Wednesday, March 18, 2009

A Letter to the Editor

As I've mentioned in several blog postings, we're now living through one of the most exciting times in the history of healthcare information technology. With change comes controversy.

Over the past week, several articles have appeared in the press about the value of electronic health records and their impact on quality/safety/cost. David Bates, Blackford Middleton, and I have been asked to respond to them. Here's one of our upcoming responses.

Dear Editor:

As Harvard Medical School faculty and experts in healthcare information technology, we wish to respond to the March 11, 2009 article "Obama's $80 Billion Exaggeration" by Jerome Groopman and Pamela Hartzband. Our response is below:

"We already have clear evidence demonstrating that electronic records improve care and reduce costs when implemented well in specific settings. Three of many examples include:

1. We (Middleton) have published a detailed case study of the cost and quality benefits of EHR at Family Care of Concord, NH demonstrating net benefits per clinician per year of $30,324. This is comparable to the cost savings we've estimated in our academic health centers.

2. We (Middleton, Bates) have published a cost-benefit analysis of hospital-based provider order entry documenting at net savings of $1.7 million per year from drug dosing guidance, nursing time utilization, and error prevention.

3. We (Halamka, Bates) have documented cost savings from automating radiology and medication ordering processes to significantly reduce utilization, pharmacy costs, and staffing.

Much of this evidence comes from a few sites which developed their own records such as the Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center. Similar benefits should be possible throughout the country, but will require successful implementation and meaningful use of the new technology. Models by the Center for Information Technology Leadership and others suggest that the total financial benefits may be very large.

The United States is behind many other countries in implementing electronic health records. Most other industrialized nations are already using them and getting their benefits. They did this without cost-effectiveness analyses, simply because it was so obvious that there would be important benefits with respect to quality, safety and efficiency. Furthermore, nearly all the major integrated delivery systems have followed suit, such as Kaiser and Geisinger Healthcare System. The Veteran’s Administration system is nearly completely electronic, and that has played a large role in the high quality performance achieved by the VA.

Groopman cites a study which we (Bates, Middleton) did which found that implementation of electronic records was not associated with improved quality across the U.S. However, he did not cite the portions of that article documenting that performance does improve substantially when the right things are included in the record.

The electronic health record represents a transformational change in healthcare, and will enable an array of improvements—although it will not necessarily result if implemented badly. The electronic record is to the paper record as the automobile was to the horse and buggy. No one will want to go back.

President Obama’s incentives should result in a major increase in electronic record adoption in the U.S., and hopefully will bring us past a “tipping point” which will result in nearly complete adoption. This will result in higher quality, safer care, and lower costs. These are goals that all Americans want and can embrace.

David Bates MD, MSc, Medical Director of Clinical Quality & Analysis at Partners HealthCare.

John D. Halamka MD, MSc, Chief Information Officer at Harvard Medical School and Beth Israel Deaconess Medical Center

Blackford Middleton MD, MPH, MSc, Director of Clinical Informatics Research & Development at Partners HealthCare"


Ahier said...

Good letter!!!
It can not be stressed enough that poor implementation will lead to poor results. I am in favor of the incentives, but fear there may not be enough "jump start" funds available for proper deployment.

Joe Weber said...

Physicians will need to pay tens of thousands of dollars for EHRs. Now, taxpayers will pay physicians tens of thousands of dollars to implement these EHRs. There is no question that there will be some benefits resulting from the obvious efficiencies and clinical alerts. But do we really believe that we know how to optimize their impact on quality and cost effectiveness? Might the net effect be an increase in the cost of care without even a commensurate improvement in quality?

Until we know how to deploy EHRs to make healthcare all it can be, why do we want to proliferate these systems? The thinking is that interoperability will solve healthcare's crisis. But ask yourself: When you've received inadequate care, what was the root cause? Was it because your doctor couldn't access the medical record in some other doctor's office? Was it because your doctor did not have access to the relevant clinical knowledge that would have led to accurate diagnosis and/or effective treatment. Or was it because medical science, itself, just does not know enough.

Of those 3 causes for suboptimal healthcare, the first one (lack of EHR interoperability), I believe, is the least impacting. The second one is important. No physician can learn all s/he needs to learn, remember all that was learned, and process/apply it effectively during a brief clinical encounter. So we should clearly enable access, at the point of care, to whatever is currently known by medical science. Not to do so is almost criminal.

The third cause, in my opinion, is actually the most important deficiency in healthcare. Medical science just does not know enough. The reason for this is that it doesn't learn from all of its own experiences. No one is analyzing all the clinical encounters every day, to determine what are the early signs of what eventually become tragic diagnoses. No one is evaluating what treatments actually work best for various conditions, and under what circumstances. Medical science only moves forward via controlled clinical studies, which are too targeted and too expensive. We need to mine the data on actual, routine clinical encounters -- nationwide. If you doubt this, think hormone replacement therapy. (This means that data interoperability, through a controlled clinical vocabulary, is more critical than operational interoperability.)

Once we have determined, through data analysis (controlling for potentially confounding variables), how to diagnose and treat more effectively, we should convert that learning into a "clinical guidance system", operational at the point of care. We would monitor outcomes, so that the system is empirically enhanced -- thereby implementing continuous quality improvement (CQI) in healthcare. That, along with systematization of healthcare delivery, via processes like triage and rational incentives, is the only way that we can prevent the apocalypse.

As the pioneer of System Dynamics once said, "Intuitive solutions to complex problems are almost always wrong." We need to conduct pilots of alternative EHR approaches, analyzing both the financial and clinical outcomes. Let's not throw money at this devastating problem until we know for sure it will buy the cure.

Peter Bachman said...

Patient centric systems will save money, because it will help patients manage their care better. I recently attended HISPC to get security and privacy requirements for patient identity, we are going to be looking at the current system as being akin to pre-internet networking, or pre-ethernet networking. Paper has advantages, being able to transfer 500 thousand records to a recovery site during an emergency evacuation is not one of them. Besides, the last time I saw my primary care doctor, after I told him what was going on, the first thing he did was to Google it. The network has become a transforming force by the use of standards that everyone can use. Expect that same kind of logic applied to EHR/PHR.

AubidadedBallad said...

I personally think its absurd that the decisions made by the higher authority is made, and when it comes down to crunch time, nobody's crunching...
Its beautiful to see Obama saying all that he says, but is it really smart and logical to move by these actions now??
Maybe we should all sit down and think for the future of this country for once, we should end many things and come up with some sense to make this world a better place!!
Medical Aesthetics Position

InformaticsMD said...


you sound like the KOL's in pharma who have been trying to push psychoactive drugs on children.

Your studies are localized, anecdotal, and contradicted by a growing body of literature on the adverse effects of HIT (which will grow faster after the gag clauses and hold harmless clauses in HIT contracts are no longer tolerated).

I suggest you look at Healthcare Renewal blog for an alternate, non Madoff "unlimited returns, no matter what" view.

By the way, I have no financial conflicts of interest with the HIT industry. Perhaps this allows me to more clearly focus my views.

-- SS

InformaticsMD said...

An illustrative post at HC Renewal is here.

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