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.


adam said...

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Amy H., RN said...

As a nurse working in an organization that has a very extensive EHR, it is impossible to even remember how it was when charting on paper. I find it puzzling that organizations are not more efficient and providing better care. In a large organization, it is imperative to have access to heath information instantaneously. I agree that there is always room for improvement in many aspects, but the ability to view labs, x-rays, consents, and other provider's notes without having to find that elusive paper chart is extraordinary!!

Dr. Steve Beller said...

In response to Amy's excellent post, I agree that the best EHRs are more helpful, or at least more convenient, than paper charts, and I support our county’s efforts to computerize the paper chart. After all, we do have to start somewhere. We should not delude ourselves, however, into believing that current day EHRs (including EMRs) are anything more than the first tiny baby steps forward. If delivering ever more effective, efficient and safe (high-value/cost-effective) care is the ultimate goal, than we have transform the immature EHRs of today into truly useful tools that help people make ever-better decision and take ever-better actions when diagnosing and managing health problems.

Such transformation requires that EHRs help increase understanding of each patient’s biomedical and psychological strengths, weakness, risks and problems, as well as helping to establish and implement the best possible plan of care for each patient, and to track and provide feedback as to clinical outcomes and costs. We have a long way to go before EHRs can provide this kind of meaningful use

Unknown said...

I am a health care admin who is researching the pros and cons of EHR and how it works. From reading this post and comments I agree with Amy H. Being able to have health information immediately is a great asset. I work for medium provider and now the time has come for us to utilize EHR to its full potential. So much patient information can be lost or looked over if relying on paper charts. I understand that we are on the first stages of the EHR, but feel that it is giant baby step forward.

Dr. Steve Beller said...

Thank you for the comment, Marie.

I like you're phrase stating today's EHRs are a "giant baby step forward."

Since I've been involved in the area of computerized health records for the past 30 years, the adoption of EHRs has been a VERY SLOW process in my eyes. Nevertheless, I'm thankful that the pace is gradually picking up!