Last week the Archives of Internal Medicine published a study that calls into question the value of electronic health records, or EHRs, clinical decision support, and the federal “meaningful use” program, which provides financial incentives to physicians and hospitals who adopt EHRs and use them in ways which should improve care. A close look reveals the study’s conclusions are unsound. But the study brings up several points on health IT and meaningful use that need clarification.
This retrospective study looked at outpatient medical visits and 20 quality measures, comparing quality scores for those visits made to a doctor using an EHR with clinical decision support to those visits made to a doctor using paper records. With the exception of improvement in 1 of those 20 measures, there was no significant improvement when care was provided with an EHR with clinical decision support.
The authors’ conclusion was to “…raise concerns about the ability of health information technology to fundamentality alter outpatient care quality.” These conclusions were then republished in many venues with expanded editorial comment questioning whether the federal meaningful use program is based on fatally flawed assumptions and thus its tens of billions of dollars of incentive money will be wasted.
Almost no attention, however, was paid to the invited commentary on that article by a “founding father” of EHRs, CDS, and clinical informatics, Clement McDonald. Dr. McDonald correctly pointed out several serious flaws in this study, including the lack of maturity of the EHRs and clinical decision support studied, and the choice of quality measures studied. These flaws alone are enough to invalidate the study conclusions, but there are even more fundamental issues to consider.
Todd Park, the chief technology officer of the Department of Health and Human Services, and I published a paper for the Center for American Progress in 2009 that discussed the interrelationship of health IT, care delivery innovation, and payment reform. We wrote that existing health IT (in 2009) was in large part immature, suboptimally implemented, and suboptimally used because of the lack of a sustainable business case for health information management and quality outcomes. We labeled this unfortunate set of conditions as a health IT “vicious cycle.”
Shifting To A Virtuous Cyle
We further described a future state where a “virtuous cycle” could exist. This virtuous cycle would be fueled by a reformed payment system, which had at its core a sustainable business case for health information management and quality outcomes. This new business case in medicine, which would more closely align payment with the objectives we all wish to see in health care, would then remove existing barriers to innovation in technology and care delivery, which would in turn lead to better health IT and its consistent use to improve care.
The implications of this 2009 paper for EHR research are abundantly clear. EHRs developed and used within the current “vicious cycle” can all but be guaranteed to show no improvement in quality. The technology was not designed to improve quality, but rather to support documentation and billing. And the physicians and other providers in the study using these EHRs did not have their workflows redesigned such that whatever clinical decision support prompts that existed in the EHRs were optimally and consistently used. Studying EHRs built and used under these circumstances is therefore an exercise in futility and adds little value to public and policy discourse on these issues.
The implications for the meaningful use program are even clearer. First of all, rather than calling into question the meaningful use program, this study actually supports its use. The HITECH Act and the meaningful use regulations reflect a shift and maturation in the thinking of policymakers regarding health IT. Succinctly stated, health IT per se is unlikely to lead to better care. But health IT built, implemented, and used in “meaningful ways” is very likely to result in better care. And even before a single meaningful use dollar has been delivered, this program has had a dramatic influence on EHR vendors such that almost every EHR built in 2011 will have new features that make the consistent achievement of better care more likely.
Secondly, as physicians and other providers start their preparation this year for meaningful use, they will be using their enhanced technology in new and better ways (such as consistent use of reports, reminders, clinical dashboards and targeted clinical decision support). That said, this first year of meaningful use sets a relatively low bar for vendors and providers. It is not until the third and final stage of meaningful use that providers will be required to use their ever-improving EHRs to their utmost capacity. And as such, a fair evaluation of EHRs and the meaningful use program cannot occur until physicians and hospitals are successful in meeting this last stage of meaningful use.
But just as health IT is not a panacea for all that ails health care, neither is meaningful use. Meaningful use at best will provide a policy and financial catalyst to point doctors and hospitals in their adoption and use of health IT toward a more effective and efficient health care system. As I mentioned above, to sustain this informed use of health IT and directional shift in health care delivery will require broad and lasting payment reform, where payment is aligned with the quality and safety goals we all wish to see. If this payment reform does not follow meaningful use, whatever real care benefits are seen because of the meaningful use program will not be sustained.