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.

3 Replies to “The Wrong Question on Electronic Health Records”

  1. Really nice consolidation of the (confusing) evidence and how we might usefully interpret it. Really liked the piece overall, but I am going to nitpick on a small part:

    When you say “..if a physician becomes more efficient…” – is this based on discussions with other physicians? I was under the impression that a lot of older/technologically less-savvy doctors just don’t want to bother to switch. Why spend a lot of $$ on a system when you’re going to retire in a few years, anyway. Rates of EHR use are pushing 50% now — are the holdouts really waiting because the financial incentives are not there?

  2. Dear Dr. Jha,
    I attended your very in formative interview on HealthCare Now Radio this afternoon.
    As a member of the Standards & Interoperability Framework since February 2011, from my clinical perspective, I believe an effective way to reduce the costs and improve the usability and quality of ambulatory and inpatient EHRs is to continue ONC’s collaborative health IT innovation initiatives that began in January 2010 with the Direct Project and were expanded with the development of a portfolio of transport and content exchange standards by the 1,700 members of the S&I Framework’s work groups.
    As part of this national effort, a practical way to ensure that EHRs do help improve healthcare quality and reduce costs is to create a new, user-friendly interface for physicians and patients so they can more efficiently view and share cumulative diagnostic test results.
    An important, but overlooked cause of the estimated 15-30% unnecessary diagnostic testing rates in our fee-for-volume payment system is the use of variable, hard to read reporting formats that display test results as incomplete, fragmented data. Unfortunately, this flawed user interface design been transferred to EHR, PHR and HIE platforms, which still display clinical lab, imaging and other test results as fragmented data, not as clinically organized, actionable information.
    The practical solution is creatively disrupting HIE 1.0 with a clinically intuitive, standard reporting format that can display the results of the more than 7,500 available tests as integrated, easily read information and enable physicians and their patients to view and share it efficiently for the first time.
    The debate over whether we should have EHRs in the emerging fee-for-value world is certainly over. The importance of creating a robust electronic health information infrastructure while adding value to EHR, PHR and HIE products by continuously improving their overall usability and functionality should also be obvious. Solving the big, wasteful and dangerous electronic results reporting problem should become part of that added value.
    Best regards,
    Bob Coli, MD

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