Category Archives: EMR Failure

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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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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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.

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Experts: US electronic health records still a way off

By: Grant Gross 7/06/2007

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.

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IT Executives Offer Advice for Adopting Electronic Records

May 21, 2007

Health IT executives at the Healthcare Information and Management Systems Society’s Virtual Conference and Expo last week gave recommendations on how to institute electronic health record systems most effectively, Computerworld reports.

Detley Smaltz, CIO at the Ohio State University Medical Center, said support teams and user response in the first three months after an EHR system is adopted can “make or break” a project. Project-level steering teams also can help quickly address questions about required changes to business processes, Smaltz said.

Salvatore Volpe, a physician and longtime user of EHRs in Staten Island, N.Y., recommended extensive upfront planning to avoid the “headaches and heartaches” that the projects can cause. Without early planning, physician practices have to pay for EHR software and services before they are ready to use them, Volpe said. He added that vendors typically begin charging users for software and services when a contract is signed, regardless of whether the physicians know how to use the product.

Denni McColm, CIO of Citizens Memorial Health Care Foundation in Bolivar, Mo., advised new adopters of EHR systems to completely eliminate all paper charts once the system has been instituted. “If you don’t, you can never achieve the financial benefits of implementing an EHR,” she said, adding, “Anything that is on paper won’t be available when physicians really need it to make critical decisions.”

Laura Jantos, principal with ECG Management Consultants, urged faster implementation. She said that organizations who quickly adopt EHR systems with extensive functionality will recover from startup financial and productivity losses faster than those moving slowly and trying to lessen the impact of the change (Havenstein, Computerworld, 5/18).


Problems abound for Kaiser e-health records management system

An internal report details hundreds of technical issues and outages

Linda Rosencrance November 13, 2006 (Computerworld) — An electronic health records management system being rolled out by Kaiser Foundation Health Plan/Hospitals has been nothing short of an IT project gone awry, according to sources at the company and an internal report detailing problems with the HealthConnect system.

Questions about the project arose last week at about the same time Cliff Dodd, the company’s CIO, resigned. Dodd stepped down last Monday after another Kaiser employee, Justen Deal, sent a memo to every company worker warning of technological and financial repercussions related to the rollout of the nearly $4 billion system from Epic Systems Corp.

Deal said he also sent letters to Kaiser management expressing his concerns. But in internal memos, officials said they investigated those concerns and denied that the implementation of the HealthConnect system has been a failure.

“In the implementation of a new, large and complex system such as KP HealthConnect, various technical problems are likely to arise, but none that you mention are unknown to KP-IT nor were as insurmountable as you imply,” Mark Zemelman, one of Kaiser’s attorneys, said in a letter to Deal.

Kaiser declined to offer specifics about Dodd’s resignation and whether questions about the project played a role in his departure. Deal, a publication project supervisor in the Health Education and Training Department at Kaiser Permanente’s Los Angeles facility, was placed on paid administrative leave after sending the memo. Deal is not an IT employee, according to Kaiser.

A 722-page internal report obtained by Computerworld details hundreds of technical problems with the system — some affecting patient care — that appear to bear out the concerns of Deal and others in the organization that the system is a failure. The report also contains suggestions on how to fix the problems.

In his memo to employees, Deal pointed to reliability and scalability issues Kaiser faces with its HealthConnect system.

When fully implemented, it is supposed to give more than 100,000 of Kaiser’s physicians and employees instant access to the medical records of some 8.6 million patients, along with e-messaging capability, computerized order entry and electronic prescribing. In addition, the system is supposed to integrate appointment scheduling, registration and billing functions and will offer various features to Kaiser members through

But according to the report, that doesn’t seem to be happening with any degree of regularity.

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What’s Plaguing E-health?

Cultural and cost issues continue to impede adoption of electronic medical records systems, but new approaches may provide relief.

Thomas Hoffman March 26, 2007 (Computerworld) — The new electronic medical records system at Harbin Clinic has the strong support of its CEO, board of directors and chief medical officer. Its technology can improve patient outcomes while saving physicians money. But cultural issues, including resistance from some of Harbin’s physicians, have stretched the implementation from two and a half years to four.

Welcome to the world of EMR, where the best technology and the best intentions come smack up against the inertia of human nature.

Advocates of EMR contend that melding these systems with the work processes of physicians, nurses and administrators can dramatically improve the quality of patient care and cut waste out of health care costs. For instance, by using an EMR system, a doctor can view a patient’s entire medical history, use a rules-based engine to pinpoint potentially harmful drug interactions and receive suggestions for new tests and medications.

Studies have shown that the use of EMR systems can help reduce medical errors, including misdiagnoses and unintentionally harmful prescriptions, leading to fewer accidental patient deaths.

But to date, EMR adoption has been a big challenge in the health care industry. Rome, Ga.-based Harbin Clinic is a case in point. Georgia’s largest privately owned, multispecialty medical clinic has 135 physicians spread out across 20 locations in northwest Georgia and northeast Alabama. With 33 different medical specialties under its roof, ranging from endocrinology to ophthalmology, Harbin has had a tough time getting various specialists to adapt their work processes to accommodate the EMR system from Chicago-based Allscripts LLC that it’s installing. Indeed, the cultural and work process differences among these specialists has made the EMR implementation “more difficult than I would have imagined,” says Harbin CIO Tom Fricks.

However, primary care physicians at the clinic immediately embraced the EMR system, since they found it easier and cheaper to key in patient information than to pay a third party to transcribe dictation, says Fricks. But high-end specialists, such as cardiologists, have been considerably more resistant to learning and using the Allscripts TouchWorks EMR system, says Fricks. Cardiologists “don’t want aggravation in their lives,” he explains.

Despite strong support of the EMR system from Harbin’s CEO, the board of directors and its chief medical officer (who happens to be a cardiologist), the project has dragged on.

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