Wednesday, August 1, 2012

What The Electronic Health Record (EHR) Can, and Cannot, Do

"The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will  improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers."

"... lives can be saved, outcomes of care improved, and costs reduced by transforming the healthcare system through the appropriate use of IT and management systems."

While the breathless exuberance if the EHR cabal continues to spin on, the Disease Management Care Blog ran into two real world studies from strong institutions that tell it what the EHR can, and cannot, do.


In the first study, Kaiser Permanente of Colorado initiated an interactive voice response outbound telephone campaign to eligible patients that, according to its EHR, had not undergone screening for colon cancer. The call lasted 5 minutes and used the telephone keypad to solicit additional information and patient preferences about screening. If the call was not completed, a mail-in screening packet was sent to the patient with a reminder letter 4 weeks later. In addition to the IVR campaign itself, there were other provider as well as staff educational and promotional campaigns, individualized physician reports and quality incentive programs. Patients with known high risk (for example, a history of polyps), removal from the screening program by request of their doctor or evidence of prior screening were not included. 58,440 patients got the IVR.  Their mean age was 59 years and 53% were female.

Results: 45% of those exposed to the IVR eventually completed the screening.

In the second study, the Veterans Administration "VistA" EHR was mined to find patients who had received at least 2 separate prescriptions for a cholesterol lowering drug during a prior 9 month baseline period that was followed by an "absent" prescription.  If a "past due date" was found, it was assumed that the patient was having a problem with medication compliance. Of an initial 1000 "past due" patients, closer examination of the records revealed that 176 had gotten the drug.  Of the 824 left over, 95 had died and 17 had entered nursing homes which were supplying the medicine. Patients were then surveyed about their medication use and 302 indicated that they had been told by their physicians to stop the medicine, had had side effects, had switched to alternative treatments or had gotten their medicine from outside the VA system.

Results:  After all this, it turned out that only 20% of the patients who, according to the EHR, had prematurely stopped their cholesterol medicine, were correctly identified.

The most generous interpretation of both studies is that something is better than nothing.  The DMCB agrees but points out that having an EHR doesn't automatically lead to 100% cancer screening rates or 100% medication compliance.

In the colon cancer study, the authors had to turn to a free standing IVR system instead of using tools resident in the ER (physician prompts, automated patient letters) to achieve their cancer screening success.  The EHR was necessary, but not sufficient.

In the cholesterol drug study, researchers had to expend a lot of time and energy to clean up the EHR's data base. While 20% of patients at apparent risk will eventually benefit, finding these patients has gone from pulling individual paper charts to pulling individual patient data.

Improve decisions and outcomes?  Save lives? Reduce costs?  You be the judge. 


Anonymous said...

This is a great example of the need to integrate the EHR into an end to end healthcare solution, and not just assume the IT will solve the problem. The EHR is a requisite basis for developing such an integrated end to end solution, but understanding the clinical model is the key to successful healthcare.
I would argue the IVR solution is a good example of such integration, whilst the second suggest that not integrating all the data sources, not just the EHR is the problem.
Essentially the current problem is that we have been led to believe that the EHR will solve all our problems. It, like all other technologies, is a tool for enhancing our clinical models, not the solution.

Jaan Sidorov said...

Well said!