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.

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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).


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.”

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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).

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AAFP survey: More family docs using EHRs

By Richard Pizzi, Associate Editor 07/16/07

A recent survey by the American Academy of Family Physicians found that the number of family physicians using electronic health records has risen consistently since the AAFP first began measuring EHR usage four years ago.

Half of the 459 respondents to the 2007 EHR survey reported that they had either fully implemented (37 percent) or were in the process of implementing (13 percent) an EHR system at their practice. The survey was mailed to a random sample of 4,000 active AAFP members in April 2007.

In the organization’s 2005 EHR survey, 30 percent of respondents reported that they were using EHRs in their practices. Only two years previously, AAFP’s survey had revealed that ten to 15 percent of AAFP members had adopted the technology.

AAFP’s current survey indicated that physicians who were most likely to have a fully implemented EHR practiced in an urban area, had practiced for seven or fewer years, did not own their practices, and worked in practices with at least two other physicians.

Steven Waldren, M.D. , director of AAFP’s Center for Health Information Technology, said that the EHR features with virtually universal appeal dealt with managing basic patient data, such as problems, medications and allergies, and with improving efficiency and documentation in the practice.

To this end, 99 percent of respondents in the process of implementing an EHR – and 99 percent of those planning to purchase one – said they were interested in using an EHR to manage patient medication lists, manage patient problem lists and display patient summaries.

Sixty percent of those respondents said they would use an e-mail or secure messaging feature in an EHR, and just 49 percent indicated an interest in using an EHR for practice-based research, according to AAFP.

AAFP also noted the following highlights from the 2007 survey:

• 26 percent of respondents said they planned to purchase an EHR in the future;
• 25 percent of respondents indicated they had no plans to implement an EHR in their practice;
• 53 percent of respondents who did not have an EHR cited cost as the reason; and
• 42 percent of respondents who had not implemented an EHR in their practices said they hadn’t done so because they were concerned about decreased productivity.


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).


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).