What is the value of Electronic Medical Records?
There are a pair of very interesting studies that I’ve seen recently that speak to different sides of this discussion. The first is a paper from Carnegie Mellon that looks at patient safety events in Pennsylvania and determines that electronic medical records are a major player in increasing safety:
We nd that the hospitals’ adoption of advanced EMRs has a bene cial impact on patient safety, as reported events decline by 27 percent. This overall decline is driven by declines in several important subcategories, 30 percent decline in events due to medication errors and 25 percent decline in events due to complications….
The study seems to have validated its results against common objections so the BS check is fairly strong. They were not looking for strong mortality impacts, but the impacts they found were notable but not statistically significant. But EMRs seem to improve safety and quality after adaption.
The Incidental Economist is passing along a study about the effectiveness of the HITECH Act of 2009 that looks at the impact of the Act which gave all providers incentives to implement EHR.
As of 2008, about 48 percent of independent hospitals and 55 percent of system hospitals had adopted at least one of two advanced EMR technologies, physician documentation (PD) and computerized practitioner order entry (CPOE). By 2011, these adoption rates for both independent and system members had risen to 77 percent. […]
Absent HITECH incentives, we estimate that the adoption rate would have instead been 67 percent. Thus, HITECH promoted adoption among independent hospitals by an additional 10 percentage points. While this may seem like a substantial effect, when we consider that HITECH funds were available for all hospitals and not just marginal adopters, we estimate that the cost of generating an additional adoption was $48 million, which is more than enough to cover the cost of a generous EMR system. We also estimate that in the absence of HITECH incentives, the 77 percent adoption rate would have been realized by 2013, just 2 years after the date achieved due to HITECH.
Now this raises a really interesting question — does $48 million dollars for an additional two years of EHR make sense? If the first study or studies like it can show that EHRs can gain between 100 to 480 Quality Adjusted Life Years in a two year period, then the HITECH Act was a great investment of social resources as the benefits would exceed the costs. The reason why the spread is so large is that there is a good deal of debate on what the US willingness to pay for a QALY is worth. Another way of looking at it is that most federal regulations assume a $6 million dollar cost in regulatory burden is a reasonable cost if it prevents one average death. With that view, if EMRs can prevent a few average deaths per year for the two years of accelerated adaption, then HITECH was a good deal.
CONGRATULATIONS!
Electronic records are only as good as what the doctors put into them.
So I have to remind my Kaiser doctor every year or so that I had my appendix removed – at his direction, at their hospital and under his care – because somebody didn’t enter it into the computer, and apparently he just won’t do it. Why this is I am not sure.
bloomingpol
I’m feeling a lot more secure about myself and even more secure about my spouse, who has a chronic illness as well as all the other “lovely” things that come with aging, especially if you did a lot of manual labor, now that we are involved in a network that keeps good electronic records and works to make sure care is coordinated and we don’t get “care” we don’t need.
scav
What information is there about finer-scaled temporal patterns of impact of adopting such systems? I’d imagine there’d be an initial pulse of adverse results as the systems are adopted, learned, people forgetting about or resisting them (“But we’ve always done our reports in Mabel’s spreadsheets! They let us keep the PC in the corner just for them! She had such a lovely retirement party too, bless.”), but I’ve not a clue as to the magnitude of the spike.
The obsessive geo-geek would also like to know about any geographical patterns observed, partially with an eye to uncovering clues about how the scale of adoption matters: one hospital all on its lonesome having to transfer patients / interact with non-adopters versus a bunch of hospitals and supporting pharmacies etc. would likely show stronger benefits. Again, an in-theory hypothesis, but clueless about if in truth and how much.
? Martin
It depends on what is enabled due to it. I’m fairly convinced that Apple is working to bring widespread two-way access to EMR records through the iPhone/iPad platform, using the same security mechanisms that they developed for their mobile payment system Apple Pay (direct ID&V with insurers and care providers tied to physical devices, fingerprint + password authentication for each access – no ability to contact the system through arbitrary systems. That is, the EMR owner needs to approve each individual device that connects so no web access.) This would allow users to bring EMR data into their iOS devices – you can see the options there in the Health app – vitals, lab results, we know it can carry prescriptions and tie into medical devices (they’re fixing an issue with blood glucose data now). This data can flow both ways with EMR systems, controllable by the user. With the mobile payments system, Apple has created an interface within the payment system to contact your issuing bank and could do the same to contact your doctor from within the health apps. It’s looking pretty likely that you’ll be able to take a prescription directly from your doctor via this service and hand it off to participating pharmacies, possibly having the software automatically put a reminder up for renewing the prescription. EMR uptake is key for services like this to even be developed. Mayo Clinic was one of the first to launch:
So I would extend the question of “does $48 million dollars for an additional two years of EHR make sense?” to “is expanding user access to EMR data and doctor access to user data worth $48 million dollars?”
The idea of hooking your personal devices into your EMR data sounds like a clear winner to me, but there are legitimate questions of whether doctors can actually use that data. Our health system isn’t structured around monitoring – your doctor generally doesn’t pay any attention to you until you arrive in their office. Can this system even change?
Ruckus
There are a couple of downsides to EMR and the first is the same as paper, the user. If they think they know everything, know everything better than anyone else, etc, how the records are kept is really irrelevant. The second is data over load and/or how the data is structured. As I’ve said before I use the VA, which is all EMR. As your file grows, it becomes harder and harder for the Dr to find out all the info, and your file grows immensely when every interaction, drug, whatever is added. You still have to remind people about your personal issues because they won’t necessarily see them. Now is this different from paper records? I’d bet not, so what I’m saying is maybe the entire concept needs a rethink, with presenting info/prescriptions etc all in one place without all the details visible. How many EMR systems are just a paper replacement? IOW a review screen first. All the info is expandable from there, any input would go to a different screen with areas for all the necessary details, such as prescription contra indication.
Now maybe some are like this but this is my second exposure to EMR and neither of these were any more than paper replacements.
piratedan
@? Martin: well docs are simply people too. Nowadays, with all of the tools out there, you can have your uncle second guess the treatment and healthcare programs that you’re on by going out to WEB MD and looking up stuff yourself. Plus, you also have to have faith that the various information that is posted online is accurate and up to date and as we’ve seen with things like Wikipedia, that you can have some bad faith players out there screwing things up just because they can. Think about our esteemed members of Congress who deny science. Just imagine if some flickering dim bulb decides to start poaching medical journals and boards with this kind of nonsense (wouldn’t be surprised if it wasn’t already happening) because we all know that you can defeat Cancer simply thru the power of prayer. Also take note, that not all docs are tech savvy. They are just as reliant on their skills in interpreting lab clinical data as we are on our car’s dashboard lights. If the lights never come on, do they have the background to know when the numbers are off or even trending in the right direction, much less the wrong one. How does the same set of clinical numbers impact the “normal” values between a 25 year old “athletic” male who is a professional athlete and a 37 year old mother of two?
While empowering us a clients and patients is a good thing, it’s also another challenge to keep the data accurate and up to date and there are a whole bevy of systems out there in your local hospital environment because the “one vendor who does everything solution” hasn’t always proven to be a winner in the medical records healthcare environment… (I know, because this is where I work). While you can have one system that attempts to rule them all, it doesn’t even mean that those modules speak and work within themselves work well. As such, healthcare on the tech side is surprisingly compartmentalized, between systems like admitting, dietary, radiology, laboratory, billing et al…. Those systems all share information and pass data between each other inside the hospital and with their affiliated physicians. Getting docs to even agree on what kind of information that they want and need and what they will share with their patients through their own portals is still open to debate out there and as such, who decides what filters are in place and how much to arm the patient with is still a good question.
After all, look at the general freak-out that the media has about Ebola despite all of the information that is out there regarding the disease and how it is contracted and spread and you STILL have the media out there behaving as if the CDC is involved in the secret FEMA relocation camps and as part and parcel of the black helicopters conspiracies that we’re out to take their guns…..
skerry
We have an Ebola Czar – Ron Klain, former Biden Chief of Staff.
Still no Surgeon General
Villago Delenda Est
You know, if it wasn’t for these stupid people involved in all this, EMR would probably work really well!
Shinobi
I’m not sure if this is part of the EMR protocol, but my partner and i have both recently visited a local hospital chain that keeps all of it’s records digitally.
For me, it was excellent because all of my test results from my ER visit are already available to my doctor, without either of us having to request files.
For HIM it was excellent because a nurse tried to give him someone else’s medication, but the bar code on the meds and his wrist band wouldn’t approve her giving him the meds. (It was the end of her shift and I”m pretty sure she meant to be at the other end of the hall. She kept mentioning a room number from the other side of the building.)
I can see how it would get cumbersome over time to keep so much information on file, especially if the dashboards are not well designed to give Doctors the information they need. But my experience with it so far was very positive.
beth
@skerry:
But he’s not a doctor and he worked on Solyndra! I just don’t know how an administration that’s so good at campaigning can be so bad at “optics”. This guy may be the smartest man on the planet but it just gives the right wing something else to point fingers and freak out about and right now I don’t think that’s what we need.
I was kind of hoping he’d appoint Ben Carson and insist he go over to Liberia to gather first hand knowledge.
jl
Would be interesting to compare US to international experience. I was shocked at how far behind the US was compared to damn near any other high income industrialized nation, from Asia to Europe to Australia and NZ. For years these other countries outspent us on per capita basis by factors of 2 to 10, and a couple by more. (Edit: went to lecture on it a couple of weeks ago).
So, there should be plenty of evidence out there from other countries.
If fear and angst about it rises from certain quarters about Kenyan totalitarian plots, remind them that the commie who got the ball rolling on adequately funded and well implemented EMRs and MARs was the socialist George W Bush. Funding from the ACA is the badly needed follow-up.
beth
@Shinobi: My husband went through cancer surgery and treatment and all of his records at the hospital are kept electronically. He goes in, scans his palm and no matter which doctor he sees (and he has to see the surgeon, the oncologist, the pulmonary guy and his regular old doctor) they all have access to the latest info on him and all his test results. It seems to be quite a great system. I can remember years ago when he was treated for a heart condition and we used to lug paper copies of all his medical records to doctor’s appointments because you could never be sure who had what info.
pete
Anecdata: As a patient of the Palo Alto Medical Foundation (PAMF), I have what is now known to be great cell arteritis (serious but manageable) but the early symptoms were confusing and potentially misleading. That I had seen doctors for headaches and persistent flu-like symptoms (and the CT scan and blood test results) was instantly available to the urgent care doctor when I woke up with double vision, and greatly helped to reach the tentative diagnosis, which led to treatment that saved my sight. In all, I saw 10 physicians in less than 2 weeks, all of whom accessed the data each of them had supplied. It worked great, and still does as I undergo monthly blood tests to make sure it’s all coming along fine (it is); I get to see the results, too.
Tommy
@? Martin: I have a Jaw Bone Up band. A terrible name for a product but kind of stunning. Tie it in with My Fitness Pro and Map My Walk and the level I can look at my health is amazing. IMHO this is the future.
Tripod
Fucking Epic.
@jl:
Prior, the US model was MD owned small practices. The capital requirements for EMR are substantial, and MD’s are being rolled up into hospital systems or large medical groups.
Villago Delenda Est
@beth: I agree. Send Ben Carson to Africa for a front line assessment. Put him in the smallest village to see what is going on on the ground itself.
Then forget about him. Forever.
The Right Wing will point and scream no matter what Obama does because Obama.
? Martin
The remaining problem with EMRs is that data cannot be easily transferred between them. My electronic Kaiser records are useless if I find myself a the Mayo Clinic – Kaiser will be faxing them to Mayo and some clerk will be furiously doing data entry. So it’s only useful within your network, assuming that you have a network of any scale. The EMR starts to be the thing that defines the bounds of your care. Apple is offering up a very lightweight conduit between these systems, however. Once Kaiser opens up access, I should be able to get some of my medical data into a device I control and be able to share it Mayo. Likely not enough to be useful, but it at least serves as an early prototype that others can build off of, and to see if there’s even a market there.
Without widespread EMRs, there’d be no market for an entrepreneur to come in and try to build such a transport service.
Mike J
@Tommy:
Do you have access to your data directly, or do you have to beg to get it back from their web site? I was given a fitbit, but I’m philosophically opposed to paying for access to my own data. I’d like to have something like it, but I want to be able to load all the data onto my own computer and analyze it any way I want, at any level of granularity the hardware supports. If they want to have a pretty web site with charts and graphs, that’s fine. They just should not upload my personal data to the site and deny me access to it.
Tommy
@Mike J: I have total access to my data. I don’t have to log into this site or that site to get it. I had to link the device, but once that was done the info is mine.
Stella B.
I’ve been retired from the biz for two years now, but the EHRs that I used were, at best, data storage facilities. They offered very little analysis and alarmed inappropriately. If you get an alarm every single time you write a prescription, you tend to miss the rare, useful warning.
I’m not sure that flooding doctors’ offices with Jawbone data from the worried well is such a great idea, unless increasing physician burn out is your ideal. The (electronic) reams of “annual bloodwork” that get transmitted in the same data flow with the medically indicated lab results are overwhelming enough, add even filtered 24 hour data from healthy people and the workload becomes completely impossible.
Frankensteinbeck
I have worked in a medical clinic, at Kaiser, during the process of switching over to electronic medical records. Here is my experience.
Electronic medical records are a boon. They are such a dramatically good thing for doctors, patients, and the entire system that you should forget costs, and focus instead on universality. The current biggest problem has been pointed out above – making records available between companies. Our doctors whined and bitched for about a month, and after that clung to Epic with rabid devotion.
A doctor without a patient’s medical records is guessing. Data on previous times patients displayed similar symptoms, old blood tests, how blood pressures have changed – these are crucial to identifying dangerous slow-moving diseases, exactly the kind of thing we castigate doctors for missing. That information makes a huge difference in identifying and treating short-term diseases.
Doctors have had medical records for a long time, but all the biggest problems of paper records disappeared with EMR. Just finding a medical record could be difficult. That much information is hard to file and access quickly in paper format. At best, you had a several minute lag, and adding several minutes to an already slow process is not good. Doctors can search EMR much faster to find the information they want. More importantly than anything, while it may not be universally available yet, the patient’s file is widely available between treatment locations. With paper records, if you went from your local clinic to the nearby hospital, they didn’t (couldn’t, not possible) have your records at exactly the time you wanted them most.
Financially, Mr. Mayhew, you have to factor in the cost savings over time. Entire departments worth of workers vanish when you move to EMR. Kaiser is union and very devoted to its employees, and had to be very careful to avoid firing people on a large scale and instead wait for attrition. Doctors can fill out medical records much faster, and even a few minutes of every doctor’s time is a serious cost saving. Nurses did not have to spend extra time making sure doctors had the right charts with the right patient, adding forms to be filled out, and making sure charts were collected and sent back for filing. A paper chart might linger in a doctor’s office for awhile as they examined a case after the patient was gone, or procrastinated on filling out a report (both happen a lot). All of these ongoing labor expenses disappear. And, of course, you no longer have to set aside a very large room. Space is at a premium in medicine.
gene108
@piratedan:
Age may play a factor.
My nephrologist is a great doctor. Knows his stuff and keeps up with the latest developments.
He’s also in his late 60’s and he’s used to paper files.
Younger docs in the practice are more comfy with electronic media for accessing records.
Also, too there’s a sub-set of Americans that feels any change influenced by the world outside our borders is a sign of weakness, whether it is EMR or the Metric System.
Mnemosyne
@Mike J:
The FitBit website is free. I’m not sure in what way you were “paying for access to your data” other than by purchasing the device.
ETA: There is a premium site, but you don’t have to pay for it if you don’t want to.
grrljock
My thoughts: I can’t access the whole paper so don’t know how the researchers based their estimate (and not sure I would understand anyway). Therefore, taking that at face value, I think $48 million for two earlier years of EHR is good value. Not only does this mean two additional years of saved lives and better quality care, but also two earlier years of vendors and providers having to think about issues related to data standards and interoperability. We’re still far from solving everything, but the accumulated experience is very helpful in figuring out potential solutions.
EthylEster
I would love this if it was implemented properly.
I get very frustrated when I am asked repeatedly to write down what meds I’m on.
And I observed that same thing for my mom when she would be taken to the ER from her ALF apt with a COPD exacerbation. Asking an 87 year old woman to list her MANY meds is a recipe for disaster. And yet that is how it is still done in most hospitals in the country with the best health care EVER!
texasdem
@Tripod: The consolidation of practices into groups or affiliations with hospital systems leads to “silos” of patients with their providers. These systems have their own EMRs, which don’t talk to one another. In my area, cancer patients often choose to go to MD Anderson, but when they become acutely ill, they then come to the local ER. I’ll get called in to see them, but have none of the recent info, and many patients can’t tell you.
EMRs do have advantages, but many of them are a pain to use, and time-consuming. What would compensate for all that, would be easy availability of someone’s information wherever they are in the country and whichever provider they see. That should have been a requirement from the very start. Now we’ll spend billions of dollars to juryrig the current systems to talk to each other.