulatory care quality indicators. These indicators covered medical management of common diseases, antibiotic prescribing, preventive counseling, screening tests and other services. According to the analysis, physicians’ performance on these quality indicators was not associated with the “use” of an EHR system.

All you have to do is read the second sentence in the paper abstract’s background paragraph to realize that the researchers were assessing “the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.” Herein lies the nuance of the study: the authors did not seek to address whether the installation of an EHR would result in better outcomes, as newspapers incorrectly interpreted. They simply sought an association between EHRs and quality of care — and that they did not find.

It’s also important to closely look at the second half of that introductory sentence: the simple phrase, “EHR use, as implemented” (emphasis added). That is the point.

So, before you swallow the mass media line of reasoning that “EHRs don’t work,” take a few minutes to understand what’s really in the study.

Continue article: http://www.ihealthbeat.org/articles/2007/7/31/EHRs-Media-and-Statistics-Misinterpreted-Results-Skew-Understanding.aspx?ps=1&authorid=1572

Rhode Island Awards Bid To Build First-Ever Statewide EHR

July 31, 2007

The Rhode Island Department of Health has awarded a three-year, $1.7 million contract to EDS to design, implement and manage the country’s first statewide electronic health record network, Healthcare IT News reports (Pizzi, Healthcare IT News, 7/30).

The contract could last up to seven years if the state uses all four of the optional one-year extensions, Government Health IT reports.

EDS will use InterSystems’ health care software to build and integrate the system.

The network, called the Rhode Island Health Information Exchange, will consolidate state residents’ health data and provide authorized hospitals, physicians, pharmacists and other health care providers with access to the health records (Wakeman, Government Health IT, 730).

The EHR network will be “developed with strict adherence to patient-consent policies and in conjunction with industry best practices with regard to security and privacy standards,” according to a press release (Providence Business News, 7/30). In addition, residents must give permission before their records are stored on the network.

The health data exchange is expected to go live in summer 2008 (Government Health IT, 7/30).

source: http://www.ihealthbeat.org/articles/2007/7/31/Rhode-Island-Awards-Bid-To-Build-FirstEver-Statewide-EHR.aspx

Vendors dispute EHR, ambulatory-care report

Article published Jul 18, 2007

A report detailing how the use of electronic health records does not necessarily lead to an increase in the quality of care may be misinterpreted by some as proof that EHRs aren’t useful. EHR vendors, consequently, are concerned.

“It’s caused quite a bit of discussion in our industry—to say the least,” said Hugh Zettel, director of government and industry relations for GE Healthcare. “We don’t believe the reporting on it has been accurate relative to the findings of that paper.”

The report, Electronic Health Record Use and the Quality of Ambulatory Care in the United States, appeared in the July 9 edition of the Archives of Internal Medicine, and concluded quite bluntly that: “As implemented, EHRs were not associated with better quality ambulatory care.”

Written by prominent health information technology figures from Harvard Medical School and Stanford University, the study examined records of 50,574 patient visits collected as part of the National Ambulatory Medical Care Survey in 2003 and 2004, and compared how physicians with and without EHRs did on 17 quality measures. The researchers concluded that EHR-using physicians had significantly better scores on only two quality indicators, had no significant difference on 14, and did significantly worse performance on one.

“The result was surprising,” said the study’s lead author, Jeffrey Linder, an assistant professor of medicine at Harvard Medical School and an internist at 746-bed Brigham and Women’s Hospital, Boston. “I was expecting to find that it (EHR use) was associated with better care.”

Linder said that most EHR quality studies have been done at what he described as “benchmark” institutions, and the intent of this study—which was sponsored by the Agency for Healthcare Research and Quality—was to take a more general view of how EHRs were being used across the nation. What the study shows, Linder said, is that with the way EHRs are being used they “are not much more than a replacement for the paper chart.”

“They’re not magic,” Linder said. “You just can’t plug it in, turn it on and watch quality magically improve.”

The two measures that the EHR-using physicians scored significantly better involved avoiding prescribing benzodiazepine to patients with depression and avoiding unwarranted urinalysis testing. The authors were surprised to report that EHRs were associated with worse quality when it came to prescribing statins to treat hyperlipidemia, or high cholesterol.

Linder said that he spent two days in vain trying to figure out that result. “It could be just statistical chance … it could be a statistical anomaly,” he said. “I don’t have a good explanation.”

Zettel disputed some of the findings, saying that GE Healthcare’s own research found that its customers had scores twice as high as those the researchers found on quality indicators relating to aspirin, beta blocker and statin prescribing. “We have a process that allows our customers to show these and other related metrics,” he said.

Mostly, however, Zettel said the findings may be a reflection of when half the data were collected: 2003.

“A lot has changed since then,” he said, and this includes an evolving definition of “EHR.”

According to the report, about 16% of the visits studied from 2003 involved EHRs, as did 20% of the visits in 2004.

Another of the study’s co-authors, Randall Stafford, an associate professor of medicine at Stanford University’s Prevention Research Center, acknowledged Zettel’s arguments, but said the findings point to the need for multidimensional solutions to confront the complex problems relating to healthcare quality. These include a need to look at how healthcare is organized and paid for and how continuity of care is provided for chronic conditions, he said.

“The bottom line is that people have to pay attention to more than just the EHR and to think that the electronic health record will improve quality on its own is ridiculous,” Stafford said. “The electronic health record in and of itself is not going to be adequate.”

Additionally, the report states that “it is worth noting that the performance on most indicators was suboptimal regardless of whether an EHR was used.”

Zettel somewhat agreed with Stafford’s assessment.

“There’s that old axiom that a fool with a tool is still a fool,” he said. “And, if you don’t change your processes, (implementing technology) will just help you make the same mistakes faster and more efficiently.”

Continue article here: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070718/FREE/70718003/0/FRONTPAGE 

Doctor EHR Adoption Could Reach 30% by 2011, Survey Finds

Nearly 18% of U.S. physicians in 2006 had an electronic health record system, and that figure could increase to 30% by 2011, according to a new survey by the Millennium Research Group, United Press International reports.

However, the survey also found that most nonhospital-affiliated small practices will find it difficult to afford the technology and justify the disruption it will cause the practice. Small practices that are not affiliated with hospitals represented nearly 70% of all office-based physicians in 2006.

This will remain true for small practices despite government efforts to aid in the adoption of health IT. However, those efforts, such as allowing hospitals to help affiliated physicians by donating or subsidizing the cost of EHR systems, will help drive growth, the survey suggested (United Press International, 7/17).

Find article here: http://www.ihealthbeat.org/articles/2007/7/18/Doctor-EHR-Adoption-Could-Reach-30-by-2011-Survey-Finds.aspx

Study: EHR System Efficiencies Can Cover the Cost of Adoption

July 13, 2007 iHeathbeat

Electronic health record systems in less than two years after adoption can create enough cost reductions to pay for the cost of the systems, according to a study published in the July issue of the Journal of the American College of Surgeons, HealthDay News/Forbes reports.

David Krusch, the author of the study, and his colleagues at the University of Rochester analyzed the return on investment of EHR systems at five ambulatory offices representing 28 health care providers. The study compared the costs of tasks — such as pulling patient charts, creating new charts, filling time, support staff salary and data transcription — in the third quarter of 2005 to costs in Q3 2003 when the EHR system was not instituted.

Using EHRs reduced costs by almost $394,000 annually, and nearly two-thirds of the savings were associated with reducing the amount of time for manually pulling charts, the study found. The EHR system in the first year cost $484,577 to install and manage, which means the hospital recouped its investment in the system within the first 16 months.

The system after the first year cost about $114,000 annually to operate, which means a yearly savings of more than $279,500, or almost $10,000 per provider using the system, the researchers found.

“Health care providers most frequently cite cost as a primary obstacle to adopting an [EHR] system. And, until this point, evidence supporting a positive return on investment for [EHR] technologies has been largely anecdotal,” Krusch said (HealthDay News/Forbes, 7/12).

Article: http://www.ihealthbeat.org

Federal IT Group To Study Secondary Uses of Health Care Data

The American Health Information Community Consumer Empowerment Workgroup on Wednesday said they would continue to study the policy issues related to secondary use of health care information, Healthcare IT News reports.

Karen Bell, director of HHS’ Office of IT Adoption, said now is the time to tackle the issue because electronic health record adoption still is low and personal health records do not yet contain much clinical information. “I think we are recognizing that we’re not even close to finding all the answers on this,” Bell said.

Charles Safran of Harvard Medical School testified before the work group on secondary uses of health data. “We believe there is tremendous value in secondary use of health information,” he said, adding, “It’s so important to national health, but we need to have better guidelines on how this information should flow.”

Guaranteeing the privacy of health data is key to winning public trust, and the technology has outpaced policies and procedures so far, Safran said. He added, “The public is woefully unaware to what is happening to their data.”

July 13, 2007 iHealthbeat

Nancy Davenport-Ennis, co-chair of the work group and executive director of the National Patient Advocate Foundation, said the group initially will focus on determining who owns the data. She added that the group should look into how to regulate a violation of stewardship over the data, how to protect consumers and how to provide incentives to consumers who make lifestyle chances based on the data collected.

In addition, the Agency for Healthcare Research and Quality recently requested information on the idea of national stewardship over the secondary use of data (Manos, Healthcare IT News, 7/12).

Article: http://www.ihealthbeat.org/

Analysts: Microsoft, Google Could Prompt Disruptive Change

July 11, 2007 – http://www.ihealthbeat.org

Analysts-Microsoft-Google-Could-Prompt-Disruptive-Change.aspxRecognizing that many Internet searches are related to health care, Google and Microsoft are working to build a presence in the health care industry, Government Technology reports. The move could significantly impact health care professionals and medical device manufacturers, according the Wireless Healthcare, an analyst group in the United Kingdom.

Google’s recent investment in the genetic profiling company 23andMe and Microsoft’s purchase of the medical search company Medstory could result in new services that are disruptive to the industry, according to Wireless Healthcare.

“We are seeing the emergence of a new e-health model that challenges some the assumptions made by existing online health care providers and medical device manufacturers,” Peter Kruger, an analyst with Wireless Healthcare, said. He added, “This new model impacts not only on how diseases are diagnosed but also the way health care is delivered and e-health services are funded.”

Kruger noted that Internet search engines currently profit mostly from advertising, which is unlikely to be the funding model used for online health. “Advertising and health care do not mix well and this issue is already proving to be controversial,” he said, adding, “I am sure that regulators would be unhappy if banner advertisements started to appear on a patient’s online medical record or diagnosis.”

Wireless Healthcare in a report details a number of funding models already used by companies marketing health care devices and services to the growing demographic of consumers ages 40 to 59 years old. Kruger in September will present research on new models for online health care at a conference in San Francisco (Government Technology, 7/10).

Article: http://www.ihealthbeat.org/

Electronic Health Records Didn’t Improve Quality Of Outpatient Care

Stanford University Medical Center July 11, 2007

Science Daily — STANFORD, Calif. — Electronic health records have been hailed as a key element in making U.S. medical care more effective and efficient, but a new study led by a researcher at the Stanford University School of Medicine shows that electronic records were not associated with improved quality of outpatient health care in 2003 and 2004.

Of 17 quality indicators assessed by the study, electronic health records made no difference in 14 measures. In two areas, better quality was associated with electronic records, while worse quality was found in one area.

Senior author Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center, said that given the overall mediocre performance of physicians in the 17 quality indicator areas, he and his colleagues had expected better quality from doctors using electronic records.

Stafford said the study doesn’t discount the value of electronic health records, but points out that the entire health-care system needs to embrace the concept of improving the quality of care delivered in clinic and office visits.

“We need to be cautious about the assumption that electronic health records are going to solve problems around health-care quality by themselves,” Stafford said. “It’s not sufficient to have an electronic health record system that provides readily available patient data and decision-making guidance. Physicians have to be receptive to that input and willing to act on that input.”

The study, produced by a team of researchers from the Stanford and Harvard medical schools, will be published in the July 9 issue of the Archives of Internal Medicine.

The 14 quality indicators for which electronic records made no significant difference included such factors as prescribing recommended antibiotics; diet and exercise counseling for high-risk adults; screening tests; and avoiding potentially inappropriate prescriptions for elderly patients.

In two quality areas – not prescribing benzodiazepine tranquilizers for patients with depression, and avoiding routine urinalysis during general medical exams – doctors using electronic record systems fared better than those who didn’t. But when it came to prescribing statins for patients with high cholesterol, physicians using electronic systems did worse.

Continue article here: http://www.sciencedaily.com/

Experts: US electronic health records still a way off

By: Grant Gross 7/06/2007 www.intergovworld.com

U.S. President George Bush’s administration gets high marks for its vision in pushing electronic health records, but the U.S. is far from implementing a national health IT system, according to an author of a government report released Thursday.

Although the U.S. could see significant benefits from more use of IT in the health-care industry, including fewer deaths from medical errors, more work needs to be done to create standards for electronic health records and other health IT initiatives, said David Powner, director of IT management issues for the U.S. Government Accountability Office (GAO).

The U.S. government still faces an “enormous challenge” in getting electronic health records to patients, Powner told the U.S. House Committee on Government Reform.

Asked to grade the Bush-created office of the National Coordinator for Health Information Technology, Powner gave the office an “A” for leadership and vision but an incomplete grade for implementation. In January 2004, Bush called for the U.S. health-care industry to embrace electronic health records, with the records available to all U.S. residents by 2014.

Powner’s report to the committee called for the Bush administration and the U.S. Department of Health and Human Services to push for health IT standards that don’t yet exist. “Otherwise, the health care industry will continue to be plagued with incompatible systems that are incapable of exchanging key data that is critical to delivering care and responding to public health emergencies,” Powner wrote.

The Bush administration is working toward setting standards, said Dr. David Brailer, the national coordinator for health IT in the U.S. Department of Health and Human Services. Next week, Brailer’s office will announce a federal government partner to harmonize health IT standards, he said.

In addition to standards, the cost of implementing electronic health records, and a lack of technical expertise, is holding up adoption at many small health-care facilities, Brailer told the committee. While existing research has sent “mixed signals” on the ability of electronic health records to cut costs, health IT can “save lives, improve care and improve efficiency in our health system,” he said.

Part of his office’s job is to convince health-care providers and patients of health IT’s benefits, Brailer added. Some health-care providers have been slow to adopt electronic health records because they’re paid per patient visit, and they aren’t paying the bills, he said. “It is against the financial interest of many providers to improve quality or to improve efficiency, because we pay by volume, and greater efficiency and quality, by definition, reduce volume,” he said.

Committee member Jon Porter, a Nevada Republican, said he plans to introduce legislation in the next couple of weeks that will require electronic health records for people using U.S. government health insurance coverage. With about 9.5 million members on the federal health plan, the requirement would push adoption to the private sector as well, Porter said.

Porter repeated concerns that the lack of electronic health records is adding to medical errors. “We are so far behind in our technology, we are costing lives of many Americans,” he said.

In 1999, the Institute of Medicine, a nonprofit health analysis organization, issued a study saying between 44,000 and 98,000 U.S. residents die each year due to medical errors.

Continue article here: http://www.intergovworld.com/

Return on Investment Does Not Drive EHR Adoption in Hospitals

The adoption of electronic health record systems is not being driven by a return on investment in hospitals and physician practices, Pat Wise, vice president of Healthcare Information Systems at the Healthcare Information Management and Systems Society, said, Healthcare IT News reports.

Wise said that although ROI could be measured as a result of adopting EHRs, many health facilities that do not use EHRs do not seem to recognize their importance.

“There is a real business case to be made for [EHRs], but the word has not gotten out,” Wise said, adding, “More organizations need to know that [EHRs] are a better business practice.”

She cited examples, such as Evanston Northwestern Healthcare in Chicago, which had a $2.5 million increase in revenue because of improved charge capture from its EHR system. In addition, North Fulton Family Medicine in Georgia has saved $775,000 in transcription costs after adopting EHRs in 1998, and it also saves $275,000 annually because of the system.

Wise added that most health facilities have adopted EHRs to improve patient care and workflow management, and surveys indicate that “a large percentage of physician practices that don’t have [EHRs] have no intention of implementing them in the near future,” she said (Pizzi, Healthcare IT News, 6/27).

Article: http://www.ihealthbeat.org