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Conventional wisdom has it that doctors who use EMRs are better prepared to treat patients comprehensively - especially those with chronic conditions. New research, though, is raising doubts. What’s the real story?
Does having an EMR really help you? Are patients more likely to get the tests they need, timely diagnoses, and proper treatments? Do you code more accurately now that your EMR is a part of your daily work flow? Does this result in higher reimbursements?
In short, are you a better doctor - both clinically and operationally - with an EMR than you were without one?
It was questions like these that Jeffrey Linder, an internist and an assistant professor of medicine at Harvard Medical School, tried to answer as he assessed the results of his study on the relationship between EMR usage and quality care. A well-known advocate for EMR implementation, he felt pretty confident the answer to all these questions would be a resounding yes.
He and his team investigated the relationship between EMRs and the quality of patient care in physician practices across the U.S. by scrutinizing the CDC’s 2003 and 2004 National Ambulatory Medical Care Survey (NAMCS). This survey asked practices if their visits were performed in offices equipped with EMRs (or EHR, as Linder and many others call the systems; the terms are interchangeable). Eighteen percent of respondents indicated that they did.
Linder’s team then compared the response to that question to 17 quality measures, including management of chronic diseases, preventive disease, treating acute problems, and avoiding inappropriate medication prescribing in the elderly, to name a few.
And what did they find? “Essentially there was no association between people saying they use EHRs and those 17 different quality measures.”
No association? How could this be in the wake of so much hype touting the efficacy of electronic records in enhancing patient care - particularly among those suffering from chronic illnesses?
Disappointing, says Linder. However, upon further reflection - and in the wake of the barrage of media attention that followed the study’s publication in the July 2007 issue of Archives of Internal Medicine - he admits the results really aren’t all that surprising.
He names two pivotal caveats:
First, the NAMCS data - the best data pool available to Linder and his team, both in terms of size and currency - was, from a technology perspective, woefully outdated. Second, the survey simply asked physicians whether they had an EMR - not how they were using it.
Hmm. That’s like saying you’ll get six-pack abs by the simple act of buying a Bowflex (if only).
“There’s nothing magic about EHRs,” says Linder. “If people are simply turning on a computer replacement for their old paper records, why would you even expect quality to improve? So in light of what was being installed, which were relatively unsophisticated EHRs, it’s not surprising we didn’t see quality improvements as well.”
Linder was very fearful that the study would be interpreted as, “Electronic health records don’t work.” He tried to send out the right message, that these high-tech systems are just tools. “You have to use a tool the right way if you want to see quality improvements. We were very careful about the bottom line in the abstract which was, ‘EHRs, as implemented, were not associated with better quality ambulatory care,’” he says.
Other studies have yielded results similar to Linder’s, including one published in the December 2007 issue of the Journal of Internal Medicine, which concluded, “Whereas EMRs can be powerful tools to improve the quality of care, their implementation is neither easy nor cheap, and barriers are especially high for solo and small group providers.”
Another study, released in July 2006 by the California Healthcare Foundation (an independent philanthropic organization that aims to improve the state’s healthcare delivery and financing systems), found that “it can take as long as several years for clinicians to fully integrate EMR functions into their daily work. Some of the functions most critical for managing disease, such as reports and health-maintenance reminders and alerts, usually are the last to come online and may have to be customized.”
Of course, all these nuances were lost on the popular press.
The power of empowerment
Jane Sarasohn-Kahn, a health economist and management consultant, who serves as president of the healthcare IT consulting firm THINK-Health, stresses the importance of using an EMR to its fullest capacity. “You can spend all the money you want on [an EHR], but if you don’t implement it fully or teach people how to use it fully, that’s the secret of the sauce right there. You can’t buy an EHR without spending a lot of money and time on implementation,” she says. “It doesn’t work by itself. You’ve got to train people to use it and re-engineer your processes and your work flow after you adopt it.”
Do it right, though, and your EMR really can pay off. Evans Medical Group in Evans, Ga., adopted EMR technology 12 years ago. The project was championed by primary-care physician Robert Lamberts; the difference in the quality of care offered before and after implementation was marked. Pre-EMR, he says, “we had no mechanism to improve quality. We had a single record that may or may not have accurate info in it.”
But today, he can say with full confidence that “our practice outperforms most practices on quality measures by at least 50 percent, and we out earn most practices; we’re in the top 5 percent of income for primary care.”
A long-time proponent and nationally known speaker on health IT automation, Lamberts can cite positive outcomes backed up by actual data - not just a gut feeling. Average LDL cholesterol for all of his diabetes patients? Under 100 - not bad. “All of our providers have 50-plus percent of our diabetics with A1c under seven,” he continues, “and around 10 percent with A1c over nine.”
Evans Medical Group understands that “if you use [your EMR] as a tool to redesign work flow, then it will greatly improve things,” says Lamberts. You can also set, track, and achieve your patient-care improvement goals. For example, the practice decided to target patient vaccination rates for Pneumovax. The result? Patient compliance is now up to more than 90 percent.
The only real obstacles to accomplishing whatever they want, says Lamberts, are time and resources. “It is hard when these things aren’t rewarded. If you don’t get paid more for doing a good job, there is no motivation. We feel like if we had financial reward for reaching any specific goal clinically, we could do it.”
Patients are part, too
There’s one more player that must be included on the team - the patient. Truly effective EMR implementation - one that achieves better patient outcomes - comes only with physician-patient teamwork. This means including regular, electronic, two-way communication as an essential component. “It ain’t just about the EHR,” Sarasohn-Kahn explains. “It’s about the ongoing communication of data with the patient, empowering the patient to engage with real data in real time and then getting that patient really interested through measuring themselves at home.”
Sarasohn-Kahn says that for outcomes to be truly optimal, your patients should be able to:
This sort of involvement, where your patient becomes an active partner in his own care, can work with your EMR to improve patient-care outcomes.
The industry perspective
Linder says he began fielding phone calls from EMR vendors a week after his study was published. One of those callers was Hugh Zettel, director of government and industry relations at GE Healthcare and vice chair of Healthcare Information Management Systems Society (HIMSS). Zettel concurs that the data used for Linder’s study was essentially obsolete. He also notes another shift in the EMR paradigm; namely, what is the definition of an EMR, and how has it changed since 2003?
“When the NAMSC asked its question about EHR use, there wasn’t a lot of specificity regarding what an EHR was,” says Zettel. “Depending on how a physician answered it, they could have been talking about their practice management system instead of an EHR.” Certainly, the impact of a practice management system on patient outcomes would be different from an EMR’s impact.
Zettel also says that the accepted understanding of what constitutes “quality care” today has undergone a sea change over the past five years. In 2003, he says, quality care was defined by:
Those are … aspects of quality that are important,” says Zettel, “but now our expectations of quality are a lot higher. Today we know that quality means doing a better job of measuring outcomes, looking at a patient’s care longitudinally, and working in an active partnership with patients to help manage their care. No one was even thinking about that back in 2003.”
“There’s the old saying that the fool with a tool is still a fool,” he adds. “When you’re implementing an EHR or any sort of healthcare IT application, you’re really transforming the way you practice medicine.” Zettel likens this to embarking on a journey with the understanding that “your success depends on whether you have the buy-in of everyone on your practice team.”
Sarasohn-Kahn agrees. Without team effort, she says, even the most top-of-the-line EMRs won’t accomplish a thing. “The EHR is necessary,” she says, “but it’s not sufficient.”
Just like everything else in life, you must take time to fully master this potentially invaluable piece of software. After that, tell the researchers to bring it on, says Lamberts. “With a good EMR, you set the bar and we can reach it.”
Barbara A. Gabriel has served as editor and writer for numerous healthcare publications over the past 10 years. Want to comment on this article? Please e-mail firstname.lastname@example.org.
This article originally appeared in the July/August 2008 issue of Physicians Practice.