It’s been interesting to watch the fireworks from a recent study in the Archives of Internal Medicine, Electronic Health Records and Clinical Decision Support Systems. People taking sides. In one corner, electronic health record (EHR) advocates (thanks, ePatient Dave). On the other, those not fond of EHRs or investments in health IT. I find myself standing in the middle. Polarized views about EHRs aren’t good for anyone — especially patients. You know, the people who all the stuff in EHRs is all about?
I’m a researcher and sometimes review manuscripts submitted to journals, so I’ll comment on the study, in a minute. First I’ll pose a few thoughts about factors, going forward, critical to the quality-EHR connection.
If EHRs are perpetually seen as professional-facing tools at the heart of care, we’ll be challenged to solve quality. If seen only as conduits to document encounters, deliver reminders and place orders, then the power of EHRs is underestimated. Context and intention are everything.
Long before EHRs existed, Edward R. Murrow , renowned American broadcaster/journalist, forecast their limitations. He said,
The newest computer can merely compound, at speed, the oldest problem in the relations between human beings, and in the end the communicator will be confronted with the old problem of what to say and how to say it.
This instrument can teach, it can illuminate; yes, and even it can inspire. But it can do so only to the extent that humans are determined to use it to those ends. Otherwise it’s nothing but wires and lights in a box.
– Edward R. Murrow
To really get to EHR impact, then, their use has to be optimized in the context of delivering care in a busy clinical environment. The best way to do that is to figure out how to deliver care outside the visit. Further, we must design with consumers as intended users. Patients will increasingly access information now locked up in EHRs. Patient access to their health information expands decision support and the reach of reminders – by engaging patients. It makes sense that if EHRs push data to personal health records, then studying what happens at a single encounter won’t accurately measure quality. When patients are intended recipients of EHR contents, we’re likely to improve quality (that includes patient experience and health).
OK, back to the study, which was done between 2005 and 2007. Stanford authors reviewed 250,000 patient visits to outpatient clinics and emergency departments. They looked for differences in “quality of care” delivered by providers who used electronic health records (EHR) with and without computerized decision support. Meaning, EHRs reminding doctors to do certain things compared to EHRs that didn’t. What they ended up comparing was visits with and without an electronic record. They didn’t find a relationship between having an EHR and having a higher level of “quality” of treatment.
The methods seem pretty sound, and the results are worth a thorough review. Yes, there are limitations, like there are in every study. Several have been nicely described in a post by Bill Hersh, Oregon Health & Science University. I might add a few more. Sites using electronic and paper records were categorized as an EHR practice (possibly overestimating EHR use). Over half the visits were in an emergency room, a very different place to combine with primary care. Plus, “quality” was measured at a visit, rather than what is usually done: measured across a population over time. Finally, 40% of sites did not agree to participate, limiting generalizability across the U.S.
Even ignoring all the limitations, I think the reviewers let the authors take liberties in their abstract and conclusions. They state, “Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits.” They conclude, “Our findings indicate no consistent association between EHRs and CDS and better quality.” The science doesn’t support these statements. These are the type made by the lay media.
This time I can’t blame the press, always on the prowl for a good story. They found one. Problem is, they didn’t realize they were only talking about the “wires and lights in a box”.