Why have EMRs not been more widely adopted?

One of the nagging questions about EHR adoption is the following: why is there such a low EHR adoption rate at the same time that there is a broad consensus that EHRs are critical to future healthcare? Sebelius, the HHS secretary, recently noted that only about 10% of hospitals and physician practices are fully digitized. But I suspect that this number is more than generous. A recent Booz Allen report cited smaller numbers.

The difference is largely immaterial. The point is that EHRs are not nearly as widely used as one would expect given the broad consensus on the need for them.

Of course, different healthcare institutions have different kinds of challenges, but I think the challenges really amount to the three “Cs” of EHR adoption:

1. Cost;
2. Culture; and
3. Content.

Cost:

When you compare the relative cost of the computers, IT support, software, etc that are necessary to implement and use EHRs, there is no question that it is more expensive than grabbing a legal pad and a pen to jot down some notes and throw it in a manila folder. Now I am not so naïve as to think that this is really how MDs track and store medical information, but for many small practices, this isn’t far off.

Even with the efficiencies that can be gained through the use of an EHR, the start-up costs are so substantial that it may never pay for itself. But for many small practices, there are no efficiencies to really gain. If you are a single MD with a single receptionist/medical record keeper and you implement an EHR that gains you even a 25% efficiency on administrative time, what do you do? You can’t exactly reduce your staff by 25%, so is there ever going to be an ROI for you?

And for lager facilities, there may be administrative cost savings, but implementing an EHR is a major undertaking that takes many years for results that are even further down the road.

Culture:

By way of analogy, thirty to forty years ago, it would have been unheard of for a CEO to type his/her own letter. Now, they write their own emails all the time. Why? It is far more efficient and they get a much quicker response. I believe we are at the dawn of a similar cultural shift with regards to the recording of medical information. MDs have been used to recording things one way and EHRs are a major shift away from that. But the problem is twofold: 1) we must make EHRs that are intuitive to use for recording information, and 2) we have to make that information available in actionable ways to the MD. In other words, the cost/benefit of email is readily apparent to CEOs, so they use it. We have to build EHRs functionality with the end in mind. The information and analysis that physicians derive from an EHR must be worth the extra effort of the information they contribute to the EHR.

Content:

EHRs are, in many instances, less intuitive and more cumbersome than paper records that can easily be modified to fit the MDs needs. And the information it produces is not actionable by its intended user. Let me illustrate.

I have a good friend who is a nephrologist in Michigan. He regularly gets referrals from other MDs in the area—some of whom dictate letters, others of whom send over an EHR. Guess which one is more useful? The letter. Typically, the EHRs come over as six or seven pages of small font forms, with most of the boxes empty, and no narrative description of why the patient is being sent. He or his staff then has to hunt through the document to find recent lab scores, and other more useful information to determine exactly why he is being asked to see this patient.

Compare this to the following dictated letter: “Mrs. Johnson is 65 and has seen decreased kidney function over the last six months.”

Part of the challenge of EHRs and the sharing of healthcare information in general is NOT capturing all the information and making it available to all appropriate clinicians, but creating the right lens for the right clinician so that the most useful information is mostly present most of the time. And, of course, there must be opportunities for exploring the information in more detail, if necessary. Now that’s a tall order.

Thus the real reason we as a country lag behind most others in EHR adoption is that EHR products haven't sufficiently proven their value to MDs such that the cost savings, convenience, quality improvements demonstrably outweigh the start-up costs and inconvenience of using an EHR. Until EHRs solve this "content" problem, we will continue to stumble over "culture".

Next up: How will the HITECH provision of ARRA address EHR adoption?

Obama and Unwarranted Variation

I watched with interest Obama’s press conference from Wednesday night, as I’m sure many people did. I think he handled himself quite well and showed an impressive command of the issues. I think the discussion definitely favors healthcare reform when it is kept high level, which is why it concerns me that the Senate is now delaying a vote on healthcare until after the August recess.

A few high level things that I noted throughout the conference: there were at least two points at which Obama used the term “unwarranted” in his answers. One was when he was talking about tonsillectomies; the other was when he was talking about bonuses for bank executives. Of course, “unwarranted” is the first half of a famous phrase in healthcare: Unwarranted Variation. This is the phenomenon observed in Medicare data that the delivery of healthcare in different regions around the country differs for reasons that have nothing whatsoever to do with illness, medical need, or evidence based medicine.

These observations were made by Dr. Jack Wennberg and colleagues at Dartmouth, and have been documented in an important project called The Dartmouth Atlas. The Dartmouth Atlas, in turn has been referenced by the likes of Peter Orszag, Obama’s Director of the Office of Management and Budget. (Incidentally, Orszag's Special Advisor for Health Policy is Ezekiel Emmanuel--Obama Chief of Staff Rahm Emmanuel's brother.) By some estimates, if unwarranted variation was completely eliminated, it would reduce Medicare costs by as much as 30 percent.

(As an aside, I think it is interesting that he is starting a subtle mantra of unwarranted variation as a bad thing, and the unseemly association of “unwarranted” with bank bonuses. If everyone had the same visceral reaction to unwarranted variation that they have to unwarranted bank exec bonuses, we'd all be much better off.)

In essence there are three categories of Unwarranted Variation:

• Effective care: Care where the evidence is incontrovertible, yet not delivered. For example, if you have had a heart attack, you should be taking beta-blocker (BB) medication. Only about 45% of patients are adherent with a BB in their first year post-heart attack. This under-use of care is unwarranted variation.
• Preference Sensitive Care: Care where the evidence supports different interventions, each with equal clinical validity. NOTE: on the link, there is a box in the lower left hand corner of the front page that talks about…wait for it….tonsillectomies. That’s right, the very example that Obama gave in his press conference concerning preference sensitive conditions is talked about as the classic example of preference sensitive care. Another more recent example (with great cost comparisons of treatments, is David Leonhardt’s discussion of Prostate Cancer in the NYTimes.
• Supply Sensitive Care: Care that tends to be driven the availability of services, not by improvements in quality. It is, in part, related to Roemer’s Law, but has broader implications. Diagnostic imaging, is a great example. When a new MRI machine is available in a community, it gets used, but the quality of the care being delivered does not appreciably improve. But perhaps most scarily, on pg. 3 of the attached brief, there is actually evidence to suggest that more care isn’t just more expensive, it can be deadly. As the brief states, “The study (comparing outcomes for patients with one of three conditions) showed increased mortality rates in regions with greater care intensity.” Yowza.

I think unwarranted variation is a great example if the way in which the healthcare debate is extremely complicated. This suggests that the problems with our healthcare delivery system are not merely about providing more care or less care, but both—as well as care that is just different.

Let me explain: if we are talking about delivering effective care, people need it, so we are talking about MORE CARE. If we are talking about supply sensitive care, we are talking about delivering LESS CARE, because too much of it is a bad thing. And if we are talking about preference sensitive care, we need to deliver DIFFERENT CARE.

And one of the real questions for healthcare reform, is how to use public policy to address unwarranted variation. This is a fairly nuanced point that has trouble making it through the cacophony of vitriol on healthcare reform. However, steps are being made in this direction.

Perhaps most importantly, the ARRA legislation (the “stimulus bill” that was passed in February) included a provision to create the “Federal Coordinating Council for Comparative Effectiveness Research” and funded it with $1.1 Billion. Some of this will get at issues of unwarranted variation; others will address lacunae in research around the delivery of qualityhealthcare.

As I said earlier, I think the major thrust of this round of reform efforts is on coverage. Lets get the 45+ million Americans without coverage covered. Then lets really start tweaking the system so we 1) know what quality is; 2) measure and report on it; and 3) incent providers to provide it—financially or otherwise.