A study was recently published by Stanford University calling into question the value of Electronic Health Records as drivers of improved patient care. This study has caused quite a buzz in the EHR community, and I think it is important for us in this community to be ready to explain how some aspects of this study can possibly lead to erroneous conclusions and to articulate why EMRs truly are a very attractive proposition for saving lives and improving outcomes. Some things to be mindful of as we look at the findings from the Stanford study:
*The three-year analysis took place between 2005 and 2007. Systems now are much more “mature” and Meaningful Use has necessitated that quality metrics be much more readily trackable in these systems than they ever were.
- The requirement for Clinical Quality Measure reporting places a whole new level of accountability and visibility on providers that never existed before.
*One of the challenges mentioned in the study is that implementers of EMRs often did not have sufficient training in the systems they were implementing (which inevitably means that some workflows that were built either potentially sub-optimized patient safety or were simply not clinician-friendly). Several years out from this study, the depth of understanding of how to implement systems has increased dramatically and more “health informatics” experts are coming out of both academia and the vendor community itself.
*A similar study several years back intimated that CPOE may have had a role in increasingly mortality at a prominent children’s hospital. In diving in deeper regarding that particular situation, it had been discovered other factors were at play that may have contributed to this spike in mortality:
- The hospital rapidly deployed their system over six days thus limiting the ability to make changes
- Order entry was not allowed until the patient physically entered the hospital
- Order sets were not developed prior to deployment
- Other major policy changes took place simultaneous to the CPOE implementation (such as moving medications to a central pharmacy) which directly affected care (source: http://www.clinfowiki.org/wiki/index.php/Impact_of_CPOE_on_mortality_rates–contradictory_findings,_important_messages)
*Upon addressing the aforementioned issues, it turned out that mortality rates did indeed drop below rates in place prior to the CPOE implementation. This, in fact, bears out the value of EHR systems and the criticality of implementing them correctly, with an unyielding eye on workflow analysis across-the-board.
*The Stanford study states that EMR effectiveness was diminished by the lack of utilization of the system by physicians. In 2011, that has become much, much less of an issue. Physicians must be involved not only in the build of the system, but they must be strong users of the system once it goes live.
*The study also only looked at ambulatory visits (physician offices and clinics) – it did not look at “acute-care” EMRs, which have historically offered broad and deep functionality. EHRs’ potential to reduce adverse medical errors in hospitals (which has historically killed nearly 100,000 patients per year) is nowhere reflected in this study.
*There are better utilities today (and continuing to improve) to provide caregivers with much more accurate patient data than existed in 2005-2007. Utilities such as access to medication histories, medication reconciliation tools, Health Information Exchanges and vastly improved alerting capabilities for Clinical Decision Support offer great opportunity for optimization of care.
It is important that we have frank discussions of the true value of all that we do. So, while it is important not to trivialize the findings of this study, it is important to realize that much is happening which is allowing EHRs to achieve their full potential, Meaningful Use is a major driver of this and that there are other studies which really bring home the patient safety benefits of electronic health records.