Tuesday, February 01, 2011

Enabling EHRs to Improve Care

In last month’s Archives of Internal Medicine, researchers at Stanford University released results of a three-year study that found EHRs in the ambulatory setting did not improve the quality of care [Reference]. There are, however, a number of limitations to the study, including the use of process measures (what was done) instead of outcome measures (the results of care) to measure care quality, the use of data that was collected around five years ago, and the fact that the doctors’ ability to use the EHRs properly were not assessed. Nevertheless, the study’s results do raise serious concerns.

To me, these findings are no surprise. I wonder why anyone would assume that today’s minimalistic and immature EHRs (in which I include EMRs)—along with a healthcare system largely based on pay-for-procedure/fee-for-service economic models—would boost care quality or efficiency. I’m not saying EHRs can’t help improve care dramatically; instead, I’m asserting that EHRs must be greatly enhanced—in both their usefulness and usability—before significant benefits can be realized.

The core issues, as I see them, are (a) EHRs’ failure to provide patient centered cognitive support and (b) our economic model in which financial incentives, such as pay-for-performance, fail to promote better quality [Reference].

One thing that’s needed is much better clinical decision support (CDS) from next-generation EHRs. The EHRs should provide CDS based on ever-evolving, individualized, evidence-based guidelines and pathways that focus on increasing value to the patient. In addition, the EHRs should deliver to researchers comprehensive (de-identified) data collected from everyday clinical practice. The researchers would use these data, along with controlled clinical trials, to develop and continually improve personalized CDS guidelines/pathways supporting diagnostic and treatment decisions for physical and psychological sick-care and well-care (prevention).
The other thing needed is to incentivize providers who deliver high value (cost-effective) care to the patient. Data from the EHRs would be used to calculate such incentives.