Despite Positive Findings, Uncertainty around Evidence Behind Electronic Medical Records

A new review of recent literature on the effectiveness of electronic medical records (EMR) from the Office of the National Coordinator for Health Information Technology (part of the Department of Health and Human Services) finds that fully 92% of reviewed papers published since 2007 have positive results. This means that the overall conclusion of the 154 papers they reviewed concluded that EMR and other health information technologies (HIT) tested were associated with improvements in care with no drawbacks, or were overall positive despite one or a few negative elements.

A recent posting raised the issue of cost and returns on investment for adopting EMR, specifically General Electricic’s Centricity EMR system. The point was made that although it can grow tiresome to forever look at dollars and cents, doc do have to find a way to pay for technology investments. Clinicians are likely more interested in how such technologies might improve their outcomes, and the health of their patients. The well-trained clinician would then turn to the literature to see what recent reviews have found.

The Authors of this new review, published in Health Affairs, found a laundry list of benefits from individual EMR and HIT studies, including things such as:

-48% reduced mortality and 25 % reduced nursing levels over 3 years at a dialysis center

-Fewer complications, lower mortality and cost at more “wired” hospitals in Texas, compared to less wired ones.

They also found some negative, potentially contradictory findings, such as:

-Higher costs at more wired facilities vs. less wired ones

-Longer time to fulfill prescriptions at facilities using e-prescribing versus those writing by hand

-Implementation characterized by increases in medical errors, medication errors, and procedural errors

Without fully detailing the individual benefits or drawbacks highlighted in each study, the authors seem to be a bit skeptical, and rightly so. There’s certainly some publication bias at work here (the tendency for positive studies to be more likely to be submitted and accepted for publication than negative findings). Study designs and statistical analysis varied extensively. Measuring outcomes from a grab-bag of benefits, ranging from improved efficiency, to lower cost, to fewer medication errors, makes it hard to draw conclusions from a many studies. With so many different systems being tested, its also hard to differentiate between which particular type of program might work better. The interface between clinician and HIT can make a huge difference in how well such technology works in the field. The authors acknowledge as much, writing that “the stronger finding may be that the “human element” is critical to health IT implementation.” Further, there seems to be a weakness inherent in publishing so few negative papers, especially about the tough implementation period that accompanies any new technology.

“The negative findings also highlight the need for studies that document the challenging aspects of implementing health IT more specifically and how these challenges might be addressed,” write the authors.

How does this help? It illustrates several potential pitfalls in the rush to adopt EMR and HIT more generally: The federal HITECH program has established funding to help doc’s go digital, but there seems to be a disconnect between what we are trying to achieve, and whether there’s any evidence that it will in fact improve health systemically.

Remind me again what the overall public health and societal goals of EMR were? Is there a master list somewhere that we are following?

Without fully enunciating what the goals of HIT are, its impossible to choose the right technology, the right measures, or to determine what success might look like, or measure whether we are getting there.

Much interest around health reform swirls around the issues of cost, and yet the data about cost-effectiveness, whether it’s ROI in dollars or cents, or ROI in terms of health outcomes, is uncertain.

Wouldn’t it help if we established some ground rules, for example: What are three things that we should expect all EMR to do, and three outcome measures that would tell us whether we are getting there?

Photo credit: The author