EHRs and their Impact on Quality of Care

Headlines this week have provided much confusion in the march towards digitization of healthcare that were based on a Stanford study published in the Archives of Internal Medicine: Electronic Health Records and Clinical Decision Support Systems with a conclusion:

Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

Needless to say a strong negative claim from a leading institution attracted a lot fo coverage (Medscape, Reuters, Health Data Management, iHealthBeat,  DotMedNews, Bloomberg.....and the list goes on). The power of the internet and the instantaneous nature of the news allows these stories to rapidly disseminate.

In fact some of this will add fuel to the HR408 Act  Spending Reduction Act of 2011 (the text of this can be found here). It is a far reaching bill attempting to reign in spending to the tune of 2.5 Trillion and includes several elements focusing on repeal of Healthcare IT stimulus spending S:302 which focuses on repealing the HITECH funding and investment - there was a good analysis in Health Data Management GOP Bill Puts Meaningful Use, HITECH Act in Peril that highlights the murky nature of the impact of this legislation.

But the power of the internet works both ways and there are several great articles that apply a sound analytical view on the study and highlight the limitations of the study. In this piece Dr WIlliam Hersh; Electronic Health Records Do Not Impact the Quality of Healthcare takes a long hard look at the study adn as he points out

Like almost all science that gets reported in the general media, there is more to this study than what is described in the headlines and news reports. The study was published in a prestigious medical journal by two Stanford researchers. The implementation of the research methods they used appears to be sound.

But as he points out there are serious limitations to this type of study based on the type of study and the data resources, in particular the study "used a data source collected for other purposes and he highlighted the following limitations:

1. A frequent challenge - the study looks at correlation, which does not mean causality
2. The quality measures used did not provide enough insight into actual quality improvement (process measures vs outcome measures)
3. No detail of the EHR's being used and if they had any decision support in place relative the the quality measures
4. THe care assessed was individual episodes of care and improvements in actual quality occur over multiple episodes of care (the longitudinal medical record)
5. Data analyzed was old (2005 - 2007) and in any field of technology including Healthcare Informatics this is old
6. No indication of the training and skill set of the clinicians being assessed and success and failure fo EHR's goes far beyond the technology and is closely tied to implementation and training

And there was extensive discussion that pointed to other articles and studies highlighting the benefits and in particular emphasize how early we are in this process. I imagine that for several other key inventions there was a similar response:

• The Electric light bulb
• Telephone

This 'telephone' has too many shortcomings to be seriously considered as a means of communication. The device is inherently of no value to us.

Western Union Internal Memo: 1876

• Automobile
• Microprocessor
• And even the internet and the world wide web

THis follow up piece by Clem McDonald: Clinical Decision Support and Rich Clinical Repositories: A Symbiotic Relationship that highlighted a range of other positive studies and identifies significant breakdown in the meta analysis that was carried out. As he states succinctly:

• First, and most important, the current article tells us nothing about which CDS guidelines were implemented in the systems that they studied. Practices and EHRs vary considerably in the number and type of CDS rules that they implement, and we do not know whether the CDS rules implemented by the practicesthat participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford.
• Second, the current study and Garg and coauthors' review considered very different categories of guidelines. Most of the guidelines (60%) in Romano and Stafford's study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg et al.3 Furthermore, in our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization.
• The third difference is that the current study examined the outcome of a single visit, while most of the trials reviewed by Garg and colleagues observed the cumulative effect of the CDS system on a patient over many visits.
• Finally, the data available from NAMCS/NHAMCS may be limited compared with what is contained in most of the EHRs used for Garg and coauthors' trials. For example, the NAMCS/NHAMCS instruments have roomto record only 8 medications, even though at least 17% of individuals older than 65 years take 10 or more medications.

The road to digitization of healthcare is long and filled with many ups and downs. This study adds the overall knowledge but should be taken in the context of what was studied and its contribution to guiding us down the correct path and not, as some would believe> halting the journey and returning to the dark ages of pen and paper.

Posted via email from drnic's posterous

Radiology Examinations - How Much is Too Much

As is often the cases conflicting information in the media on the benefits of screen, x-rays and healthcare.
This piece in the NY Times: CT Scans Cut Lung Cancer Deaths, Study Finds suggests that annual CT Scans of current and former smokers reduces the risk of death form lung cancer:

Annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent, a huge government-financed study has found. Even more surprising, the scans seem to reduce the risks of death from other causes as well, suggesting that the scans could be catching other illnesses.

And while there does seem to be some benefit as Dr Patz (professor of radiology at Duke who helped devise the study) put it:

he was far from convinced that a thorough analysis would show that widespread CT screening would prove beneficial in preventing most lung cancer deaths. Dr. Patz said that the biology of lung cancer has long suggested that the size of cancerous lung tumors tells little about the stage of the disease. “If we look at this study carefully, we may suggest that there is some benefit in high-risk individuals, but I’m not there yet,” Dr. Patz said.

And before you run out the door to get your CT scan its worth taking note of Dr Ben Goldacre's insightful blog Bad Science that takes a hard look at the science behind claims and does a great job debunking the myths and taking a hard look at statistics. But as we have seen over the last few months there is an increasing focus on excessive use of imaging technologies. Earlier this year the Imaging e-Ordering Coalition (Co Chaired by our very own Scott Cowsill) Successfully made a case to congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation:

the Coalition is making several recommendations to policy makers in Congress and CMS...One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR's appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.

In recent news the Healthcare alliance aims to improve the imaging process, Changing the Game the coalition continues to push for

E-Ordering, also referred to as clinical decision support (CDS) (to) provide(s) physicians with real-time, electronic access to pre-exam, case-by-case decisions linked to evidence-based clinical guidelines and tailored to a patient’s specific circumstances

and cites a 7-year study at MGH (pub 2009) that showed a dramatic decrease in the growth rates of several imaging exams

• CT exams down from 12% growth to 1%
• MR exams down from 12% dropped to 7%
• Ultrasound down from 9% to 4%

So with that in mind the concurrent news that Minnesota’s Institute for Clinical Systems Improvement (ICSI) is spearheading the First Statewide Effort to Help Ensure Patients Receive Appropriate High-Tech Diagnostic Imaging Tests that is targeted to save Minnesota healthcare community more than $28 million annually (this was the savings estimated from the year long pilot with 2,300 physicians from five Minnesota medical groups, five health plans taking part. You can read more about it here, and here in the Star Tribune in Minneapolis St Paul and here on ZDNet

The process and challenges are outlined in this video:



Showing how you can help the busy clinician by providing them with a simple, intelligent and above all standardized appropriateness criteria to guide the clinician in ordering the most appropriate study for the patient at the time of consultation. This improved patient satisfaction, clinic efficiencies and reduced administrative costs. While there will be those who distrust technology over seeing clinical decision making the solution does not force or prevent clinicians from ordering the test they deem the most appropriate. What it does do is provide evidence based guidance on the suitability or clinical appropriateness of the test.

How do you feel as a patient or as a clinician on technology guiding care choices? Like it or not expect to see more as we continue to cope with a veritable Tsunami of clinical data, studies and discoveries that by some estimates require a doctor to read for 70 hours per week just to keep up in their one speciality.

Mixed Results from Healthcare IT Technology

In an interesting article in HealthAffairs this month "Mixed Results In The Safety Performance Of Computerized Physician Order Entry" (abstract only - subscription required for full article) the authors carried out a simulation of Computerized Physician Order Entry (CPOE) effectiveness.

It is a unique study with a relatively small sample size (62 facilities) that was self selecting that does represent some bias through small sample size, self selection and simulation vs reality. All that said there is still a surprising conclusion that

Many hospitals only detected 44% of adverse drug events and the best performing only detected 70-80%.

Not only is this wide variation and poor results for a very costly highly disruptive technology that is mandated in meaningful use. There is a clear need to validate the value of technology that is being suggested and especially if it is being mandated in the complex world of healthcare

These are, as many folks have commented to me  "very interesting times" but lets not loose sight of the science that formed the basis of some of the most significant advances in medicine encompassed in Randomly Controlled Trials.

Does your experience vary. Have you seen the value of CPOE or has it been a challenge in your facility?
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