If they save money and don't kill you, digital records could save healthcare
Study shows no improvement in care; but ignores main goal
This could be an awkward week for some in the healthcare industry.
Especially those working on IT projects being funded by as much as $27 billion set aside by the Obama administration to help get the U.S. healthcare system to upgrade from its record-keeping from the paper, parchment and cuneiform it loves so much to actual computerized versions everyone can use.
Yesterday the Archives of Internal Medicine published a study from Stanford showing that, even when paired with decision-support tools designed to make complex decisions simpler and more accurate, EHRs may do little or nothing to improve the quality of care patients receive.
"I believe this study suggests that it is naive to believe that the simple presence of an electronic health record or even these systems with more advanced functionality will by themselves change the quality of care," according to an interview Reuters did with the lead author, Randall Stafford of Stanford's Prevention Research Center.
A similar study Stafford published in 2007 looking at EHRs without decision support returned the same result.
The study is getting a lot of exposure and a lot of discussion online, but it faces the wrong direction to get a result that's relevant to most of the industry and those who pay for or rely on it.
The study focuses on whether or not EHRs improve the quality of care, and is a surprise because it is logical to think they would.
It doesn't look much at the cost or efficiency of supporting, delivering and paying for care, which is the real point of the pressure to upgrade to digital records.
It's not that Stafford is wrong, or even offbase, really. He's no piker -- faculty member at Stanford and Harvard, PhD, fellowship in epidemiology at the Centers for Disease Control (which is like going to the Vatican to study how design big, silly hats and dignified-looking bathrobes for men).
He's also done a lot of research on how to improve the quality of care by changing the way doctors run their offices and how they interact with patients. Things like how the way they give physical exams, the types of questions they ask patients, how much time they spend with each patient, rather than focusing strictly on things that ooze or scream when you poke them.
That's exactly the kind of process analysis that would show the benefits EHRs are supposed to deliver, but only if the analysis focused not on the person doing the poking, but the number of people, amount of work and amount of time required to get all the information in one place that would give the poker the timely information he or she needed to know where to poke and how hard.
Right now getting a diagnosis from a specialist could involve collations of data that would give a DBA headaches. Your bloodwork might come from the hospital's lab in the basement, which puts all its data on a server that may not be accessible to independent specialists like yours, who only rent space in the hospital and don't have to adhere to its IT standards.
Knowledge of your innards could come from an MRI clinic across the street that deafened you while magnetizing your gut and routes gigantic image files only through secure, high-bandwidth network connections for which the specialist has to pay extra.
Your main medical record has to come from your primary doc, couriered over in a file folder filled with paper and disks in incompatible file formats going back years. Without that record -- which includes those last two embarassing physicals and an explanation that the mass in your gut is a slow-healing lump from the time when you slipped a wheelbarrow poked its handle in your belly as revenge for having overloaded it in the first place -- the specialist might send you down for surgery, not out for ice cream on the way home.
So far, though, only half of U.S. hospitals have even qualified for the upgrade program, only 12 percent completed adoptions of ERH systems as of January, 2010, and fewer than 2 percent were doing enough with them to qualify for the TARP money.
Just getting the record together, let alone collecting and updating it within each office or dealing with insurers to pay for everything, is so huge a pain that allowing it to continue with a mix of paper and non-standard digital formats is criminally stupid and fiscally irresponsible.
Medical-support staffs, to give them their due, make the whole gummed-up red-taped-up process work, though no one knows exactly how.
Picture a broken aqueduct that still delivers a reliable water supply because people with buckets fill the gap, filling up on one side and pouring out on the other, as most of the water goes to waste soaking them and eroding the base of the structure.
A 2009 study of physician practices estimated that, nationwide, the cost of dealing with insurance companies in the U.S. is between $23 billion and $31 billion per year.
The study found each doctor needed two-thirds of an administrative worker's time just to deal with insurance companies, at a cost of $85,276 per physician.
That's about 10 percent of the gross revenue for each doctor's office, and 6.9 percent of all the money spent on doctors every year.
That's out of a total of $2.5 trillion spent on healthcare in 2009 in the U.S., according to the Dept. of Health and Human Services -- a total of $172.5 billion every year.
A 2007 study from the University of Rochester Medical center found switching to electronic health records saved a net $9,983 per health-care provider, at a time when adoption of standardized EHRs was so small that their benefit to the efficiency of the whole system was still minimal.
A more recent study showed that even physicians' offices that are not owned by or located within major hospitals -- the most isolated and reputedly the lowest-tech offices -- can increase net revenue almost $50,000 per physician when using EHRs, compared to those using paper records.
One office in the study cut labor costs by 10 percent, but office supplies by half and increased billing for services it was already providing by 15 percent.
As of October of 2009, only 1.5 percent of doctors' offices were using EHRs in a comprehensive way, and only 10 percent of hospitals had completed the switch.
Pretty pathetic. And the pace may slow if the pressure lightens up at all on recalcitrant portions of the industry (doctors) who would rather run things the way they always have than switch to one someone else invented.
That would cost, and continue to cost, the rest of us a lot more than $27 billion.
If there are investigations to be carried out of the legal or economic variety, rather than medical, it's the failure to upgrade we should be looking at, not changes in the quality of care that are only partially relevant.
The Stanford study is probably right that switching to digital records alone won't improve the quality of patient care.
Not doing it will continue to make care so expensive that insurance companies get to continue to call as many of the shots as doctors and whether or not to go see someone about a cold that might be pneumonia becomes a major economic question, not just one that depends on how gross things get when you sneeze.