This Part 1 of 2 posts concludes “yes”
The following are
interview excerpts from F David Winter, Jr, MD, MSC, FACP
The excerpts from the interview with DAVID
WINTER, MD can be viewed on the documentary website, http://www.emr-ndr.net
IN: Some broadly publicized studies have examined the effect
of EMRs on medical costs and quality of care.
F. DAVID WINTER, JR.: A Rand study indicated EMRs would reduce medical costs and improve quality of care; but a Harvard group questioned whether hard evidence existed to support Rand’s findings.
IN: Have you had changes in costs and quality of care since your EMR system was implemented?
F. DAVID WINTER, JR.:
Costs have not decreased. EMR systems are expensive to install and maintain; I
do not expect ours to reduce total costs. On the other hand, we used to spend
much more on transcription; we have reduced costs there and could end up breaking
even.
F David Winter, Jr, MD, MSC, FACP
David Winter serves HealthTexas Provider Network, a 475+
physician organization in partnership with Baylor Health Care System, as its
Chairman of the Board and Chief Clinical Officer. He also is in the private practice of
internal medicine at the Tom Landry Center
on the campus of Baylor
University Medical
Center
END of
excerpt
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The authors of a Rand paper (Hillestad, Bigelow et al. 2005) state that health information technology can decrease healthcare costs in the USA. In this paper, health information technology (HIT) which is also referred to as electronic medical record (EMR) systems include the EMR, clinical decision support (CDS), IT-enabled functions and a central data repository (CDR) for the information. EMRs contain present and past patient information. CDS presents best practice protocols for patient treatment. An example of an IT-enabled function is computerized physician order entry (CPOE). CDR is the database that contains all this information. (Hillestad, Bigelow et al. 2005) Most medical records are in paper form. Therefore, the information on the paper cannot be easily used to coordinate patient care, measure quality or track medical errors.
The National Ambulatory Medical Care Surveys, produced by
the CDC, did a national probability sample survey of nonfederal office-based
physicians.” In 2005, 23.9 percent of the physicians polled had adopted an EHR.
The numbers have steadily risen with a 48.3 percent adoption rate at the end of
2009.” (Hsiao, Hing et al.)
The central assumption of this Rand study that EMR systems
can influence healthcare cost savings, improve healthcare outcomes and patient
safety is based on the assumption that “interconnected and interoperable EMR
systems are adopted widely and used effectively."
The
impact of vendor barriers to sharing
information was emphasized by the Rand study’s “lower-bound estimate of
HIT adoption which assumed an integrated system that had an EMR, clinical
decision support, and a central data repository—from the same vendor to ensure
interoperability.”
The “estimation
of potential HIT efficiency savings” was based on a “literature survey” to
identify “evidence of HIT effects”. Expert opinion was sought for their opinion
of this evidence. The authors conceded that the “evidence is not robust enough
to make strong predictions, and we describe our results only as
"potential." Nonetheless, the authors believe that their estimates
are most likely an underestimation of the healthcare cost savings due to a
number of factors not included in their analysis. Other factors such as “as
transaction savings, reductions in malpractice costs, and research and public
health savings” can reduce costs as a result of using EMR systems.
Interconnected EMR systems may be more effective, than current sources of
medical information, in providing data that characterizes the effectives of
patient treatments. Potential changes in
the cost and quality of long term care between the current systems of medical
information with a fully integrated EMR system is not included in this study’s
estimates.
The authors did not include evidence of a “negative or no
effect of HIT” because they felt that such a result would be due to
“ineffective or not-yet-effective implementation [of EMR systems].Our next blog issue will focus on
analyses that do not indicate that EMR systems will result in large healthcare
savings.
The authors assumed a ten- and fifteen-year adoption periods
“and excluded products that did not have most of the desirable features of an
ambulatory EMR system.”
The authors estimated the “potential safety benefits” by
using medication error and adverse drug event rates from the literature, as
well as limited evidence of CPOE’s reduction of medication error rates”.
Interventions for disease prevention and chronic disease
management were used to estimate “other potential health benefits” that would
result from the use of “key features of HIT”. The authors used the “literature
and clinicians’ opinions regarding the effect of the interventions” to
calculate the “potential safety benefits” that would be realized by the use of
EMR systems.
The authors analyzed evidence from other industries
(telecommunications, securities trading, and retail and general merchandising)
that adopted IT for its impact on productivity.
The impact of IT on these industries over more than years can be seen
with the introduction of “bar-coded retail checkouts, automated teller
machines, consumer reservation systems, and online shopping and brokerages.”
Experts estimated that about 25-35% of the 6-8 percent of the annual
productivity growth was related to its “IT investments”. On the other hand, the
hotel industry did not experience a significant increase in productivity
presumably because it “underused its IT investment”. The authors estimated
productivity gains in healthcare over an 8 year period to be from 1.5% to 4%
annually. This represents the productivity gains in retail/wholesale and half
of that realized in telecommunications. This represents an “average annual
[healthcare] spending decrease of $346 billion, and the upper end, $813
billion. “
The authors identified
6 “ingredients” that were needed to achieve a productivity growth that
was realized by “the telecom and securities industries: gains of 8 percent or
more per year, year after year”. The ingredients were “strong competition on
quality and cost, substantial investments in EMR systems, an enhanced
infrastructure that can accommodate increased future demand or reduce costs
without increasing labor, a strong champion firm or institution that drives
change and integrated systems”. Most of
these factors are “absent” in our healthcare industry.
The Potential Efficiency Savings from HIT were based on the
assessment of decreased costs from both outpatient and inpatient activities
based on “a simulation model of HIT adoption and scaling literature-based HIT
effects”. The outpatient activities included transcription, chart pulls, lab
tests, drug usage, and radiology. The inpatient ones were nursing time, lab
tests, drug usage, length of stay and medical records. The largest sources of
the estimated savings were from “reducing hospital lengths-of-stay, nurses’
administrative time, drug usage in hospitals, and drug and radiology usage in
the outpatient setting.”
The authors estimated that at 90% adoption rate of EMR
systems would results in average annual savings of $77 billion. This estimate
is smaller than the “annual IT-enabled productivity gains just described in
other industries”. “Process changes” and
“resource reduction” are needed to realize this savings rather than “radical
changes in the health care delivery system”. These efficiencies and costs
savings could be used to improve health care quality. Healthcare providers,
according to the authors, have less incentive to purchase EMRs because there is
usually a net revenue loss from this expense.
In February 2009, Congress passed a stimulus bill allocating
$150-billion to healthcare. A large portion of this, thirty-six and a half
billion dollars, is for health information technology. Most of these billions
will be spent on electronic medical records (EMRs).
CPOE is at the heart of the potential safety benefits of EMR
systems with its use of reminders, alerts and other components contained in
this system. “CPOE makes information available to physicians at the time they
enter an order”. This is called “decision support”. Drug-drug interactions are
such an example. These systems can track each step involved in a drug order and,
therefore, enable it to update the process when errors are discovered. In the
in-patient setting, alone, the authors estimate a $1 billion per year savings
by reducing adverse drug events. Length of hospital stay, in this estimate, is
significantly impacted by decreasing adverse drug effects in those older than
65 years of age. The amount of hospital bed days caused by adverse drug effects
is so large that estimated savings accrues even though this age group comprises
only 13% of the population. There is less data on the frequency of adverse drug
events in the out-patient setting and, hence, on the estimated savings that might
accrue due to a reduction in such events. But, small practices such as the solo
practioners could comprise about 37% of the potential savings in this
out-patient setting. (Wang 2003)
The potential health benefits of EMR systems are based on
two interventions: disease prevention measures and chronic disease management. The following components of EMR systems will
be used to realize improved safety benefits: “communication, coordination,
measurement, and decision support.” These components will allow a reduction in
the 50% failure rate of physicians to deliver the recommended care to their
patients. The cost of caring for patients with chronic disease consumes 75% of
the national health care dollars. (McGlynn, Asch et al. 2003) Similar failure rates found
in adults to delivery care were found in children. ."(Mangione-Smith,
DeCristofaro et al. 2007)
Reactions to the McGlynn study have ranged from agreeing
with its predictions and suggesting that future studies should look for
improvement of these numbers (Steinberg 2003) to skepticism that the authors
recommendations can be carried out in a significant manner because physicians
workloads presently leave little room for a significant increase in hours
worked that would be required to implement the changes they recommend. (Spiegel
and Pechlaner 2003)
Another aspect in the ability of EMR systems to achieve
health care benefits is through the use of health information exchange regional
health information network (RHIN) or personal health records can facilitate the
more accurate flow of patients’ medical information with multiple chronic
illnesses between different physicians’ and hospitals. This issue will be
discussed in a future blog.
EMR systems use “patient data (such as age, sex, and family
history)” to identify patients needing “preventive services (such as screening
exams)”. Reminders have been shown to increase patient compliance “with
preventive care recommendations” when they are used during routine patient
follow up visits. (Burack 1997 )
Although increased compliance results will increase health
care use and cost “modestly.” The authors estimate that cervical cancer
screening can increase life years gained as a result of this screening by
13,000 at a cost of $0.1-0.4 billion.
Using HIT for near-term chronic disease management
Over a 3 year period through 2000, 15 chronic diseases
accounted for 50% of the increase in healthcare expenditures, 5 of which
accounted or 31% of that increase. (Thorpe, Florence et al. 2005)
EMR systems can use predictive modeling algorithms to target
high risk populations for specific types of interventions that can prolong
survival, decrease complications and costly acute interventions.
The authors of the Rand study stated that using national
disease registries allows for physicians to compare their performance to
others. Electronic messaging can facilitate communications between patients,
specialists and remote home monitoring of a patient’s data. This allows health
care provides to quickly respond to a developing medical problem. Web based patient
education can “increase the patient’s knowledge of a disease and compliance
with protocols.”
Improved control of acute care episodes of four common
chronic diseases, asthma, congestive heart failure (CHF), chronic obstructive
pulmonary disease (COPD), and diabetes with EMR system management resulted in a
decrease of admissions to hospitals decreases and increased outpatient office
visits and use of prescription drugs for a net decrease in the cost of managing
these diseases by as much as $10 of billions of dollars per year.
The authors identified a “key misalignment of incentives”,
the savings resulted from a decrease in acute care provider income, which is an
“important barrier to EMR adoption.
“Since chronic diseases are, by and large, diseases of the
elderly, a large fraction of the long-term savings attributable to prevention
and disease management would accrue to Medicare. Yet, to realize these
benefits, people would have to begin participating in these programs as
relatively young adults.”
“We estimated the potential combined savings, again assuming
100 percent participation, to be $147 billion per year.”
For these benefits to be realized a “a substantial portion
of providers and consumers participate.” The authors assume that about half of
the patients will be compliant with the EMR systems because that is the
percentage that complies with their medical therapy. (Haynes, McDonald et al.
2002) Only about 10% of patients comply
with physicians’ lifestyle recommendation. (Roter, Hall et al. 1998)
The authors assume that with “EMR-based reminders and decision support and
patient-physician messaging, we could realize at least 20 percent of the
long-term benefits.” This represents a net savings on the order of $540 billion
per year.
The estimated of the costs of implementation of EMR systems
in physician offices in the United States has been in the range of “$28 billion
per year during a ten-year deployment, $16 billion per year thereafter and net
savings ($21.6–$77.8 billion per year, depending on the level of
standardization) of a broadly adopted, interoperable EMR system.” For hospitals, the “cumulative cost for 90
percent of hospitals to adopt an EMR system is $98 billion if 20 percent of
hospitals now have such a system.”
The net cumulative and yearly potential savings
For hospitals and physician practices, the benefits over
costs from EMR systems could be nearly $371 and $142 billion over fifteen
years. This benefit doubles if the “savings produced by chronic disease
prevention and management were included. “
Although the authors predict that “potential savings would
outweigh the costs relatively quickly during the adoption cycle” of EMR
systems, there are barriers that might impede the “adoption and effective
application of EMR systems”. These are the “acquisition and implementation
costs, slow and uncertain financial payoffs, and disruptive effects on
practices… providers must absorb the costs of EMR systems, but consumers and
payers are the most likely to reap the savings and the market might fail to
develop interoperability and robust information exchange networks. “ (Bates,
Ebell et al. 2003; Miller and Sim 2004) Because of this the authors conclude
that there is a “substantial rationale for government policy to facilitate
widespread diffusion of interoperable HIT.”
Richard Hillestad (Richard_Hillestad@rand.org) and James
Bigelow are senior management scientists at RAND in Santa Monica, California.
Anthony Bower is a senior economist there; Federico Girosi is a policy
researcher; and Robin Meili is a senior management systems analyst. Richard
Scoville and Roger Taylor are senior consultants at RAND Health—Scoville, in
Chapel Hill, North Carolina, and Taylor, in Laguna Beach, California.
This report is a product of the RAND HIT Project. It
benefited from the guidance of an independent Steering Committee, chaired by
David Lawrence, and was sponsored by Cerner, General Electric, Hewlett-Packard,
Johnson and Johnson, and Xerox.
Updates from literature since this
publication:
A review of just a few of the more recent publications that support
the RAND HIT Project’s predictions are summarized.
The Health Information Technology for Economic and Clinical
Health Act (Blumenthal 2009)has provided incentives for the adoption and
implementation of EMR systems.
Miler describes a 10 percent increase in births that occur
in hospitals with EMRs reduces neonatal mortality by 16 deaths per 100,000 live
births as a result of EMR “assisted careful monitoring” . The authors calculated “cost-effectiveness”
valued at $531,000 per baby's life saved. (Miller and Tucker 2011)
The use of the EMR was associated with a significant
reduction in hospital mortality in trauma patients. (Deckelbaum, Feinstein et al. 2009)
The adoption of EMR systems allowed an increase in chart
reviews which resulted in an increase in antimicrobial recommendations. This
was associated with a sustained decrease in antimicrobial use and nosocomial
infections with methicillin-resistant Staphylococcus aureus following
implementation of the EMR. (Cook, Rizzo et al. 2011)
Summary
In summary, the authors of the Rand paper outline the basis
for their projections of large cost savings with the implementation and
widespread use of EMR systems in the USA. Two of the ingredients, discussed in
this Rand paper, strong competition on quality and cost and integrated systems,
will have a limited impact on the EMR systems’ ability to deliver such savings until
the present barriers of patient privacy regulations and the proprietary nature
of medical information can be adjusted to accommodate the sharing of medical
information between hospitals and physicians.
(Blogs 1, 2, 3).
The assessment of the quality of patient outcomes in an more
accurate manner then is done today would require that medical databases use the
master patient index (MPI) that allows the tracking of individual patient
treatments and outcomes as compared to the standard of “de-identified data”
used in medical databases across the country except for a few states like Utah
that uses the MPI. Nonetheless, that the state of Utah was able to introduce
the MPI to replace the use of de-identified data in its state medical database
indicates that patient privacy and proprietary medical information can co-exist
with this method of tracking individual patient outcomes.
Another issue raised by this Rand paper is that Americans
will have to start making value judgments about the cost of extending patients’
lives which medical innovations allow. The EMR systems will be an integral
component of this process as discussed in this paper. For example, an increase
in patient compliance with cervical cancer screening can increase life years
gained as a result of this screening by 13,000 at a cost of $0.1-0.4 billion. This
comes out to a healthcare expenditure of $7,692 to $30,769 per patient for each year
of life extended for the high and low end estimated cost of the screening.
Clearly, each country has to decide the value that the
public and private healthcare sectors will pay for each year of life that is
extended by such screenings. Today, such decisions are made on a case by case
basis in committees that, often, are not transparent to the public, by private
insurance companies and the federal government. As the economist, John
McCracken, said in the documentary, “EMR and Healthcare Reform” which can be
found at www.emr-ndr.net, there is no
right or wrong answer to this issue. It is a matter of values.
Part 2 of this topic will be in the next blog which will
present the case that the large cost of implementing EMR systems in all
hospitals and physician offices in the USA, estimated by some experts to be
more than $100 billion over a ten year period, will not realize the large
healthcare dollar savings that experts on the Rand panel have predicted. Some experts have said that the cost to
implement the federal mandate to install EMR systems nationwide by 2014 could
be one of the most expensive failed federal government initiatives because
these EMR systems cannot produce the cost savings that experts have predicted
relative to the cost of implementing these systems.
Words 3135, 3523 with references, 3688 with
references and footnotes
Metamorphoses
Healthcare is a non-profit organization that advocates for the establishment of
a national disease registry as an adjunct to the federally mandated purchase
and installations of EMRs in all hospitals and physician practices by 2014.
The
views presented in this organization’s documentary, “Electronic Medical Records
and Health Reform”, focus on physicians' opinions about these issues. These
physicians represent a diverse group. They are from a different background in
regards to race, ethnic ancestry, religion, regions of the country, medical
specialties, and political views (from conservative to liberal viewpoints).
The
goal of this organization is to identify reforms that benefit the quality of
patient care outcomes. We do not advocate a particular political point of view.
That is we are a non-partisan organization.
A
transcript of the full interview will be sent with the purchase of DVD of the
documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM. http://www.emr-ndr.net/index.html
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