EHR benefits and costs

In our previous Tech Tools column (“An EHR Primer Part 1: Current laws and incentives,” July 2013 Contemporary OB/GYN) we introduced the concept of electronic health records (EHRs), the associated technology, and the government-supported programs that encourage their use and adoption. In this installment we will review the perceived versus the actual benefits of EHRs and the costs associated with EHR adoption.

When looking broadly at EHR adoption, the move from paper to digital makes sense. The immediate accessibility of patient demographics, pertinent medical problems, and past medical history is an attractive part of almost every EHR. In fact, embedded safety checks reduce the effort needed to find specific information and help minimize physician errors. However, the price of improved efficiency is the cost of learning a new process for patient care. Until an EHR is completely implemented, it can be cumbersome to retrieve information from patients' records in the same time it took in a traditional "pen & paper" office.

EHRs touch many aspects of health care practice, but the 5 areas in which the technology can have a dramatic impact are these:

           1)             Improved Communication

For patients with multiple physicians, an open-architecture EHR can facilitate enhanced provider-to-provider communication. Ideally, these relationships would include a given patient’s pharmacy, hospital, and any other healthcare entity. Similarly, patient and physician communication can be streamlined through direct and secure “web portals” and other methods of safe electronic communications. Patients can then be empowered to manage their healthcare needs by accessing their own health records.

2)            Reduced paperwork for physician and patient

When data-collection systems communicate better with one another, clipboards will begin to disappear, along will the stacks of paperwork exchanged between patient and provider. As more information is entered into an EHR, those data will support a more productive and streamlined encounter between patient and physician.

3)            Streamlined coordination of care

EHR systems will become effective tools to accumulate and share personal health information (PHI), simplifying the sometimes formidable task of coordination of care and reducing medical mistakes. In the future, it would be ideal if all providers could use the same PHI record and, thus access the most current, complete, and accurate data.

4)            Enhanced patient safety

EHRs are ideal for alerting providers to allergies, drug interactions, abnormal laboratory test findings, and redundant test orders. As an EHR becomes more comprehensive and “intelligent,” it can trigger provider-alerts to health safety issues such as newly identified medication side effects, product recalls, and new strategies for disease management and preventive care. Such a system would allow a provider to “preemptively” notify patients of important health issues based on a continual automated process of cross-referencing of their medical histories with the latest medical findings. That could change health care from an encounter- and patient-complaint-driven system of care to a more proactive approach to complete health management.

5)            Patient-controlled direct access to PHI

Patients have a legal right to their health records. In addition, patient portals to the EHR can further improve the accuracy of the PHI by identifying omissions and inaccuracies. Giving patients secure online access to their PHIs can encourage them to proactively follow up on health-related needs. Establishing protocols for this direct access to PHI will empower patients to manage their health care.

When evaluating how EHRs improve efficiency, the Healthcare Information and Management Systems Society, a nonprofit organization dedicated to promoting discussions about health information technology (HIT), describes 5 broad categories of values attributable to HIT investments (eg, EHRs) for which they use the acronym STEPS (Figure 1).¹

By the end of 2013 Q1, the Centers for Medicare & Medicaid Services (CMS) had paid doctors and hospitals more than $13.7 billion to facilitate EHR implementation through the HITECH Act of 2009.² That has spurred doctors to embrace EHRs because most of the government subsidies require continued use. In fact, an Accenture study showed that 93% of American physicians routinely use EHRs, compared with 95% in Spain, 93% in Germany, and 92% in France. Figure 2 illustrates the results of the survey, which included 3700 physicians in 8 countries.³

The Accenture study also revealed a 32% annual increase in routine use of HIT by US physicians, compared with a 15% increase among peers in other countries surveyed. US physicians also had the highest routine use of e-prescribing (65%) and electronic documentation (78%). Most compelling was the finding that 57% of US physicians reported regularly using electronic lab orders-a 21% annual increase versus a 6% global decline.³

A case study by the Commonwealth Fund found that one of the most important factors in building support for an EHR was having clinical staff drive the process and involving as many staff members as possible in its design and development.⁴ Building support among physicians, the authors note, requires "nurtured physician champions" who are either proponents of adopting a comprehensive EHR from the start or become enthusiastic early in the process, and are viewed as having influence over other physicians. The ultimate goal is to aggregate the physician champions with other EHR “supporters” to build clinical teams for EHR development.

The table below is an overview of how some hospitals use their clinical teams.⁴ After Gundersen Lutheran Hospital implemented an EHR, for example, medication errors per 1000 hospital days decreased from 17.9 to 15.4, and the percentage of medication-related injuries decreased from 66.5% to 55.2%.⁵

It appears that more physicians are using electronic resources and that CMS is paying more and more physicians. At the same time, however, due to the inability to adhere to strict requirements of EHR meaningful use, some physicians have stopped accepting Medicare & Medicaid Services. In fact, the large upswing in EHR adoption may be due to hospital-associated adoption. According to the CMS nearly 10,000 physicians who had previously accepted Medicare opted out of the program in 2012, up from just over 3500 in 2009 (out of the 685,000 physicians enrolled last year).⁶

A recent Reuters article recounts the story of a patient-advocate who helped transition a family member from a hospital to a rehabilitation facility. ⁷ During that transfer of care, the patient-advocate noted that the electronic chart that was printed at the hospital had to be retyped into the proprietary system at the rehabilitation facility. During this "repopulation" of the EHR, the patient’s hypothyroidism was mistakenly recorded as hyperthyroidism. The patient could have been prescribed the wrong medication, with disastrous results. The record error led the patient’s family to question the quality of care the patient was receiving. Unfortunately, this anecdote is not unique. Although EHRs can catch dangerous medication interactions and physician errors, they are fallible computer programs. Like paper charts, the information entered EHRs is subject to human error. With an EHR, however, the mistakes may be easier to track.

References

1. The HIMSS health IT value suite. http://www.himss.org/ValueSuite. Accessed August 19, 2013.

2. Sullivan T. EHR incentives surge to $13.7B. May 8, 2013. http://www.healthcareitnews.com/news/ehr-incentive-payments-surge-137b. Accessed August 19, 2013.

3. EMR and HIE use increases among U.S. doctors, Accenture annual survey finds. May 9, 2013. http://newsroom.accenture.com/news/emr-and-hie-use-increases-among-us-doctors-accenture-annual-survey-finds.htm. Accessed August 19, 2013.

4. Silow-Carroll S, Edwards JN, Rodin D. Using Electronic Health Records to Improve Quality and Efficiency: The Experiences of Leading Hospitals. New York: The Commonwealth Fund, July 2012. http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jul/Using-EHRs-to-Improve-Quality-and-Efficiency.aspx. Accessed August 19, 2013.

5. Zlabek, JA, Wickus, JW, Mathiason, MA. Early cost and safety benefits of an inpatient electronic health record. J Am Med Inform Assn. 2011;18(2):169–172.

6. CMS.gov. Research, statistics, data & systems. http://www.cms.gov/Research-Statistics-Data-and-Systems/Research-Statistics-Data-and-Systems.html. Accessed August 19, 2013.

7. Pinsker B. Your Money: Electronic health records still require manual labor. August 12, 2013. http://www.reuters.com/article/2013/08/12/healthcare-costs-electronicrecords-perso-idUSL1N0GA0SE20130812. Accessed August 19, 2013.