The Impact Of EHRs On Patient Care

By Ken Congdon, editor in chief, Health IT Outcomes

More bad press for EHRs crossed the wire last week as results of a three-year study by researchers from the Stanford University School of Medicine indicates that EHRs do little to improve the quality of patient care. The study titled, Electronic Health Records And Clinical Decision Support Systems: Impact On National Ambulatory Care, analyzed data from nearly 250,000 patient visits in 2005 through 2007. EHRs were used in 30% of those visits and, according to the report, there was "no consistent association between EHRs and better care quality."

Personally, I'm starting to get pretty tired of these misguided studies. First off, a study that measures the impact of EHRs on the healthcare system would be premature even if conducted today, let alone one based on four- to six-year-old data. Why? The penetration rates and meaningful use of the technology are still relatively low. EHR adoption still only penetrates a fraction of the market (36.1% of physicians utilize EHRs according to a 2010 study by SK&A). This figure was less than half that in 2005 (14.1%). I equate this study with trying to measure the impact of electric cars on our environment. There simply aren't enough in play to draw any meaningful conclusions.

Defining "Patient Care"
Another problem I had with this particular study is the subjective nature of "patient care." How does one measure patient care? Well, Stanford University relied on 20 key indicators in 5 categories to make their assessments. These categories are: 1) pharmacological management of common chronic diseases; 2) appropriate antibiotic use in urinary tract infection and viral upper respiratory infections; 3) preventive counseling regarding diet, exercise, and smoking cessation; 4) appropriate use of screening tests for blood pressure measurement, urinalysis, and electrocardiography; and 5) inappropriate prescribing in elderly patients. Do these categories accurately sum up quality of care and the overall patient experience? I don think so. The initial value EHRs offer is availability of information. Having patient data at your fingertips and audited by a series of programmed checks and balances helps physicians spend more time with patients and respond to their needs more quickly. This is the immediate patient care benefit derived from EHR use. Through use of sophisticated clinical support capabilities embedded in many EHR products, many of the 20 indicators utilized by the Stanford study can also be better addressed. However, the fact is that only a small fraction of the 36.1% of physicians that use EHRs actually leverage these clinical support tools.

Evidence Of Impact
I was probably most troubled by the following quote by one of the study's authors, Dr. Randall Stafford: "There's a lot of enthusiasm and money being invested in electronic health records. It makes sense, but on the other hand, it's an unproven proposition. When the federal government decides to invest in healthcare technology because it will improve the quality of care, that's not based on evidence. That's a presumption."

No evidence? It took me less than 5 minutes to perform a search on our site using the keyword "EHR" to find a boatload of evidence that I could reference regarding the positive impact EHRs are having on patient care. While it may not speak directly to improved antibiotic use or diet counseling, I assure you it's stuff that patients (and clinicians) care about. Below are a few examples:

• Albany Obstetrics & Gynecology — Improved workflow as a result of EHR use enabled this provider to eliminate the 5 to 30 minutes it spent each day searching for each individual patient charts. This increased productivity allowed the provider to see more patients and shortened patient wait times. Furthermore, the ability for doctors on-call to access electronic patient records (including lab results) while out of the office improved the timeliness of patient care.
• Cottonwood Medical Center — With EHRs at their fingertips, patient inquiries are now handled in minutes instead of hours, lab orders are completed 50% to 75% faster, and pharmaceutical refills now take less than a minute as opposed to 24 hours. Furthermore, improved productivity as a result of EHR use allows physicians to see 10 to 20 additional patients per day with no additional personnel.
• Diabetes & Endocrine Associates Of The Treasure Coast — EHRs allow physicians to respond immediately to patient needs, where it used to take as long as 8 hours with patient charts. Furthermore, the checks and balances system embedded in the EHR software ensures that important patient data isn't overlooked or missed.
• Baptist Health South Florida — Deployment of an EHR system decreased the time nurses spent charting by 50%, enabling them to spend more time focused on delivering care to their patients.

I don't know about you, but this seems like some fairly compelling evidence to me.

Technology Alone Is Not Enough
While I disagree with Stafford on the evidence issue, I agree with him on another key point. In a news release about the study Stafford states, "Electronic health records and clinical decision support by themselves don't improve quality. If we want improved quality, we have to look at the whole range of issues that affect quality care and not put all of our hopes on a single technology."

He's right. Just like a car will do you no good if you don't know how to drive, simply plugging in an EHR system won't improve the effectiveness of your practice or the quality of care it delivers. Effective use of the EHR platform requires education, training, application integration, and established use policies and procedures. This was the failing of many EHR systems deployed prior to 2009, and exactly what the federal government is trying to correct with ARRA (The American Recovery and Reinvestment Act). The health IT stimulus funds outlined in ARRA don't simply award a provider for installing an EHR system, the facility needs to demonstrate meaningful use of the technology. Provisions are even set aside for special education and training on EHRs. When these EHR systems are installed correctly and medical staffs are properly trained to use them, the outlook for patient care is very promising indeed.

Ken Congdon is Editor In Chief of Health IT Outcomes. He can be reached at ken.congdon@jamesonpublishing.com.