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..)