Wednesday, August 31, 2011

EHR Incentives Likely to Improve Quality

Federal Investment in Electronic Health Records Likely to Reap Returns in Quality of Care

Healthcare is one of the last industries in the United States to universally incorporate technological advancements. While most sectors have made significant investments in information technology to improve efficiency and consumer relationships, America’s health care system is still largely paper-driven. As a result the healthcare system is plagued by inefficiency and poor quality. Delivery is slower, more prone to errors, and harder to measure and coordinate than it should be. Investments in health information technology can help improve this situation. Research published in the New England Journal of Medicine (FREE FULL TEXT) gives cause for optimism that efforts to increase adoption of electronic health records (EHRs) will provide major benefits in better patient care and health outcomes. Perhaps we can finally move away from using a dead tree medical recod system in this country.

To start with take a look at this video from a 1961 study that concluded that one day it is going to be possible to relieve the nurses and doctors of some of their paperwork, it is going to be possible to have correlation of diseases which we have not had before, and it is going to be possible to eliminate errors in medications and tests which would have been harmful to the patient:

“We were not surprised by these results,” said Randall D. Cebul, M.D., a professor of medicine at Case Western Reserve University and the study’s lead author who I was able to speak with earlier today. “They were influenced by several factors, including our public reporting on agreed-upon standards of care and the willingness of our clinical partners to share their EHR-based best practices while simultaneously competing on their execution.”

The research involved more than 500 primary care physicians in 46 practices that are partners in a region-wide collaborative known as Better Health Greater Cleveland (Better Health). This alliance of providers, businesses and other stakeholders is dedicated to enhancing the value of care for patients with chronic medical conditions in the region. Launched in 2007, the organization is one of 16 that the Robert Wood Johnson Foundation chose to support in its nationwide initiative, called Aligning Forces for Quality. This initiative is the foundation’s signature effort to lift the overall quality of health care in targeted communities as well as reduce racial and ethnic disparities and provide models that will help propel national reform. Common themes across the communities include public reporting of performance and community-wide initiatives to improve care.

As important as electronic health records are, Dr. Cebul said, their greatest value merges when used in conjunction with other approaches, such as the sharing of best practices and coaching offered through collaborations such as Better Health Greater Cleveland. "We've been doing summits twice yearly and will continue in the future so that we can identify and share best practices among providers. We also will provide ongoing coaching to practices that wish to continue to improve clinical outcomes," he said. The patient centered medical home is built on the foundation of electronic health records, and Better Health is working with employers and payers in the region to develop medical homes as well as exploring opportunities to participate in new payment models.

I asked Dr. Cebul what impact health information exchange will have on continuing improvements, particularly in the area of clinical care coordination. "I think that HIE will have a big benefit and it's value will be as much in cost reductions as it will in improving quality of care. For the smaller practices it will be very valuable in providing data from outside providers and specialists. HIE will enable us to reduce unnecessary emergency room visits and hospital readmission, as well as reducing duplicate testing. This will also accelerate the process of clinical evaluation and save money."

The authors did caution that they could not conclude that EHRs were the only explanation for quality differences. Other potential causes could be "the participation of exceptional EHR-based organizations, a nonrepresentative sample of paper-based organizations and inadequate adjustment for patient characteristics," they stated. Their study also would have provided even more compelling evidence for an advantage to EHR use if they had measured before-and-after performance for groups that had switched away from paper-based to using an EHR. But this study absolutely provides a basis for determining that digitizing medical records can have a substantial impact on quality of care.

The study involved more than 27,000 adults with diabetes and found that those in physician practices using EHRs were significantly more likely to have health care and outcomes that align with accepted standards than those where doctors rely on paper records. Improvements in care and outcomes over a three-year period also proved greater among patients in EHR practices. The study’s findings remained consistent for patients regardless of insurance type, including the uninsured as well as patients insured by Medicare, Medicaid, and commercial payers.

The data shows a staggering difference in performance among practices with EHRs as compared to those without: 51 percent of diabetes patients in EHR practices received all the care they needed as compared to only 7 percent in practices with paper records. A similar variation was also reported for diabetes patient outcomes—how well patients and their doctors were able to effectively manage their condition. For both care and outcomes, patients treated at practices with EHRs far outpaced those in paper practices across all insurance types—whether patients were on Medicare, Medicaid, a commercial plan or uninsured. Breaking the data down further shows that for practices using EHRs, the percentages of patients meeting standards for diabetes care were higher for making sure hemoglobin A1c tests were performed, kidney management was maintained, eye examinations were made than for those practices using paper records.

The Better Health study focused on a 12-month window spanning 2009 and 2010, and also followed trends over a three-year period. The study also measured achievement by age, gender and racial and ethnic categories as well as language preference and estimated patient income and education. The locally vetted national standards for care included timely measurements of blood sugar, management of kidney problems, eye examinations, and vaccinations for pneumonia. Outcome measures included meeting national benchmarks for blood sugar, blood pressure and cholesterol control, as well as achieving a non-obese Body Mass Index and avoidance of tobacco use. Patients who made at least two visits to the same primary care practice within a single year were included. The researchers reported results for individual standards as well as separate composite standards for care and outcomes. In the future they will be also developing metrics for patient satisfaction, as well as possibly adding childhood obesity and hypertension.

The study’s findings were striking – even after researchers statistically accounted for differences between EHR and paper-based practices in the characteristics of their patients.

  • Standards of Care: Nearly 51 percent of patients in EHR practices received care that met all of the endorsed standards. Only 7 percent of patients at paper-based practices received this same level of care – a difference of 44 percentage points. After accounting for differences in patient characteristics, EHR patients still received 35 percent more of the care standards.
  • Patient Outcomes: Nearly 44 percent of patients in EHR practices met at least four of five outcome standards, while just under 16 percent of patients at paper-based practices had comparable results. After accounting for patient differences, the adjusted gap was 15 percent higher for EHR practices.
  • Trends Over Time: After accounting for patient differences, EHR practices had annual improvements in care that were 10 percent greater than paper-based practices as well as 4 percent greater annual improvements in outcomes.
  • Performance Across Insurance Types: Patients in EHR practices showed better results, including improvements over time, in both standards of care and outcomes across all insurance categories – commercial, Medicare, Medicaid and uninsured.
“These results support the expectation that federal support of electronic health records will generate quality-related returns on our investments,” said David Blumenthal, M.D., M.P.P., professor of medicine and health care policy at Harvard Medical School and past National Coordinator for Health Information Technology. “I am especially pleased that the benefits reported in this investigation spanned all insurance types, including Medicaid and uninsured patients, since it is essential that the modern information technologies improve care for all Americans, including our most vulnerable citizens.”

“Cleveland stands as a pioneer in the burgeoning movement to leverage local resources and federal reform opportunities to improve health care quality,” said Anne F. Weiss, M.P.P., who leads efforts to improve the quality of American health care at the Robert Wood Johnson Foundation. “Electronic health records alone cannot solve the nation’s health care quality problems, but they are an important part of the fix. Cleveland’s use of electronic health records is a model for all health care organizations working to implement health reform.”

“Better Health seeks to improve the value of health care for all of the region’s residents and those who pay for their care,” said David L. Bronson, MD, FACP, president of Cleveland Clinic Regional Hospitals and President-elect of the American College of Physicians. “As the program moves forward, we expect that EHR-based sharing of information across different health care systems, and with our patients, will help us to keep our patients healthier and foster more discriminating use of expensive resources, such as our emergency departments and hospitals.”

This perspective is also echoed by other national leaders as well. Not only do such collaborations enhance care and outcomes, but they also provide rich opportunities to test the impact of different approaches and innovations. As Dr. Carolyn Clancy, M.D., director of the federal Agency for Healthcare Research and Quality, explained: “The results of this study support both the value of electronic health records and community-based partnerships to improve quality of care.”


  1. Brian,
    Thanks for featuring this Cleveland initiative. A major milestone in the use of EMRs.

  2. Thanks John. I am thrilled that we are starting to see some data which supports our contention that EHRs can improve quality. :-)

  3. This is correlation not causation, though. The more advanced medical practices will adopt EHR. And of course they will have better outcomes for the same reason they adopted EHR: they are better practices! We might also find that the practices that adopted various other trends in the past also had better outcomes, even when those trends became discredited, again for the same reason.

    If you really want to test a hypothesis you have to disprove it. You can't say "If A then B, B therefore A". C may cause B also. But we can say "If not B then not A." So if our thesis is that EHR improves quality, we must see if there are cases of not having quality that still have EHR. That would disprove our thesis that it's EHR that raises quality.

    And my gut feeling is this will happen, b/c it's never really the tool, but how it's used that matters. This leads me to the conclusion that we'll need to have EHR managed by some major players if it's really going to work right b/c otherwise it will get screwed up. Thoughts?