Monthly Archives: September 2012

The Wrong Question on Electronic Health Records

The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be.  Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question.  An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs).  This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.  While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it.  The problem is that the WSJ piece, and the studies it points to, are asking the wrong question.  The right question is:  How do we ensure that EHRs help improve quality and reduce healthcare costs? 

The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate.  Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available.  Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment.  I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.

The problem is that some Health IT boosters over-hyped EHRs.  They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace.  We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.  Most EHR vendors today sell their products to doctors promising increased “revenue capture” (that is, improved billing resulting in greater payments to physicians and higher costs to the health care system).  In a fee-for-service world, the EHR, which is nothing but a tool, helps you get more “fee” for your “service”.  It’s not surprising that we aren’t seeing huge savings.

To understand how to best leverage the potential of EHRs to help the US improve care and save money, we will have to answer a series of other related questions:  how do we create incentives in the marketplace that reward physicians who are high quality?  How do we allow physicians to capture efficiency gains?  Today, if a physician becomes more efficient, he/she will likely lose revenue to insurance companies or to government payers.  When Kaiser Permanente installed an EHR and gave patients the ability to use the electronic system to message their physicians, they saw their ambulatory care visit rate fall by 20%.  This is a disaster in a fee-for-service world.  Sure, Kaiser was able to see real financial gains from their EHR – but how do we help the thousands of other physicians and hospitals that are not Kaiser gain efficiencies from their EHR?  That’s the question I’d like to see answered.

Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world.  I am sure that the healthcare industry single-handedly keeps the fax machine industry alive.  We need to stop. Period.  Every other part of our lives has become electronic and the benefits are clear.  Our lives are better because we bank online, communicate online, shop online.

The debate over whether we should have EHRs is over.  Can we fix our broken healthcare system without a robust electronic health information infrastructure?  We can’t.  Instead of re-litigating that, we need to spend the next five years figuring out how to use EHRs to help us solve the big problems in healthcare.

Getting the Right Benchmarks for Stroke Care

Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts.  It’s a plain document, mostly in black and white, much of what you might expect from a state government report.  Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.  For many patients, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home.  There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home?  Is “pretty good” good enough for your loved one?

The Massachusetts Department of Health has put substantial effort in this area and the numbers have steadily improved.  By many accounts, this is a success story (the number was 66% in 2008, rising to 83.5% in 2011).  But this level of performance is not nearly good enough.

There are plenty of hospitals that seem to get it right.  I counted 14 that were at 100% and another dozen or so that might have missed it on one patient.  But here’s the problem.  From a clinical perspective, so few patients with stroke ever show up in the magic window of less than 4.5 hours of the onset of symptoms (that’s the cut-off for using t-PA) that the average hospital in Massachusetts sees about 8 such patients per year (less than one a month).  If you were unfortunate enough to end up at Lowell General, there was nearly a 40% chance (depending on which campus) that you won’t get tPA.  At Milton hospital, there was a 60% chance that you wouldn’t get tPA.  These numbers may be getting better slowly, but that’s cold comfort to those permanently disabled because hospitals haven’t yet put in the systems needed to reliably provide a therapy we’ve known is effective since 1995.

So what might state and federal policymakers do if they wanted to get serious about improving these rates?  There are lots of potential solutions, including greater training, more oversight, even robust pay-for-performance.  I have a simpler request:

Stop setting the benchmark at the state average.

In this report (like almost every other report card), you are judged against the “average”.  So, if your state is lousy, a lot of mediocre hospitals can look fine.  Instead, set a goal for what you want to achieve.  In this case, the goal is 100%.  Period.  Tell me which hospitals were “statistically” worse than 100%.  That’s a lot more meaningful than which hospitals were “statistically” worse than average.

In this report, 64 out of 69 hospitals were labeled “equal” because they weren’t statistically worse than average, including South Shore Hospital, which failed to provide t-PA to 8 of their 31 patients (26% failure rate).  Lucky for them, that’s not statistically worse than the state average of 17% failure – but perhaps not so lucky for those 8 patients.  For the 64 hospitals that are labeled as “equal”, such as South Shore, there is little motivation to improve.  Yet, I’m confident that South Shore would be having a very different set of internal discussions if the benchmark was 100%.

If we’re going to use transparency to improve, we need to choose the right benchmarks.  In situations in which strong, evidence-based processes are involved (like providing a life-saving drug), the benchmark should be 100%.  Benchmarking to the average is benchmarking to a “C”.  We spend a LOT of money on healthcare – we deserve better, and our hospitals can do better.  With all the knowledge and expertise in the medical field, we don’t have to settle for a “C”.  We should demand that our hospitals provide “A” care consistently and reliably to all their patients.