Electronic Health Record Portals: So What Is the Evidence That Supports Their Use?

Talk about a compelling story that went ignored.

In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesn't mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portal's stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, referrals and prescription referrals as a standard for the medical home.  Finally, the Fed's promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

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Another Study on Electronic Health Records Fails to Show Cost Savings

Like President Obama's search for the precise rhetoric that can finally turn Republican obstructionism into cooperation, as well as Governor Christie's search for the one cure that turns girth into svelteness, electronic health record (EHR) advocates keep looking for that one EHR study that proves that their financial black holes are really sources of profitability.

News reports like this suggest that this just-published Annals paper is that study. Unable to help either President Obama or Governor Christie, the curious DMCB took a look at the EHR manuscript.

Alas, it came away disappointed. EHRs have yet to consistently "save money."

The DMCB explains.

The Massachusetts eHealth Collaborative (MAeHC) has been promoting the community-based installation of EHRs since 2006.  32 Bay State communities applied for their assistance.  Three were selected.  Thanks to MAeHAC, by January 2008, 167 outpatient physician clinics (86% of the total in these communities) were outfitted with one of several commercially available EHRs.

The cost  to MAeHC was a whopping $130,822 per provider.

Realizing a "natural experiment" outcomes study could be fashioned, considerable demographic analytics and statistical effort was used to identify which non-EHR communities most closely resembled the three winners described above. Six communities were selected as comparisons. Two (unnamed) commercial health insurers provided claims data for the patients in the three EHR communities and the six best-matched non-EHR communities.

Keep in mind that the health care system has an ongoing background rate of cost inflation. In this study, the baseline period ran from January 2005 to March 2006 (before the EHRs were installed anywhere), while the EHR-live period ran from January 2008 to June 2009. This allowed the researchers to compare the two community groups' increases in health care claims expenses compared to baseline once the EHR went live.

After looking at more than 4.8 million patient-months worth of data, the researchers found:

Total health care costs increased over baseline by .78% in the EHR communities vs. 1.09% in the non-EHR communties.  This .31% difference was not only small, it failed to achieve statistical significance.

The per member per month (PMPM) costs went from $151 to $173 ($22 increase) in the EHR communities vs. going from $155 to $179 ($24 increase) in the non-EHR communities.  Once again, tests of statistical significant indicated these small shifts could have been the result of randomness. 

When categories of health care utilization were examined, there was no meaningful impact on inpatient or pharmacy utilization.  The two pieces of good news were that a) the trend for ambulatory (or outpatient) favored the EHR communities (.41% baseline to 1.12%) vs. the non-EHR communities (.14% baseline to 1.2%), and b) the trend for radiology studies favored the EHR communities (1.03% baseline to .6%) vs. non-EHR communities (-.25% baseline to .94%).

For the 25% of the study population with one or more chronic conditions, there was no impact on total or ambulatory cost trends.  Radiology, however, showed a statistically significant shift that favored the EHR.

The authors relied on trend calculations to calculate how the PMPMs would have compared in the intervention vs. control communities.  Even though the savings of $5.14 was not statistically significant, the authors projected a 7 year timeline "... to recoup the projected 5 year adoption cost in the (EHR) communities of $130,822 per provider."
 
The DMCB's take

Despite the pro-EHR spin, this Annals article falls far short of being a study that the medical-technological complex can use to justify its existence. The bottom line is that costs did not drop in statistically significant (p less than .05) or financially significant (a seven year return based on a faux $5 PMPM savings) manner.  Let's be honest: there is only one beneficiary of the MAeHC $100K per doc investment, and it's not the patient, the providers, payers or government: it's the vendors that sell these systems to a technology-addled health system with the collusion of too many naïve policymakers.

If ACOs really think their EHR systems are going to be the panacea that helps them tame health care costs, this study tells them that they may be in for a nasty surprise.

The good news here is that this research suggests that the EHR may have had an impact on ambulatory care and radiology claims expense.  The DMCB says "may" because it knows that multiple subgroup comparisons can generate statistically significant findings faster than med-mal plaintiff attorneys around a dollar bill.  Even if the impact is real, the miniscule savings were washed away by the tide of total costs and hardly meet the original vision of President Bush or HITECH.

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Going Long on the Patient Centered Medical Home (PCMH) Despite the Prattling Pinheads of Pessimism

Is the Disease Management Care Blog worried about the prognosis of the Patient Centered Medical Home (PCMH)?

Not in the least.

It's simply marching from its "Peak of Inflated Expectations" through the "Trough of Disillusionment." Before you decide to short the PCMH, check out this very enlightening Bloomberg editorial, Lure More Doctors Into Primary Care With 'Medical Homes.'

Noting that many commercial insurers remain committed to the medical home model of care, Bloomberg's business-savvy editorial board also points out that the PCMH has the added quality of attracting physicians to careers in primary care. The Josia Macy Jr. Foundation has some preliminary data suggesting that experience in medical home settings increases medical students' enthusiasm for primary care.

It's a timely article.  While prattling pinheads of pessimism (examples here and here) glom onto imperfect research methodologies and findings that are unequal to the task at hand, top notch organizations like Sutter, University of Pittsburgh Medical Center and Horizon Blue Cross Blue Shield are going long on the PCMH.

These guys know something that the academics are missing.

Too bad there isn't a PCMH futures market; the DMCB could make some serious money.

Image from Wikipedia

Being Bullish on the Patient Centered Medical Home, Despite What the Annals of Internal Medicine Has To Say

The Disease Management Care Blog recently received a curious email from the Patient Centered Primary Care Collaborative.  As readers may recall, this is the Washington DC-based coalition that advocates on behalf of the Patient Centered Medical Home(PCMH). 

The content of that rather defensive communication can be found here.

What provoked this? The premier internal medicine specialty journal, the Annals of Internal Medicine, published a comprehensive review of the peer-reviewed literature on the PCMH, and its authors skeptically concluded:

The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes

Ouch. No "economic outcomes" means that there is no proof that the PCMH saves money.

Unlike the PCPCC membership, regular DMCB readers aren't surprised.  For example, the DMCB pointed out months ago that the U.S. government's Agency for Healthcare Research and Quality ("AHRQ") had concluded the same thing.  Countless other DMCB posts on the medical home have pointed out that there were problems with the published PCMH literature (for example, here and here).

Thanks to a past Congressional Budget Office report, the DMCB feels the PCPCC pain. It also knows that a) finding statistically significant cost savings in health insurance data bases are notoriously difficult, b) successful medical home initiatives that are outside the academisphere are the least likely to be reported it in the peer-reviewed literature, c) "savings" isn't the only measure of patient value and d) journals like the Annals of Internal Medicine are being sidelined by innovators who are more astute judges of what works for their patients.

What's changed for the medical home and the PCPCC after this unpleasant dust-up?  Ultimately nothing. Pairing nurses and physicians in team-based care, whether it's done remote telephonic "disease management" style or in the clinic "medical home" style is ultimately a good idea with obvious face validity. The Annals' problem is that we don't have pristine scientific methodologies that can identify, capture and measure the benefit.

The good news is that the science is getting better. Until it catches up, the population health and disease management service providers will remain in business and the medical home will continue to have a bright future.