Electronic Health Record and Eficiency (2)

Part 2.


..Why such inconsistency? Physicians might resent the loss of professional autonomy or have limited tolerance for on-screen prompts. In one survey, 75 percent of physician respondents admitted ignoring reminder icons, and more than half seldom or never acted on the information. The Electronic Health Records also impedes addressing other immediate patient needs in a time-limited office visit.
Electronic Health Records advocates also point to errors of commission. For example, important information might be missing from paper records, including radiology or laboratory tests Accordingly, if inaccessible records are responsible for costly retesting, reductions should be readily achievable. This was not the case at Kaiser Permanente, where "use of clinical laboratory and radiology services did not change conclusively" over a two-year transition to the Electronic Health Records .
Excessive testing could be more a function of defensive medicine, ease, or fear of uncertainty. Electronic Health Records decision support tools—including peer management, guideline promotion, and alerts about cost or redundancy—might reduce this. However, an Electronic Health Records -based decision support system that is cost-saving, generalizable, and sustainable remains elusive. Finally, ancillary testing is an important source of revenue. "Profit center" laboratory or radiology departments will not necessarily welcome Electronic Health Records -based interventions that lead to fewer tests and less revenue.

Storage of other encounter data.
Medical records are notoriously vulnerable to damage or disappearance. Hurricane Katrina’s destruction of Gulf Coast physician office practices has been cited as an example of the need for electronic medical information storage. Yet Hurricane Katrina’s cost was not factored into any of the previous savings estimates; in fact, the president’s endorsement of the Electronic Health Records predated this disaster by more than a year. Furthermore, the history remains a time-honored and reimbursable feature of every physician-patient encounter. Aside from the few situations in which patients are too ill to communicate, patients’ recall of past medical facts is accurate across a wide range of conditions. It is also far cheaper than remote storage. (countinued..Medication error avoidance..)

Electronic Health Record and Efficiency (1)

Part 1.

As noted, the Electronic Health Record’s potential is based on its ability to introduce new efficiencies to health care delivery. Each is examined below :

Worker productivity gains.
One analysis showed that the Electronic Health Record increased documentation time among physicians by approximately 17 percent, while computerized provider order entry (CPOE) increased it by 98 percent. In a separate study, Electronic Health Record implementation at Kaiser Permanente resulted in a 5–9 percent decrease in office visits replaced by telephone contacts.9 Even if future "smart texts" or automated physician orders correct these inefficiencies, it is unclear whether the Electronic Health Record enables gains in provider-to-patient ratios. Rather, these studies suggest that a possible outcome is that the same providers would serve the same patients, with fewer office visits, more remote communication, and more documentation.
However, the Electronic Health Record can enable clerical staff reductions amounting to $13,000 per physician per year.10 For these savings to be realized, staff employment would need to be completely terminated. Although this is likely in outpatient settings, anecdotes of health care systems (where Electronic Health Record's are prevalent) offering displaced workers other employment opportunities (including in IT departments) are commonplace enough to dilute these savings.
Ultimately, if the Electronic Health Record consistently reduced labor costs, lower staffing ratios should enable insurers—representing the "front line" in managing health care costs—to reduce their fee schedules among Electronic Health Record-enabled providers. The same should be true for participants in consumer-directed health plans. There is little evidence that this is occurring among the 17 percent of practices possessing an Electronic Health Record.

Billing optimization.
Not only are the Electronic Health Record’s labor savings questionable, but increased billings are another likely outcome. Thanks to underlying decision logic previously only available to large institutions, the Electronic Health Record can "auto-populate" or scour the record to justify a greater intensity of service. Accordingly, "increased coding levels" account for the return on investment. Alternatively, better "capture of charges" and fewer "billing errors" can lead to a five-year $86,400 "benefit" per provider.
Although additional detail may warrant increased payment, the "content" might be unchanged from the point of view of the patient (the end user). Physicians are prone to under-documentation, but these Electronic Health Record enhancements, appropriate or not, arguably increase health care costs without any corresponding increase in quality.

Medical mistake avoidance.
Electronic Health Record advocates point to "decision support" that reduces errors of omission and commission at the point of care as a critical safety advantage. The Agency for Healthcare Research and Quality (AHRQ) has endorsed several IT interventions that promote patient safety (such as error tracking and alerts about the timing of tests); however, mention of the Electronic Health Record is conspicuously absent. In fact, AHRQ’s "20 tips to help prevent medical errors" also fail to mention the Electronic Health Record, versus interventions such as hand washing or relying on large-volume hospitals for complicated surgeries. The Electronic Health Record’s failure to pass muster with AHRQ’s evidence-based approach to translating research into practice might explain the necessity of funding a large number of projects to better evaluate the Electronic Health Record’s role in patient safety.
Indeed, the available evidence is decidedly mixed. Examples of omission-type error reductions include alerts about vaccination status among children cared for in the emergency department; inpatient vaccination and anticoagulation reminders; diabetes, hypertension, vitamin B12 deficiency, thyroid and anemia screening in the elderly; health maintenance and counseling in a pediatric practice; and hypertension identification and control. However, Electronic Health Record decision support has no effect on adherence to primary care guidelines for asthma or angina management; it leads to "variable" and "limited" adherence to diabetes and coronary artery disease reminders; it has no effect on evidence-based interventions for heart disease and heart failure; it causes no change in the care of patients with depression; it leads to "unwieldy" tracking and monitoring of preventive health and chronic illness; and it has no impact on diabetic glucose control.
Why such inconsistency? (continued..)

The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs

Electronic health record (EHR) advocates argue that Electronic health record's lead to reduced errors and reduced costs. Many reports suggest otherwise. The Electronic health record often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the Electronic health record is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the Electronic health record alone.

The Privacy of Medical Records (2)

Part 2.

The basic solutions that are being proposed are, first, to require record makers and keepers to implement a set of technical steps to protect the security of medical records and, second, to impose penalties on makers and keepers of records who release them for unauthorized or inappropriate purposes. Technical steps being touted include unique patient and access identifiers; "audit trails," which are electronic methods of detecting and recording the identities of anyone who accesses a record; encryption of external transmissions of record information; appointment of internal information security officers with responsibility to police record-keeping practices; and "firewalls," which are electronic barriers that isolate records systems from unauthorized access or penetration.

The Issues
The problem is that these techniques are expensive and no one is sure how well they work. I received a glimpse of how unrealistic these solutions might be at a meeting on medical records privacy I attended as a member of a joint working group of the Joint Commission on the Accreditation of Healthcare Organizations ("JCAHO") and the National Committee for Quality Assurance ("NCQA"), the organization that accredits managed care organizations. One member of the working group, the person in charge of medical records at a large managed care plan, pointed out that neither she nor anyone else in her organization knew what records existed or where they were! She suspected that this was likely to be true of most managed care plans and provider organizations. Moreover, she explained that the greatest single threat to the privacy of medical records was post-it notes: people jotted down their passwords and pasted them on or near their computers. The more passwords, personal identifiers and other electronic steps a person had to take to access records, the more these little reminders would be necessary, rendering the fancy security techniques ineffective.Some of the other issues that are being debated by policy-makers include:

• Whether electronic medical records requiring patient enrollees to authorize each release of medical records or only to require them to give a blanket release, say upon enrollment. Advocates of blanket releases argue that requiring a signed authorization for every record release would be burdensome and most patients don't care. Proponents of individual authorization respond that this is necessary to alert patients that their records are being disclosed so they can take steps to prevent inappropriate disclosures.
• Whether electronic medical records establishing uniform standards or minimum standards. Managed care organizations and other record makers and keepers like uniform standards because it tells them clearly what they have to do. Some patient advocates propose minimum standards to enable plans to compete for enrollees on the basis of how well they maintain privacy: plans that adopted more stringent security measures could publicize this fact to potential enrollees who have a choice of plan.
• Whether electronic medical records to enact a federal law that pre-empts stricter state laws. A uniform law would facilitate interstate business by allowing a managed care plan to comply with one standard nation-wide. But some patient advocates urge that states be allowed to adopt more stringent security requirements, if only to permit experimentation to see what works best at protecting privacy.
• How much electronic medical records control giving patients over what goes in and what stays in their medical records. Most privacy proposals would give patients the right to correct inaccuracies in their records but not to delete material. Some patient advocates argue that patients should have the right to block the entry or remove information that they fear would stigmatize them or lead to insurance or employment discrimination. Health care professionals are concerned that incomplete records could interfere with proper medical management. Patient advocates respond that, so long as the incomplete records are marked as such, patients should be permitted to weigh the risks of stigma or discrimination against the risks of a reduced quality of care.

There is almost certainly going to be federal legislation on medical record privacy. But this will not end the debate. Accreditation organizations such as the JCAHO and the NCQA will establish their own standards; managed care plans and provider organizations will adopt their own internal policies and procedures. Meanwhile, the science of electronic records and their security will develop, presenting new options and challenges. Stand by for further reports.

Maxwell J. Mehlman, J.D.

The Privacy of Medical Records (1)

Part 1

Within the past two years, a substantial amount of attention has been paid to the issue of the privacy of patient records. The Health Insurance Portability and Accountability Act of 1996 required the Secretary of Health and Human Services to make recommendations to Congress on ways to protect the privacy of medical records. Secretary Shalala submitted her proposals to Congress on September 11, 1997. The National Academy of Sciences and the National Association of Insurance Commissioners have issued recommendations of their own. Senator Robert Bennett (R. - Utah) has circulated draft legislation entitled the "Medical Information Confidentiality Act" that may well be the focus of congressional action.Two developments account for this flurry of interest. The first is the growth of electronic medical record-keeping in place of paper records. The National Academy of Sciences report states that the health care industry spent between $10 and $15 billion on information technology in 1996. Much of this expenditure is attributable to creating electronic medical records systems and converting conventionally stored data to electronic formats.
Electronic medical records ("EMRs") appear to present new threats to maintaining the privacy of patient-identifiable medical records. An Electronic medical records can be called up instantaneously by someone with access to the data system and the relevant passwords. Although a paper record can be photocopied and faxed, it is less easy to distribute widely, and requires physical possession for accessibility. Computerized records systems are "black boxes" to many health professionals who are otherwise familiar with traditional records systems; they fear losing control of the systems and having to rely on computer experts who may not have internalized the privacy-related ethics of the medical profession. At the same time, one hears proposals to link all medical records systems so that patient data can be accessed wherever and whenever patients require medical services. This raises the prospect that access to one portion of one record may afford access to all records on an individual.

The Managed Care Conflict
A second reason for the increased concern over medical records privacy is the growth of managed care organizations. In the traditional, fee-for-service model of health care delivery, patient records would be produced and retained by the physician or other provider of services. The patient's health insurer would be given access to selected records needed for claims review. Disclosure of the records required patient authorization, although, typically, patients executed these authorizations automatically and in blanket fashion. In a managed care organization, on the other hand, the provider of care and the insurer, in some sense, are the same entity. Any medical information in the possession of the provider also is held by the insurer. This is clearest in a closed-panel HMO like Kaiser but is present, to a varying degree, in all forms of managed care.The fear here is that the insurer will gain access to medical records that the patient and the provider would not normally transmit and that the insurer will use the data to take action adverse to the patient's interest, such as limiting benefits or terminating the patient's insurance coverage.Special problems are created by employer-sponsored health plans. Here, the plan is essentially the same entity as the employer and the concern is that the employer will have access to medical information possessed by the health plan and will use the information contrary to the employee's interests, such as to terminate employment.The basic solutions that are being proposed are, (continued...)

Why we must invest in electronic medical records (2)

Part 2.

Quite simply, the entire country should have the highest quality care we can afford, along with electronic medical records such as those used by the VA. That's why Sens. Hillary Clinton, D-N.Y., Mike Enzi, R-Wyo., Edward Kennedy, D-Mass., and I are working together to make sure that we do. We've proposed bipartisan legislation that would begin the process of setting up a system that allows data sharing, available everywhere, and protects privacy while rewarding quality.
To begin with, Americans should be able to access their medical records wherever they go. This ranks as a high priority, because existing systems like the VA's are useless outside of the organizations that build them. If two travelers get into a car accident a thousand miles from home, the emergency room they arrive at should be able to access a medical records system that can bring up their full medical history, their allergies and information about the medications they take. Right now, in fact, outdated government regulations stop many hospitals from setting up systems that would do this.
Making such a system available everywhere, however, will take a lot more than computers, satellites and fiber-optic cable. It will also require the government to work with hospitals and doctors to create common terminology for medical records and a common data format for sharing them. Because the federal government pays more medical bills than anyone else, its own health-insurance programs -- Medicare, Medicaid, the Indian Health Service and the State Children's Health Insurance Program -- should help take the lead in promoting the use of electronic health records for beneficiaries.
In addition, my colleagues and I also believe that the electronic medical records system should include legal and technological safeguards to ensure that, except in life-or- death emergency situations, nobody can access a patient's medical records without permission from that patient.
Finally, we should use the improved data we collect to reward quality care. Doctors and hospitals who do a good job should receive extra pay from both public and private insurers and those who experience problems should get help to improve. This should begin to erase many of our nation's disgraceful health-care disparities by raising the quality of care for everyone.
For far too long, America has invested too little in health information technology. It's time for a change. Patients around the country need to become full partners in their own health care and drive the system along. Electronic medical records will help do that. If we create privacy-protected electronic medical records for every citizen who wants them, we will save money and, most important, we will save lives.

William H. Frist

Why we must invest in electronic medical records (1)

Part 1.

At a Department of Veterans Affairs Medical Center just a few miles from my office in the United States Capitol, visitors can see the future of American medicine. Sitting at an ordinary desktop computer, Dr. Ned Evans hits a few keys on the keyboard and clicks his mouse a few times. Sample patient data spill out: X-ray images, lab notes and blood-pressure numbers. "Everything I might want, everything I need, I can see right here," he says. "It's a seamless part of life. It lets me do just about everything better."
And when the New England Journal of Medicine used 11 measures to compare VA patients treated in the VA's own hospitals with Medicare patients treated in a mixture of private and public hospitals, the VA's patients were in better health and received more of the treatments professionals believe they should. According to the VA's own medical professionals, a computer system called Vista is the key to their success. "I'm proud of what we do here, but it isn't that we have more resources," explains Stanford Garfunkle, the director of the Washington VA Medical Center. "The difference is information."
While the VA has invested a lot in its computer system, most hospitals, clinics and doctors haven't invested enough. Among America's important economic sectors, health care spends the smallest percentage of its revenue on information technology -- only about 3 percent. Industries such as banking spend 10 percent or more.
Our underinvestment in health-information technology has dire consequences for all Americans. Researchers at Dartmouth University found that America wastes as much as a third of the $1.8 trillion it spends on medical care -- much of the waste comes from disorganization and lack of information. This, in turn, results in orders for unneeded tests, ineffective procedures and simple human error. Sometimes our failure to use health information technology has deadly consequences. Doctors write about 2 billion prescriptions each year but, because of unclear handwriting, some get filled incorrectly; about 7,000 people die each year as a result. Even worse, enormous disparities exist in the quality of health-care patients receive. Members of some ethnic minorities, residents of rural areas and people with low incomes are more likely to have complex health problems than members of other groups yet are less likely to receive appropriate, high- quality care. At least some of the difference is attributable to the lack of good medical records. So good medical records is important.( countinued..)

William H. Frist

What Are The Potential Health Benefits Of Electronic Medical Record Systems? ( Part 2 )

Using Health Information Technology for short term/long term disease management

Using Health Information Technology for near-term chronic disease management. The U.S. burden of chronic disease is extremely high and growing. In one study, fifteen chronic conditions accounted for more than half of the growth in health care spending between 1987 and 2000, and just five diseases accounted for 31 percent of the increase. Disease management programs identify people with a potential or active chronic disease; target services to them based on their level of risk (sicker patients need more-tailored, more-intensive interventions, including case management); monitor their condition; attempt to modify their behavior; and adjust their therapy to prolong life, minimize complications, and reduce the need for costly acute care interventions.
Electronic Medical Record systems can be instrumental throughout the disease management process. Predictive-modeling algorithms can identify patients in need of services. Electronic Medical Record systems can track the frequency of preventive services and remind physicians to offer needed tests during patients’ visits. Condition-specific encounter templates implemented in an Electronic Medical Record system can ensure consistent recording of disease-specific clinical results, leading to better clinical decisions and outcomes. Connection to national disease registries allows practices to compare their performance with that of others. Electronic messaging offers a low-cost, efficient means of distributing reminders to patients and responding to patients’ inquiries. Web-based patient education can increase the patient’s knowledge of a disease and compliance with protocols.
For higher-risk patients, case management systems help coordinate workflows, including communication between multiple specialists and patients. In what may prove to be a transformative innovation, remote monitoring systems can transmit patients’ vital signs and other biodata directly from their homes to their providers, allowing nurse case managers to respond quickly to incipient problems. Health information exchange via RHINs or personal health records promises great benefits for patients with multiple chronic illnesses, who receive care from multiple providers in many settings.
We examined disease management programs for four conditions: asthma, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes (Exhibit 4 ) and estimated the effects of 100 percent participation of people eligible for each program. By controlling acute care episodes, these programs greatly reduce hospital use at the cost of increased physician office visits and use of prescription drugs. As shown, the programs could generate potential annual savings of tens of billions of dollars. Keeping people out of the hospital is, of course, a health benefit, but we can also expect important outcomes such as reductions in days lost from school and work and in days spent sick in bed.

Exhibit 4 also highlights an important disincentive for health care providers to offer these kinds of services or to invest in Health Information Technology to effectively perform them: The savings come out of provider receipts, as patients spend less time in acute care. This key misalignment of incentives is an important barrier to Electronic Medical Record adoption and, more generally, to health care transformation.
Using Health Information Technology for long-term chronic disease prevention and management. A program of Electronic Medical Record enhanced prevention and disease management should change the incidence of chronic conditions and their complications. We considered cardiovascular diseases (hypertension, hyperlipidemia, coronary artery disease/acute myocardial infarction, CHF, cerebrovascular disease/stroke, and other heart diseases), diabetes and its complications (retinopathy, neuropathy, lower extremity/foot ulcers and amputations, kidney diseases, and heart diseases), COPD (emphysema and chronic bronchitis), and the cancers most strongly associated with smoking (cancers of the bronchus and lung, head and neck, and esophagus, and other respiratory and intrathoracic cancers). Using our MEPS-based model, we estimated how combinations of lifestyle changes and medications that reduced the incidence of these conditions would affect health care use, spending, and outcomes (Exhibit 5 ).
Savings are evenly divided between the populations under age sixty-five and those age sixty-five and older, despite the fact that the older population constitutes only 13 percent of the total. Since chronic diseases are, by and large, diseases of the elderly, a large fraction of the long-term savings attributable to prevention and disease management would accrue to Medicare. Yet, to realize these benefits, people would have to begin participating in these programs as relatively young adults.
We combined the effects of the reduced incidence attributable to long-term prevention and management and reduced acute care due to disease management. We estimated the potential combined savings, again assuming 100 percent participation, to be $147 billion per year.
Realizing the potential of these interventions. Realizing the benefits of prevention and disease management requires that a substantial portion of providers and consumers participate. Since, on average, patients comply with medication regimens about half the time, it is plausible to assume that about half of the chronically ill would participate in disease management programs and, therefore, the health care system would reap about half of the estimated short-term benefits, assuming that Electronic Medical Records systems and community-based connectivity were operational.
Patients comply with their physician’s lifestyle recommendations only about 10 percent of the time. We assumed that in a future with Electronic Medical Records -based reminders and decision support and patient-physician messaging, we could realize at least 20 percent of the long-term benefits shown in Exhibit 5 .
Under these assumptions, the net savings would be on the order of $40 billion per year. We varied the participation in disease management and prevention activities parametrically to show the potential beyond these estimates.

Richard Hillestad

What Are The Potential Health Benefits Of Electronic Medical Record Systems? (Part 1)

Using Health Information Technology for preventive care

Part 1

Beyond safety, the literature provides little evidence about Electronic Medical Records systems’ effects on health. We must, therefore, hypothesize about both mechanisms and magnitudes of effects. We considered two kinds of interventions intended to keep people healthy (or healthier): disease prevention measures and chronic disease management.
These interventions are key to understanding Health Information Technology’s potential. First, they would exploit important features and capabilities of Electronic Medical Records systems: communication, coordination, measurement, and decision support. Second, they are potentially high-leverage areas for improving health care. Physicians deliver recommended care only about half of the time, and care for patients with chronic illnesses absorbs more than 75 percent of the nation’s health care dollars. Third, evidence from regional health information network (RHIN) demonstrations suggests that these are key applications of Health Information Technology.
Using Health Information Technology for short-term preventive care. Electronic Medical Record systems can integrate evidence-based recommendations for preventive services (such as screening exams) with patient data (such as age, sex, and family history) to identify patients needing specific services. The system can remind providers to offer the service during routine visits and remind patients to schedule care. Reminders to patients generated by Electronic Medical Record systems have been shown to increase patients’ compliance with preventive care recommendations when the reminders are merely interjected into traditional outpatient workflows. More systemic adaptation—for example, by Kaiser Permanente and Group Health Cooperative—appears to achieve greater compliance.
We estimated the effects of influenza and pneumococcal vaccination and screening for breast cancer, cervical cancer, and colorectal cancer, using data about the current compliance rate, the recommended population, and the costs. We assumed that the services are rendered to 100 percent of people not currently complying with the U.S. Preventive Services Task Force recommendation. We also applied the health benefit estimates from the literature to this population (Exhibit 3 ). We conclude that all of these measures, except for pneumococcal vaccination, will increase health care use and spending modestly. But the costs are not large, and the health benefits are significant: for example, 13,000 life-years gained from cervical cancer screening at a cost of $0.1–$0.4 billion.

Richard Hillestad