Friday, 9 April 2010

Electronic health records and e-health technology in the USA

Research in the USA suggests that "The implementation of electronic health record systems may not be enough to significantly improve health quality and reduce costs" - Electronic Health Records' Limited Successes Suggest More Targeted Use, published in Health Affairs, by Catherine M. DesRoches, Eric G. Campbell, Christine Vogeli, Jie Zheng, Sowmya R. Rao, Alexandra E. Shields, Karen Donelan, Sara Rosenbaum, Steffanie J. Bristol, and Ashish K. Jha, researchers from the Mongan Institute for Health Policy at Massachusetts General Hospital.

They found, from analysing very comprehensive data (from a 2008 survey sent to chief operating officers of acute care hospitals belonging to the American Hospital Association, with completed surveys returned from almost 3,000 hospitals in the 50 states and District of Columbia), that "currently implemented systems have little effect on measures such as patient mortality, surgical complications, length of stay and costs. The authors note that greater attention may need to be paid to how systems are being implemented and used, with the goal of identifying best practices."

"Our findings suggest that hospitals need to pay special attention to how they implement these systems. Simply having the technology available is probably not going to be enough," says DesRoches, an assistant professor of Medicine at Harvard Medical School. "Hospitals will need to effectively integrate new systems into their current practices. Studying institutions that have been successful will provide important lessons for everyone."

The abstract:

"Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care."

In other words, if you build it they will not necessarily come - technology alone is not enough, implementation and processes matter as much if not more (along with high level buy-in and comprehensive stakeholder engagement, of course), as anyone who has ever been involved in a technology project will know.

Now it seems that if you actually ask the patients what they want from technology, and honour their values and preferences, electronic medical records adoption and use of health information technology will rise. Goodness me, what a novel idea!

But seriously - there's been a separate study in the USA showing this, "Patient Experience Should Be Part Of Meaningful-Use Criteria" by James D. Ralston, Katie Coleman, Robert J. Reid, Matthew R. Handley and Eric B. Larson, from Group Health Research Institute, also published in Health Affairs. This was specific to one particular organisation, Group Health Cooperative, which was an “early adopter” of health information technology that directly engages patients online.


"The proposed federal "meaningful use" criteria for electronic health records include the direct engagement of patients in their care. In this study, we sought to describe the adoption and use of online services linked to the electronic health record at Group Health Cooperative. By August 2009, six years after the introduction of these services, 30 percent of outpatient "encounters" were actually conducted through secure electronic messaging. Meanwhile, 10 percent of enrollees reviewed medical test results online, while 10 percent went online to request medication refills. These results highlight the need to measure the patient experience as part of meaningful use and to enact policies supporting online and phone communication by patients and providers."

And from the news report, with YouTube video:

"Group Health was an “early adopter” of health information technology that directly engages patients online. By 2003, Group Health patients could use its Web site to: exchange secure e-mail with their health care providers; schedule office visits; get after-visit summaries and medication refills; and see parts of their electronic health record (EHR), including test results, medications, and immunizations. Since then, the integrated health care system has kept improving its health information technology based on surveys of randomly selected patients every two years.

Dr. Ralston used those biennial surveys as part of an evaluation of Group Health’s use of health information technology. He found patients were highly satisfied with the technology, and they
were most satisfied with the services they used most often: reviewing test results, requesting medication refills, exchanging secure e-mail with providers, and reviewing after-visit summaries.

By the end of 2009, 58 percent of Group Health’s adult patients had registered for access to online services, and that percentage keeps rising. And of every 10 times that Group Health patients consulted with their primary care team, three times were through secure e-mail, two were over the phone, and five were in person.

The Stimulus (American Recovery and Reinvestment Act) of 2009 included incentives for medical systems to adopt EHRs if they use them “meaningfully.” Accordingly, in 2011, the Centers for Medicare and Medicaid Services (CMS) will start paying incentives to providers and hospitals that show “meaningful use” of EHRs. But current meaningful-use criteria don’t include any assessment of patients’ experience.

“Based on our evaluation, we strongly urge policy makers to include measures of patients’ experience when setting criteria for meaningful use of health information technology,” Dr. Ralston said. “Because of concerns about disparities in access to care, especially the ‘technology gap,’ patients must be able to communicate with providers in the way they need or prefer, whether in person, over the phone, or through secure e-mail.”

At Group Health, patients can connect with their health care providers in whichever way they prefer. And providers are paid on salary for caring for a group of patients, not reimbursed for each visit and procedure they do. By contrast, most U.S. providers are paid for each procedure and office visit—but not for connecting with their patients by e-mail or phone."

The payment reforms they urge make a lot of sense.

For those interested in these areas, see the April 2010 Health Affairs issue generally (needs subscription for full access).

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