Are Electronic Medical Records a Cure for
Health Care?
CASE STUDY QUESTIONS
1. Identify and describe the problem in this case.
2. What management, organization, and technology factors are responsible for the difficulties in building electronic medical record systems? Explain your answer.
3. What is the business, political, and social impact of not digitizing medical records (for individual physicians, hospitals, insurers, patients, and the U.S. government)?
4. What are the business and social benefits of digitizing medical recordkeeping?
5. Are electronic medical record systems a good solution to the problem of rising health care costs in the United States? Explain your answer.
CASE STUDY #1
During a typical trip to the doctor, you’ll
often see shelves full of folders and papers devoted to the storage of medical
records. Every time you visit, your records are created or modified, and often
duplicate copies are generated throughout the course of a visit to the doctor
or a hospital. The majority of medical records are currently paper-based,
making these records very difficult to access and share. It has been said that
the U.S. health care industry is the world’s most inefficient information
enterprise. Inefficiencies in medical record keeping are one reason why health
care costs in the United States are the highest in the world. In 2012, health
care costs reached $2.8 trillion, representing 18 percent of the U.S. gross
domestic product (GDP). Left unchecked, by 2037, health care costs will rise to
25 percent of GDP and consume approximately 40 percent of total federal
spending. Since administrative costs and medical recordkeeping account for
nearly 13 percent of U.S health care spending, improving medical record keeping
systems has been targeted as a major path to cost savings and even higher
quality health care. Enter electronic medical record (EMR) systems.
An electronic medical record system
contains all of a person’s vital medical data, including personal information,
a full medical history, test results, diagnoses, treatments, prescription
medications, and the effect of those treatments. A physician would be able to
immediately and directly access needed information from the EMR without having
to pore through paper files. If the record holder went to the hospital, the
records and results of any tests performed at that point would be immediately
available online. Having a complete set of patient information at their
finger-tips would help physicians prevent prescription drug interactions and
avoid redundant tests. By analyzing data extracted from electronic patient
records, Southeast Texas Medical Associates in Beaumont, Texas, improved
patient care, reduced complications, and slashed its hospital readmission rate
by 22 percent in 2010.
Many experts believe that electronic
records will reduce medical errors and improve care, create less paperwork, and
provide quicker service, all of which will lead to dramatic savings in the
future, as much as $80 billion per year. The U.S. government’s short-term goal
is for all health care providers in the United States to have EMR systems in
place that meet a set of basic functional criteria by the year 2015. Its
long-term goal is to have a fully functional nationwide electronic medical
recordkeeping network. The consulting firm Accenture estimated that
approximately 50 percent of U.S. hospitals are at risk of incurring penalties
by 2015 for failing to meet federal requirements.
Evidence of EMR systems in use today
suggests that these benefits are legitimate. But the challenges of setting up
individual systems, let alone a nation-wide system, are daunting. Many smaller
medical practices are finding it difficult to afford the costs and time
commitment to upgrading their record-keeping systems. In 2011, 71 percent of
physicians and 90 percent of hospitals in the United States were still using
paper medical records. Less than 2 percent of U.S. hospitals had electronic
medical record systems that were fully functional. It’s also unlikely that the
many different types of EMR systems being developed and implemented right now
will be compatible with one another in 2015 and beyond, jeopardizing the goal
of a national system where all health care providers can share information. No
nationwide software standards for organizing and exchanging medical information
have been put in place. And there are many other smaller obstacles that health
providers, health IT developers, and insurance companies will need to overcome
for electronic health records to catch on nationally, including patients’
privacy concerns, data quality issues, and resistance from health care workers.
Economic stimulus money provided by the American Recovery and Reinvestment Act
was avail-able to health care providers in two ways. First, $2 billion was
provided up front to hospitals and physicians to help set up electronic
records. Another $17 billion was available to reward providers that successfully
implement electronic records by 2015. To qualify for these rewards, providers
must demonstrate “meaningful use” of electronic health record systems. The bill
defines this as the successful implementation of certified e-record products,
the ability to write at least 40 percent of all prescriptions electronically,
and the ability to exchange and report data to government health agencies. But
in addition to stimulus payments, the federal government plans to assess
penalties on practices that fail to comply with the new electronic
record-keeping standards. Providers that cannot meet the standards by 2015 will
have their Medicare and Medicaid reimbursements slowly reduced by 1 percent
year until 2018, with further, more stringent penalties coming beyond that time
if a sufficiently low number of providers are using electronic health records.
Electronic medical recordkeeping systems typically cost around $30,000 to
$50,000 per doctor. Although stimulus money should eventually be enough to
cover that cost, only a small amount of it is available up front. This would
burden many providers, especially medical practices with fewer than four
doctors and hospitals with fewer than 50 beds. The expenditure of overhauling
recordkeeping systems represents a
significant increase in the short-term
budgets and workloads of health care providers—as much as 80 percent, according
to Accenture. Smaller providers are also less likely to have done any preparatory
work digitizing their records compared to their larger counterparts. Implementing
an EMR system also requires physicians and other health care workers to change the
way they work. Answering patient phone calls, examining patients, and writing
prescriptions will need to incorporate procedures for accessing and updating
electronic medical records; paper-based records will have to be converted into
electronic form, most likely with codes assigned for various treatment options and
data structured to fit the record’s format. Training can take up to 20 hours of
a doctor’s time, and doctors are extremely time-pressed. In order to get the
system up and running, physicians themselves may have to enter some of the
data, taking away time they could be spending with their patients. A 2009
National Research Council study found that EMR systems were often poorly
designed. For example, in one of these systems, it took eight mouse clicks on a
digital record to locate patient information that fit easily on a single sheet
of paper. Health care professionals will resist these systems if they add steps
to their work flow and compound the frustration of performing required tasks.
The Obama administration has worked on standards to improve EMR usability. Many
smaller practices and hospitals have balked at the transition to EMR systems
for these reasons, but the evidence of systems in action suggests that the move
may be well worth the effort if the systems are well designed. The most
prominent example of electronic medical records in use today is the U.S.
Veterans Affairs (VA) system of doctors and hospitals. The VA system switched
to digital records years ago, and far exceeds the private sector and Medicare
in quality of preventive services and chronic care. The 1,400 VA facilities use
VistA, record-sharing software developed by the government that allows doctors and
nurses to share patient history. A typical VistA record lists all of the
patient’s health problems; their weight and blood pressure since beginning
treatment within the VA system; images of the patient’s x-rays, lab results,
and other test results; lists of medications; and reminders about upcoming
appointments. But VistA is more than a database; it also has many features that
improve quality of care. For example, nurses scan tags for patients and medications
to ensure that the correct dosages of medicines are going to the correct
patients. This feature reduces medication errors, which is one of the most common
and costly types of medical errors, and speeds up treatment as well. The system
also generates automatic warnings based on specified criteria. It can notify
providers if a patient’s blood pressure goes over a certain level or if a
patient is overdue for a regularly scheduled procedure like a flu shot or a
cancer screening. Devices that measure patients’ vital signs can automatically transmit
their results to the VistA system, which automatically updates doctors at the
first sign of trouble. The results suggest that electronic records offer significant
advantages to hospitals and patients alike. The 40,000 patients in the VA’s
in-home monitoring program reduced their hospital admissions by 25 percent and
the length of their hospital stays by 20 percent. In addition, more patients
receive necessary periodic treatments under VistA (from 27 percent to 83
percent for flu vaccines and from 34 percent to 84 percent for colon cancer
screenings). Patients also report that the process of being treated at the VA is
effortless compared to paper-based providers. That’s because instant processing
of claims and payments are among the benefits of EMR systems. Insurance
companies traditionally pay claims around two weeks after receiving them,
despite quickly processing them soon after they are received; governmental
regulations only require insurers to pay claims within 15 days of their receipt.
Additionally, today’s paper-based health care providers must assign the
appropriate diagnostic codes and procedure codes to claims. Because there are
thousands of these codes, the process is even slower, and most providers employ
someone solely to perform this task. Electronic systems hold the promise of
immediate processing, or real-time claims adjudication just like when you pay
using a credit card, because claim data would be sent immediately and
diagnostic and procedure code information are automatically entered. VistA is
far from the only option for doctors and hospitals starting the process of
updating their records. Many health technology companies are eagerly awaiting the
coming spike in demand for their EMR products and have developed a variety of different
health record structures. Humana, Aetna, and other health insurance companies
are helping to defray the cost of setting up EMR systems for some doctors and
hospitals. Humana has teamed up with health IT Company Athena health to
subsidize EMR systems for approximately 100 primary care practices within
Humana’s network. Humana pays most of the bill and offers further rewards for
practices meeting governmental performance standards. Aetna and IBM, on the
other hand, have launched a cloud-based system that will pool patient records
and can be licensed to doctors both inside and outside of Aetna. There are two
problems with the plethora of options available to health care providers.
First, there are likely to be many issues with the sharing of medical data between
different systems. While the majority of EMR systems are likely to satisfy the
specified criteria of reporting data electronically to governmental agencies,
they may not be able to report the same data to one another, a key requirement
for a nationwide system. Many fledgling systems are designed using VistA as a
guide, but many are not. Even if medical data are easily shared, it's another
problem altogether for doctors to actually locate the information they need
quickly and easily. Many EMR systems have no capacity to drill down for more
specific data, forcing doctors to wade through large repositories of
information they don't need to find the one piece of data that they do need.
EMR vendors are developing search engine
technology intended for use in medical records. Only after
EMR systems become more widespread will the
extent of the problems with data sharing and accessibility become clearer. The
second problem is that there is a potential conflict of interest for the
insurance companies involved in the creation of health record systems. Insurers
are often accused of seeking ways to avoid or delay paying health care claims. While
most insurers are adamant that only doctors and patients will be able to access
data in these systems, many prospective patients are skeptical. A May 2012
survey conducted by Harris Interactive found that only 26 percent of U.S.
adults wanted their medical records converted from paper to electric. Most of
those surveyed worried about the security of electronic records, the potential
for misuse of personal information, and the inability of physicians to access patient
records during a power or computer outage. Worries about privacy and security
could affect the success of EMR systems and quality of care provided. One in
eight Americans have skipped doctor visits or regular tests, asked a doctor to
change a test result, or paid privately for a test, motivated mostly by privacy
concerns. A poorly designed EMR network would amplify these concerns. Finally,
evidence is mounting that electronic health records may be contributing to
rising Medicare costs by making it easier for hospitals and physicians to bill
for services that were not actually provided. Some electronic health record
programs allow doctors to automatically cut and paste the same examination findings
for multiple patients or bill for procedures that never took place. More
controls and federal oversight are required to make electronic medical record
systems produce the results that were originally intended.
Sources: Nicole Lewis, “Healthcare Cost
Cutting Hinges on IT,” Information Week, August 10, 2012; Reed Abelson, Julie
Creswell, and Griffin J. Palmer, “Medicare Bills Rise as Records Turn
Electronic," The New York Times, September 21, 2012; Neil Versel,
“Consumers Still Wary of Electronic Health Records,” Information Week, August
9, 2012; Ken Terry, “Docs May Overestimate EHR Capabilities,” Information Week Health
Care, August 2012; Steve Lohr, “Seeing Promise and Peril in Digital Records,”
The New York Times, July 17, 2011; Russ Britt, “Digital Health Push Woos Tech
Firms, Pains Doctors, MarketWatch, June 2, 2011; Marianne Kolbasuk McGee, “Better
Clinical Analytics Means Better Clinical Care,” Information Week, May 21, 2011;
Eric Engleman, “More Physicians Adopting Electronic Health Records, U.S.
Reports,” Bloomberg News, April 26, 2011; Jeff Goldman, “Implementing Electronic
Health Records: Six Best Practices,” CIO Insight, March 7, 2011; Robin Lloyd,
“Electronic Health Records Face Human Hurdles More than Technological Ones,”
Scientific American, April 16, 2011; Katherine Gammon, “Connecting Electronic
Medical Records,” Technology Review, August 9, 2010; Tony Fisher and Joyce
Montanari, “The Current State of Data in Health Care,” InformationManagement.com,
June 15, 2010; and Jacob Goldstein, “Can Technology Cure Health Care?”, The
Wall Street Journal, April 13, 2010.
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