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Think Big

July 1, 2006
by Justin Graham, M.D., M.S.
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By focusing too narrowly on EHR adoption, are we missing the point?

You didn't need to set foot in the convention center at February's HIMSS conference to get a taste of the electronic health record (EHR) marketplace hype. Vendors took over downtown San Diego, plastering banner ads on every available flat surface and positioning themselves and their giveaways on strategic street corners.

Inside the convention center, on the exhibit hall floor, the air was thick with deal making, and the booths were crowded with providers nervously clutching their checkbooks. Meanwhile, pundits and academics were enjoying expensive, vendor-sponsored dinners and speculating whether or not the country was going to achieve President Bush's goal of an electronic health record (EHR) for every American by 2014.

I admit to my own excitement at seeing the deluge of interest (and funding) flowing into healthcare information technology (HIT). But I can't help but wonder if the nation's providers will end up drowning in a sea of good intentions. The problems with American healthcare today, so well described by the Institute of Medicine's "2001 Crossing the Quality Chasm" report, are not going to be solved by EHRs alone. In fact, the extreme emphasis on EHR adoption, without specifically addressing improvement in the processes of patient care, may prove counterproductive and even widen the healthcare quality chasm.

This is not to say that I'm a technophobe. I've spent more than 10 years studying, promoting, and implementing HIT. When I round on patients at my community hospital without an EHR or even reliable computerized results reporting, I feel like I'm practicing medicine in the dark. But some of my recent experiences with early adopter small medical practices in California have left me wondering if HIT is really a panacea.

The Lumetra mission

Lumetra has been helping educate and train small- to medium-sized primary care practices about HIT since we started designing Medicare's Doctor's Office Quality — Information Technology (DOQ-IT) program in 2003. Funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services, DOQ-IT was intended not only to help practices overcome barriers to EHR adoption, but also to create a transformation in patient-care delivery, through access to and analysis of patient population data, intelligent decision support, and electronically enabled patient-centered care.

Hundreds of practices joined our program, most seeking to learn how to select and implement their first EHR. We've been very successful in helping them advance along our roadmap towards EHR adoption and utilization. And overall, it appears the majority of DOQ-IT participating practices are satisfied with the EHR systems they implemented. However, we have heard a worrisome number of anecdotes from our participating physicians about practices that, despite their best intentions, have been unable to realize significant quality-improvement gains for their patients after expending significant capital on an EHR.

I visited a practice like this last year, in California's rural Gold Country. Two years post-implementation of a state-of-the-art EHR, this solo physician was still routinely leaving the practice at 10 p.m. because she was unable to complete her documentation at the point-of-care. Older lab results were often unavailable and repeated because previous results were buried in stacks of paper faxes that no one had time to abstract into the electronic record. The physician and the staff were understandably unhappy that the EHR they had been sold had only made their practice's problems worse.

We've seen other practices with similar problems. Some have never been able to convince the majority of their physicians to start using the system, leaving them with a hybrid paper-electronic records system with limited utility for managing their combined patient population. Others have found, to their dismay, that their electronic patient data is still accessible only one patient at a time, and their EHR vendors are unwilling or unable to generate population reports from their proprietary databases.

A half-hearted implementation is worse than none at all. Hybrid workflows can never realize the efficiencies and the power of a paperless system, so the practice bleeds money, energy, and morale. With patient records partially kept on paper, only a handful of a practice's providers, if any, can realize the promise of improved patient care using data-driven tools like intelligent decision support, planned templated visits, chronic-disease population management, and increased patient involvement in their own care.

Most of these problem practices implemented their systems without the help of DOQ-IT, swayed by hope of ROI or a vague notion that an EHR was somehow going to solve their operational problems. They swallowed the sales hype. Money and software changed hands. Now they find themselves not far from where they started. Patients belonging to these practices meet the broad criterion of "having an electronic medical record," but I'm not sure they're seeing a benefit.

Super pupils

By contrast, our star DOQ-IT practices have truly begun to transform the way they practice medicine. They are using their HIT systems to implement small tests of change, analyze the results, and build on successes.

Using the EHR, they have created new workflows and eliminated inefficiencies by discarding traditional models of staff roles and working more closely in teams. They have used their systems to create chronic-disease-care dashboards to monitor progress and identify problem patients or processes. And now, these practices are cashing checks from California's pay-for-performance programs.

Instead of the narrow national focus on EHR adoption, a better goal might be "the right care for every person, every time" for every American by 2014. Appropriate use of HIT is necessary, but not sufficient to meet this challenge. We also need to think more seriously about complete structural redesign of healthcare financing; revamping medical education to emphasize on quality improvement, medical information management, and team approaches to medical care; and focusing on value, quality, safety, and efficiency rather than cost-avoidance and costly new drugs and procedures.

Those tough issues probably won't translate into the fancy displays and expensive dinners at HIMSS. Transforming American healthcare is a heck of a lot harder than just implementing EHRs. It's time we widen our focus on the ends, not just narrowing in on the means.

Justin Graham, MD, MS, is medical director for quality and informatics at Lumetra, Medicare's Quality Improvement Organization for California, an independent, nonprofit organization focused on improving the quality, safety, and integrity of healthcare for providers and consumers. Graham helps lead Lumetra's physician office EHR initiatives, and provides infectious disease consultation for patients at several San Francisco hospitals.

This material was prepared by Lumetra under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

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