Healthcare // Electronic Health Records
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9/28/2012
10:47 AM
Paul Cerrato
Paul Cerrato
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EHR Savings Debate Grows

Credible sources are raising serious concerns about the value of health IT. Some, but not all, of their criticism is warranted.

12 EHR Vendors That Stand Out
12 EHR Vendors That Stand Out
(click image for larger view and for slideshow)
The last two weeks haven't been kind to the vendors and users of electronic health records.

A recent column in The Wall Street Journal challenged the notion that EHRs are reducing healthcare costs, citing data from an exhaustive scientific review of 36,000 studies on the subject.

Similarly, the Center for Public Integrity, an investigative news organization, last week posted an article saying that healthcare providers may be inappropriately using EHRs to justify higher evaluation and management (E&M) coding levels, a practice it maintains is costing Medicare billions of dollars a year. The article, by Fred Schulte, charges that federal officials, because they were intent on increasing adoption of EHRs, ignored warnings that the systems could help physicians raise coding levels.

The core of the allegations is that EHRs let doctors copy and paste findings from previous notes into current notes, providing documentation that can be used to justify higher coding levels. In a letter sent last week to major national medical organizations, U.S. Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder stated: "There are troubling indications that some providers are using [EHR] technology to game the system, possibly to obtain payments to which they are not entitled."

[ For more on the role of EHRs in clinical research, see Health IT's next challenge: Comparative Effectiveness Research. ]

These accusations echo concerns I've had over the last year or so. When I first signed on as editor of InformationWeek Healthcare in 2011, I expressed guarded optimism about EHRs, guarded in part because "with so much money in play, I'm sure some hospitals and group practices will try to game the system--with taxpayers and patients picking up the bill."

Just last week I posted a column about accountable care organizations, in which I wrote again about the risk of upcoding and gaming the system. In that column I discussed the shaky research foundation on which ACOs are based: pilot projects that likewise used "creative medical coding" to justify their cost savings.

That said, not all of the recent criticism heaped upon EHR vendors and buyers is justified. The Wall Street Journal critique, by Stephen Soumerai, a professor at Harvard Medical School, and Ross Koppel, from the University of Pennsylvania, doesn't tell the whole story.

Based on their reading of what they refer to as an "extensive new study," their column concludes that "the most rigorous studies to date contradict the widely broadcast claims that the national investment in health IT--some $1 trillion will be spent, by our estimate--will pay off in reducing medical costs."

There are several problems with their analysis.

The original research paper they refer to was published online October 7, 2011, not exactly what I'd call new. More important, after the investigators sifted through the 36,000 reports, they were left with 31 that were considered worth analyzing, and of that small group, all were performed no later than 2009. In fact, 12 of the 31 economic analyses were at least ten years old.

It's unfair to conclude that currently available EHR systems are a bad investment by looking at implementations and cost analyses that are relatively old. In this fast-evolving EHR market, 2009 is practically ancient. Likewise, a deeper dive into the research paper, published in the Journal of the American Medical Informatics Association (JAMIA), raised other doubts about whether the economic analyses are grounds for questioning the value of EHRs in the current U.S. healthcare system.

For instance, several of the studies looked at health IT projects in other countries. And the single 2009 cost analysis, which looked at the benefits of a medication safety alert system, concluded that the system would likely result in a cost savings of about $450,000.

To be fair, while the JAMIA study doesn't convincingly prove that EHRs are a waste of money, neither does it lend strong support to the extravagant claims made by advocates who sold the federal government on the health IT incentive plan. As Soumerai and Koppel point out in the Wall Street Journal column, "Lobbyists promised that these technologies would make medical administration more efficient and lower medical costs by up to $100 billion annually."

We're not there yet--by any stretch of the imagination.

InformationWeek Healthcare brought together eight top IT execs to discuss BYOD, Meaningful Use, accountable care, and other contentious issues. Also in the new, all-digital CIO Roundtable issue: Why use IT systems to help cut medical costs if physicians ignore the cost of the care they provide? (Free with registration.)

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Dave W
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Dave W,
User Rank: Apprentice
10/9/2012 | 7:38:13 AM
re: EHR Savings Debate Grows
Deja vu all over again...this is a mirror of the discussion of the value of ERP systems in the 1990's, the Internet in the early 2000's and others too numerous to mention. Early in the adoption lifecycle there are always naysayers who latch onto any negative data to make their point that the change is a bad thing. Take the HHS letter to the hospitals about upcoding which sounds political to its core.

Does an electronic system allow for upcoding? Sure. No more nor less than the old systems ever did...but committing it to an EMR can improve compliance and the ability to investigate fraudulent behavior such as upcoding. Is an equally plausible explanation be that the accurate capture of encounter data allows for the [more] accurate coding for billing purposes and that this accuracy could contribute to increased charges? Sure it could. The problem is nobody has reduced this debate to fact...so the politics continue.

Having spent significant time in my past at Kaiser Permanente helping to implement their EMR, there are a lot of good reasons for doing so. Capturing clinical data so that it is computable (which it emphatically is not in a paper chart!) is extraordinarily valuable...and takes time and new, innovative efforts to capitalize upon. Achieving integration among the dog's breakfast of legacy clinicial systems is equally time consuming but the aggregation of the data into usable information can (and in some places, does) have a measurable impact on performance (both cost and clinical quality).

How many of the health systems implemented EMRs because they wanted the HHS money or because the were "compelled to" by the APA/HITECH provisions? That is no reason to undertake such a large ORGANIZATIONAL CHANGE initiative (it isn't an IT project!). Those organizations that invested in EMRs for all the right reasons - Kaiser, Group Health, Intermountain, UPMC, and others - are getting their benefits and are not looking back. Others, not so much...

I will close with a thought and a quote. The thought is that if you understand that the EMR is a foundational investment required to deliver the value of population health, patient-centered care, and other interesting delivery models that are impossible without access to computable healthcare information, you have the ability to manage the changes that it will require in your health system to deliver the benefits that the lucky few have achieved. The quote is from Churchill: "This is not the end; it is not even the beginning of the end. It is, perhaps, the end of the beginning..."
jaysimmons
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jaysimmons,
User Rank: Apprentice
10/7/2012 | 2:28:51 AM
re: EHR Savings Debate Grows
I think it would be rather difficult to completely ascertain the cost savings EHRs have until they are more widely adopted by physicians. We are only beginning to see the critical mass on EHRs and have yet to see the same numbers of the connectivity between systems that will probably ultimately end up saving the money. One only has to look at Kaiser to see how good EHRs and Patient Portals are for business.
Jay Simmons
Information Week Contributor
GAProgrammer
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GAProgrammer,
User Rank: Ninja
10/1/2012 | 5:56:23 PM
re: EHR Savings Debate Grows
"The original research paper they refer to was published online October 7, 2011, not exactly what I'd call new. " Not a good defense, considering the amount of time it takes to conduct these research projects.

Also, whenever the federal goverment starts making new requirements, the subjects of the new requirements expect the federal government to pick up the tab. Being able to copy/paste for new payments could be gaming the system. It could also have the unintended consequence of making the doctors lazier in their documentation.

There are lots of issues with EHR, even without speaking to privacy/hacking concerns. There needs to be much more research conducted before we force our healthcare providers into this system.
JEngdahlJ
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JEngdahlJ,
User Rank: Apprentice
10/1/2012 | 4:03:48 PM
re: EHR Savings Debate Grows

Business intelligence can help hospitals get a better return on investment for their electronic medical records. http://www.healthcaretownhall....
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