Early adopters and lemmings: look before you leap into electronic records

Physician Executive, July-August, 2005 by Mitchell Diamond

Late one evening as the sun was beginning to set, I heard the thunderous footfalls of what seemed like thousands of people outside my home. I ran to the window and lo and behold, thousands of physicians and practice administrators were marching, almost running, down the street along with many of my colleagues.

"Joe," I shouted, "Where is everyone going?"

"We're buying EMR systems," Joe shouted back.

"Why?" I asked

"They will improve quality and save money," he responded.

"How much and for whom?" I called back.

"I don't know, but a thousand lemmings can't be wrong. You better hurry," Joe replied.

And as the sun slowly set and I looked toward the horizon, all I could see were masses of lemmings running towards the cliffs by the sea.

Moving from a paper medical record system--that began 3,000 years ago in ancient Egypt by healers recording their notes on papyrus--to an electronic medical record (EMR) is an important step in the evolution of medical care.

However, it is important not only to understand how far the technology has come, but where it is going. An EMR by itself is not the panacea, even though it's highly touted by the federal government, states and national and local medical societies.

Although accessibility to clinical data is important, the areas that show the greatest promise of providing discernable benefits in the near future are:

* Online computerized provider order entry (CPOE)

* Clinical decision support tools (CDS)

EMR systems by themselves are acknowledged to be repositories for information previously captured in paper records. They provide the opportunity to deliver better care if the information they contain can be accessed and utilized when and where it is needed.

The CDS and CPOE tools being developed are where significant improvements in quality and savings are expected.

CPOE

Blackford Middleton, MD, MPH, MSc, chairman of the Center for Information Technology Leadership in Wellesley, Mass., estimates that for the average ambulatory care provider with a panel of 2,000 patients, using advanced CPOE tools will provide $28,000 in saving a year for the health system.

For CPOE tools to be effective, they need to connect to pharmacies, laboratories, radiology and other providers, so that when someone enters an order the system will:

* Confirm that the test, prescription, etc. was ordered (or advise the physician that someone else has already ordered the test or that a drug is contraindicated based on other drugs dispensed)

* Provide results of lab and other diagnostic tests

CPOE tools are provided at very low cost or even given away by many health plans, laboratories and others who benefit from their use. CPOE tools may be interfaced with EMR systems to allow physicians to simultaneously enter new orders into the CPOE and EMR databases.

However, the CPOE tools are not "integrated" into the EMR. The CPOE data are typically retained in databases at various labs, pharmacy benefit managers, etc. As a result, only the tests ordered by providers sharing the same system are retained in the EMR.

CPOE tools that are not linked to the major pharmacies, labs, etc. in the community are far less likely to eliminate duplication of services and adverse drug events.

CDS

The greatest untapped potential for EMR systems is the use of CDS tools. Although these tools may provide long-term benefits with respect to preventive health, in the short term their greatest potential benefit is to more effectively address the needs of the complex, chronically ill population.

Ten chronic care improvement pilot projects being administered by Centers for Medicare & Medicaid Services are targeted at complex diabetic and congestive heart failure (CHF) beneficiaries. Organizations awarded the contracts are required to produce a savings of approximately $850 per year per beneficiary.

Assuming 300 (15 percent) of the 2,000 patients in an internal medicine practice are Medicare patients, and the complex diabetic and CHF population targeted for the chronic care improvement pilot program constitutes 10 percent of that patient population (1.5 percent of the total practice), there should be 30 patients in the practice who--if they comply with evidence-based protocols--would produce a savings of (30 X $850=) $25,500 per year.

Assuming 34 (2 percent X 1,700) of the remaining non-Medicare patients in the practice also were complex diabetic or CHF patients, this would produce $28,900 per year in savings or a total of $54,400 in annual savings (exclusive of the additional savings derived from the use of the CPOE tools).

In response to this opportunity, a few physicians across the country are adopting EMR systems that allow them to refine, build, trade or sell their "templates" to other physicians using the same systems. As a result, we assume (although there are no large trials):

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* Disparities in medical care and medical errors in these practices are decreasing

* Use of evidence-based protocols recommended at the time of a specific visit--and the quality of care measured on what the physician does at the time of the visit--are rapidly improving