The EMR – Value add or not?

A recent opinion piece in the Wall Street Journal this week Obama’s $80 Billion Exaggeration created a veritable firestorm of comments and was possible one of the most active discussions I have seen on one of the listservs I belong to. The writers were responding to the claims made from the recent Health Care Group (also referred to as a summit – but since this did not seem the “highest level” I think group is a more accurate term). The claims:

…the national adoption of electronic medical records — a computer-based system that would contain every patients clinical history, laboratory results, and treatments. This, he said, would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.

As the authors stated there are

there are real benefits from electronic medical records. Physicians and nurses can readily access all the information on their patients from a single site. Particularly helpful are alerts in the system that warn of potential dangers in the prescribing of a certain drug for a patient on other therapies that could result in toxicity

But at issue is do “these benefits translate into $80 billion annually in cost-savings?”. And certainly of more concern were the specific issues of additional errors introduced as a result of these systems and lack of data to support the increase in quality of care post implementation of these systems and after Doctors are burdened with checking off scores of boxes on the computer screen to satisfy insurance requirements, so called “pay for performance.”

But again, there are no compelling data to demonstrate that such voluminous documentation translates into better outcomes for their sick patients. As one commentator put it

I don’t think you can honestly disagree with the comments about the poor signal-to-noise ratio of electronic notes

True and the EMR has the potential like many technologies to increase the noise and make some of the noise poorer quality but this depends very much on the usage and the way in which the technology is incorporated.

There was some suggestion that the major drive behind the changes and the EMR related to fraud and the identification of fraud. This raises some significant concerns on the part of clinicians who already feel challenged by the burden of data capture and entry asides from the need to practice of defensive medicine. The addition of a further level of scrutiny focused on tripping up the beleaguered physician is a major concern. There is fraud and unfortunately a need to search and identify cases but to many upstanding responsible clinicians feels very much like a very broad brush that catches good and bad alike. This report from ONCHIT Report on the Use of Health Information Technology to Enhance and expand Health Care Anti-Fraud Activities (caution pdf) from 2005 estimated that in 2003 $51 Billion was lost to fraud (and could have been as high as $170 Billion). So there is warranted focus on fraud prevention but this should not be a focal point and does create an element of mistrust – the best analogy I can offer is having the IRS providing everyone with personal financial systems to replace Quicken for instance. I suspect many would be uncomfortable trusting the IRS with all our personal data not that we are trying or intending to commit fraud but as we capture and monitor our own finances not all of this information is relevant or something we would want ot share with the IRS.

But putting aside the challenge of fraud systems in EMRs many of the groups and chats I follow most are in agreement that EMR’s offer the potential to improve the quality of care, making it safer and better. But technology is just a part of the equation and just focusing on medication errors misses the bigger picture of fixing the a more systematic approach to the whole process that includes tools, checklists and decision support systems. This was covered in an thoughtful piece in the Journal of the American Medical Association (JAMA) titled: Diagnostic Errors—The Next Frontier for Patient Safety (unfortunately a subscription is required to access the full text) by David E. Newman-Toker, MD, PhD; Peter J. Pronovost, MD, PhD.

it’s high time for diagnostic errors to get the same attention from medical institutions and caregivers as drug-prescribing errors, wrong-site surgeries and hospital-acquired infections (the technological and cultural lower hanging fruit of safety reform)

Many weighed in to say that there was much personal and anecdotal experience to suggest the value that could be linked to some obvious benefits of the EMR associated with easier and more ready access to information – detailed here from one author:

suggesting that EMR’s do not help with diagnostic decision support is overlooking all of our anecdotal experiences….this is not studied well at all, but I think that the most important type of decision support, while not very exciting or complicated, is having all the data at your fingertips. In the past with hit or miss medical record availability, long delays in receiving old records even when available, and illegible notes, clinicians were making both diagnostic and therapeutic decisions on incomplete data. Almost all clinicians that have practiced in a system that can provide old data within seconds as compared to maybe hours to days, if available, feel that they make better  diagnoses and treatment decisions with the availability of that data. This is not something that is easy to prove, but I think that most would agree is true.

This is fair comment and there is data to support the value of EMR’s – this study: RTI Report on Data Quality in EHRs, released nearly 2 years ago (pdf) and the summary here and included some recommendations on how to avoid EHR-mediated fraud.

The consensus was that EMR’s do provide value, just perhaps not $80 Billion savings per year. Questioning the financial justification for investments in these systems is appropriate and the piece in the WSJ article does just that. The authors in this case want more data to justify these large investments and to help derive the most value from the necessary and inevitable changes to our healthcare system

So do EMR’s offer value – absolutely and as patients, clinicians, healthcare professionals we should be asking that this technology is part of what is included in the changes and updates to our healthcare system. Let me know what your experiences are as a consumer of these systems as a patient or healthcare provider – good or bad.