EHRs and Patient Safety – a reply to a #medlibs chat

Last Thursday Jon Goodell (@jonspoke) mentioned that EHRs can worsen pateint safety and posted a JAMA article from 2005 http://jama.jamanetwork.com/article.aspx?articleid=200498
I knew we had used newer things in a class presentation earlier this year in my Clinical Information Systems class. While our talk was mainly about EHR costs, safety was a big part of that since poor safety records are costly. There are a few places where mention is made of figures from the presentation, but we pulled them from the articles mentioned so you should be able to see them. My team mates, Michelle Tellez and Spoorthi Velagapalli, were great to work with and it was an enlightening project.
I hope the following from our presentation is helpful:
How can an Electronic Health Record system reduce expenditures?
There have been many reasons given for why EHRs will reduce expenditures and increase profits for those who use them.
• A good system adds value to the organization by allowing the organization to do things it could not do before. It expands the business possibilities and recognizes that data and information are an organizational asset.
• Quality based interventions should improve outcomes that translate into savings.
• Worker productivity gains – computers are fast and accurate so worker using them are expected to be more productive
• Billing optimization -More complete documentation of patient encounters potentially allows visits to be billed at a higher level of service.
• Storage of other encounter data – lots of information can be stored and retrieved, decreasing redundant tests and studies. Decrease storage space for paper files, easy to retrieve in an emergency such as Katrina.
EHR can help improve the culture of safety
• Malpractice reduction because there are fewer errors and better documentation.
• Medication error avoidance through alerts, decision support and CPOE.
• Medical mistake avoidance – decision support would decrease the errors of omission (forgetting to do something like vaccines) and those of commission (doing the wrong thing like the wrong medication).
• Impact on outcomes -outcomes research savings in chart reviews and timely updating of charts.
• Increasing number of patients enrolled in research – EHRs can compile lists of patients eligible to participate in clinical research to improve treatments.
• Provider profile and reputational incentives – EMRs can be used to track how well providers adhere to quality standards proposed in Meaningful use requirements. Those providers who do better will have better reputations with patients and the institutions they work for.
However, the reality is not quite what was predicted…
• Quality based interventions that measure “quality of life” or “years of life” have not translated into actual cost savings.
• Clerks may become more efficient but some may lose their jobs as clinicians do most of the entry of data. MDs may be less efficient as it take longer to record encounters, many cannot type as well or do not feel as comfortable with computers (Maybe this is this an age factor)
• Studies are suggesting that lawsuits are more likely associated with bed-side manner than with the errors themselves, so malpractice is not reduced.
• Medication error avoidance works in some cases but new sets of errors (unintended consequences) have appeared.
• Medical mistake avoidance -AHRQ did not include EHRs as one of the 20 tips to decrease errors… it did not pass its threshold.
There many important unintended consequences, such as:
• more/new work for clinicians;
• unfavorable workflow issues;
• never ending system demands;
• problems related to paper persistence;
• changes in communication patterns and practices;
• negative emotions;
• generation of new kinds of errors;
• unexpected changes in the power structure; and
• overdependence on the technology.
Others have found that as currently implemented, hospital computing might modestly improve process measures of quality but it does not reduce administrative or overall costs. (Himmelstein Du, Wright A, Woolhandler S. 2010)
Sidorov suggest that there is too much bias on the research
Renner is a 1996 article predicted that – The benefits and the costs often include intangibles that are difficult to quantify i.e. the qualitative benefits associated with computerizing clinical information(Renner, 1996).
While Wang and el attribute the conflict to underlying assumptions in calculations can cause significant variation in whether EMRs results in net expense or profit (Wang, et al., 2003).
One of the common comments when looking at costs is that EHRs have not actually been proven to have positive outcomes. A recent systematic review showed that most articles on health information technology do show improvement for various measures. Some of these measures cannot be factored into cost calculations, but they must always be an underlying consideration when looking at total costs of setting up EHRs and other computerized health systems.
But there are newer studies that show benefits over time.
A recent article by Colene Byrne and a group from The Center for IT Leadership looked at the value of the investment the Department of Veterans Affairs has made in information technology. While the VA spent proportionately more on IT than the private health care sector spent, it achieved higher levels of IT adoption and quality of care. This graph from the article shows that a higher percentage of diabetic patients in the VA system received the tests necessary for their chronic condition, and a smaller percentage had their HbA1c levels under poor control, compared to the private sector comparisons with similar IT in place.
This graph from the same article shows the costs and benefits. The gross value of the VA’s investments in VistA applications was projected to be $7.16 billion. Cumulative reductions in unnecessary care attributable to prevention of adverse drug event-related hospitalizations and outpatient visits as a result of VistA was the largest source of benefit in our projections, with an estimated value of $4.64 billion, or 65 percent of total estimated value.
Zlabek, Wickus, and Mathiason found that the number of laboratory tests per week per hospitalization declined from 13.9 pre-EHR to 11.4 in the 9 months after CPOE implementation, a decrease of 18.0% (p<0.001). There was also a decline in radiology examinations and medication errors. They concluded "Implementation of a commercially available inpatient EHR with CPOE appears to have quickly reduced cost of care and improved safety in our hospital."
Lapoint, Mignerat, and Vedel (2011)
Did a lit review and found a very limited number effects of EHRs are being explored and confounding factors in HIT cost research are not being controlled for (e.g. measurement errors, time lags, financial benefit redistribution, and management characteristics).
A wider range of variables need to be included and measured in the cost models, implementation characterization accounted for, multiple levels of perspective (individual, group and organizational) and multiple stakeholder perspectives (managers, health professionals and patients) must be included in the analysis.
The authors feel that too many studies don't look at all the areas where there are costs and benefits from EHRs. Costs need to be considered in context and in relation to efficiency, quality, outcomes, access, accessibility, compliance, and overall success for research findings to be really meaningful to clinical practice
This figure from Lapoint, Mignerat, and Vedel show the stakeholder of the overall success of the EHR. Each group of stakeholder has a different set of needs and perspectives on what consist a benefit or a cost.
As an example we could say that
Administrators may focus on efficiency of reporting and billings cost reduction
While health care professionals are more focused on quality of care, flexible workflows, UI, etc
And patients want to be empowered, maintain privacy and receive high quality care…
From your stake holder perspective what are the costs and benefits of the wide spread use of EHR?
Some studies are showing better patient care using techniques that are only possible with EHRs. Jackson, Casy, Frieder, and Schaeffer found that data mining derived algorithms improved empirical antimicrobial therapy in outpatients with urinary tract infections.
It is hard to find exact costs for some factors that impact the bottom line, like patient satisfaction, but they need to be considered as well. Kazley, Diana, Ford, and Menachemi found that EHRs improved 3 of 10 measures of patient satisfaction, including how the patient rated the hospital and if they would recommend the hospital. Both of which are hard to place a value on.
Final thought: "My own personal experience in switching my practice from paper to EHRs showed that the change requires some initial effort; however, it did not interrupt work flow in the clinic. The results are better care for patients and new opportunities for the physician and staff to improve quality outcomes." Surgeon General Regina Benjamin, M.D
Dr. Benjamin switched to EHRs in her Gulf Coast Alabama family practice after two hurricanes and a fire destroyed the clinic's paper records.
(Quote from a March8, 2011 press release : http://www.hhs.gov/news/press/2011pres/03/20110308a.html)
References
1. Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). 2011;30:464-471.
2. Byrne CM, Mercincavage LM, Pan EC, Vincent AG, Johnston DS, Middleton B. The Value From Investments In Health Information Technology At The US Department Of Veterans Affairs. Health Aff. 2010;29:629-638.
3. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13:547-556.
4. Gardner E. Trial runners. A two-physician practice goes on a roll with its EHR, generating extra revenue from clinical trials. Health Data Manag. 2009;17:44, 46.
5. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005;24:1103-1117.
6. Himmelstein DU, Wright A, Woolhandler S. Hospital Computing and the Costs and Quality of Care: A National Study. Am J Med. 2010;123:40-46.
7. Jackson HA, Cashy J, Frieder O, Schaeffer AJ. Data mining derived treatment algorithms from the electronic medical record improve theoretical empirical therapy for outpatient urinary tract infections. J Urol. 2011;186:2257-2262.
8. Kazley AS, Diana ML, Ford EW, Menachemi N. Is electronic health record use associated with patient satisfaction in hospitals? Health Care Manage Rev. 2012;37:23-30.
9. Lapointe L, Mignerat M, Vedel I. The IT productivity paradox in health: A stakeholder's perspective. Int J Med Inf. 2011;80:102-115.

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2 Responses to EHRs and Patient Safety – a reply to a #medlibs chat

  1. Margaret says:

    I’ll look into the book. We studied Lawrence Weeds’ problem based record method in my Practice of Healthcare class and it was very interesting.

  2. BobbyG says:

    See Lawrence and Lincoln Weeds’ “Medicine in Denial.”

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