Casey Quinlan wrote a really fantastic article about why “What’s the ROI?” is only half the question in healthcare IT. She quickly identifies the real challenge with putting an ROI on an EMR implementation by acknowledging that an ROI discussion quickly leads to a financial discussion. Indeed! The financial side is only have of the EMR ROI question.

I’ve written about the EMR ROI up down backwards and forwards. You have the camp that wants EMR software saying that it provides a great ROI and you have the camp that doesn’t want EMR saying that it doesn’t. The correct answer is that they’re both right. Your EMR ROI is often what you make of it. Not to mention that what you make of it starts with your EMR selection.

In any ROI discussion, I quickly point people to this list of EMR benefits. In EMR presentations, I like to divide that list of benefits into “Guaranteed Benefits,” “Possible Benefits,” and “Debatable Benefits.” In fact, I should probably do the same on that page when I have some free time.

However, Casey, in the article linked above asks a very important additional question, “What will it cost to do nothing?” Then she suggests, “The answer to that question shows the way forward.”

I’ve now had two people send me links to a study coming out of Stanford University that says that EHR software doesn’t improve patient care in the US (Here’s one story about it from Reuters). So I figure that it must be a topic that my readers would enjoy me discussing. Here’s a portion of their summary:

A team from Stanford University in California analyzed nationwide survey data from more than 250,000 visits to physicians’ offices and other outpatient settings between 2005 and 2007.

They found electronic health records did little to improve quality, even when there was “decision support” software that gives doctors tips on how best to treat individual patients.

I’ve always found it a bit off to talk about EMR software as a means to improve the quality of care that a doctor provides. For the vast majority of healthcare, more information, clinical decision support, drug to drug interaction checking, drug to allergy checking, etc aren’t going to improve the care a doctor provides. First, because the doctors have been well trained to do many of these things already. Second, because if I come in as a generally healthy patient with a common cold, then of course the doctor doesn’t need any of these advanced EMR functionality.

Now in more advanced and complicated cases, there is potential that an EMR software could offer some benefit. I remember a doctor commenting back in 2009 on my blog about how the Body of Medical Knowledge could become to complex for the human mind to process it all. Whether we’re there or yet, is open for debate, but the concept is interesting. Although, this still only applies to the outlier cases.

I remember one time hearing a clinician tell me about how the Drug to Drug interaction alerts informed her of some medical knowledge that she hadn’t known previously. So, there are instances where various parts of an EMR software can provide better patient care, but is it dramatic enough difference to really improve the quality of care? I think that’s a hard argument to really make. At least with the current iteration of EMR software.

Other EMR Benefits
Quality of Care aside, I think the thing that studies like this (and their related headlines) miss is the other benefits of having an EMR system (see also my list of EMR benefits in my EMR Selection e-Book).

I can’t tell you how many times I’ve heard doctors talk about how they love the legibility and accessibility of patient charts in the EMR. No difficult to read handwriting (others or their own). No waiting for chart pulls. These are guaranteed benefits to having an EMR system. Sure, it’s hard to quantify them when it comes to dollar signs or improved quality of care. However, they’re a real tangible benefit to having an EMR. Not to mention that I still think there’s long term benefits to widespread adoption of EMR that we can’t even imagine yet.

I could go on about many of the other benefits. It’s just unfortunate that studies and those who report on these studies don’t take into account these other benefits of EMR software.

UPDATE: Over at HIStalk, Mr. H also points out that the study only focuses on a couple quality measures. So, it doesn’t actually say that EHR doesn’t improve quality of care, but instead it says that it doesn’t improve quality of care when it comes to the couple simple measures that the study used to measure it. There could be many other quality measures where EHR does improve the quality of care. We just don’t know.

A source just told me that an insurance company that does only professional liability insurance for doctors is providing a 5% discount to all doctors who implement EHR and use it in a meaningful manner.

This is really interesting news for me since I’ve seen a number of really interesting debates about whether use of an EHR would actually raise liability insurance for doctors or lower it. This is the first confirmed company I’ve found that has actually acted on a doctors use of an EMR in their liability insurance premiums (of course, maybe there are more I don’t know about).

Of course, there are a lot of details missing in the statement posted above. For example, how does the liability insurance company plan to measure if the doctor is using an EMR in a “meaningful manner”? Will they discriminate (not in a bad way, but in a good business way) against EMR software which isn’t up to snuff?

Lots of other issues that could be talked about, but I’m heading to the Digital Health Summit at CES. So, this should start a really interesting discussion and I’m sure I’ll do some follow up posts on this subject since I have plenty to say about it.

Also, looks like I’ll have to add liability insurance savings to my list of EMR benefits. I’m thinking it’s about time to do a series of posts on the “EMR Benefits.” One EMR benefit post a day would start a really interesting set of discussions I think.

I’m currently in Denver attending the AAFP conference. So far I’m really glad that I’ve come to the conference. It’s really fantastic to be surrounded by providers. It’s a stark contrast to HIMSS where you’re mostly surrounded by industry insiders and not that many providers. The practical questions the doctors ask are fascinating.

Of course, the comments they make are also fascinating. The title of this post is a comment one lady made in the David Kibbe session on Meaningful Use:
“I use EMR and so I am MY OWN transcriptionist.”

The problem with this comment is that it just doesn’t have to be true. It could be true depending on which EMR software you selected and how you implemented the EMR. However, that’s a choice you make when you choose and implement an EMR without any transcription.

I’ve actually seen a number of EMR vendors that have some really nice and deep integration between their software and transcription companies. There are even transcription companies that are building their own EMR software which obviously leverages the power of transcription.

Plus, many doctors happily use voice recognition like Dragon Naturally Speaking to still do what essentially amounts to transcription with their EMR.

Add in developments around natural language processing and the idea of preserving the narrative that is so valuable and interesting while capturing the granular data elements is a really interesting area of EMR development.

Of course, one of the problems with this idea is that many people like to use the savings on transcription costs as a way to justify the cost of purchasing and implementing an EMR. Obviously, you’ll need to look for other EMR benefits if you choose to continue transcription.

Just to round out the conversation, there are a wide variety of EMR vendors which each have their own unique style of documentation. Part of the problem is that many people don’t look much past the big “Jabba the Hutt” EMR vendors which are these ugly click interfaces that spit out a huge chunk of text that nobody wants to see. There’s plenty of EMR vendor options out there. Keep looking if you don’t like an EMR vendor’s documentation method.

Sometimes when we think about EMR, I think we forget about the subtle nuances of paper charts that make them so undesirable. Check out this story which I got in response to my post called “Think About the Problems with Paper Charting.” It’s a a good illustration of some of the more simple things we often forget about:

I was recently visiting a relative at a major teaching hospital in the Midwest. While in the hall I noticed that they had charts in binders stored in boxes affixed to the wall. Just as I was wondering why such a prestigious institution relied on paper charts a nurse went to re-insert a chart into its box. She was in a hurry and missed, the chart dropped to the floor and binder opened and paper went all over the hall. What was even more surreal was the nurse did not at fist notice her mistake and was at leas 6 feet away before she noticed it and fixed her error.

Sometimes it’s not what you get from an EMR, but what you don’t get that matters.

Back in April, Evan Steele, CEO of SRSsoft, wrote an interesting post about EMR adoption and he asked the question, “Why Are You Still on the Fence?” It’s a very good question. Plus, he adds some value to the conversation by listing some of the problems with paper charts versus an EMR. Here’s a section of his post:

So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!

• The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.
• Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.
• Slow responsiveness to primary care physicians limits referral volume.
• Profitability is further affected by billing bottlenecks that delay revenue collection.
• The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.
• Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.

So, why are doctors on the fence with EMR? The sad thing for me was the pre-EMR stimulus money, I felt a shift in the tone of conversation around EMR adoption. Doctors had mostly moved from wondering if they should implement an EMR to how they should implement an EMR and which EMR they should implement. They were off of the fence and I saw the tide shifting.

And then in one anti-stimulative swoop, the HITECH act rolled out and doctors decided to go back to the sidelines and see this government incentive play out. Now they’re waiting for meaningful use to be defined. While the HITECH act has increased EMR awareness 10 fold, it’s also done much damage on the short term EMR adoption. I’m not sure that the increased awareness will overcome the damage that it’s caused.

Of course, the damage is done and so we have to go forward from here. I suggest we go back to pre-EMR stimulus times and focus more effort back on the benefits of EMR and the costs of paper instead of the government handouts. If we do that, we’ll see a fantastic shift to more widespread EMR adoption.

One of my readers emailed me about a presentation he was looking at doing about EMR software and consumers. I was really intrigued by the idea of presenting on the benefits of an EMR to the consumer (Translation: Patients). I’d spent quite a bit of time thinking about the benefits of an EMR to doctors, but I hadn’t put as much thought and effort into the benefits of an EMR to patients.

Here’s our initial brainstorm on the benefits of an EMR to patients. Feel free to add to the list in the comments:
-Online Appt Scheduling
-Online Prescription Refills
-Online Patient Information
-Online Forms (possibly pulled in from a PHR)
-e-Visits (this is a controversial one)
-Secure communication with doctor
-Recall/Reminders Electronically
-Patient participation in health record (ie. diet journals)
-Better point of care
-Clinical decision support
-Better access to your health records
-Less errors
-Lower cost
-Better collaboration and communication between primary care and specialty Drs

No doubt some of these benefits should have a ? mark by them. Although, I like the idea of looking at the EMR from the patient perspective. I do after all think that consumers might be the key to “forcing” broad EMR adoption.

An EMR vendor saw my question, “Has EMR helped?” and they sent it to one of their EMR users to get some feedback. Here’s their response:

I am absolutely in the camp where this transition to EMR has been helpful. Long and steep learning curve but the benefits of accessing readable notes and histories and helping patients off hours has all been great. I believe I am writing better notes and noticing HCM issues more, and I hope the drug interactiion piece will be helpful down the road also.

SO, yes, this has been great.

I’d love to hear more people’s response to the question: “Has EMR helped?”

I’m still a little bit partial to my list of EMR benefits which is pretty specific in its description of the possible benefits of an EMR. However, today in an EMR stimulus webinar they listed the following reasons for adopting an EHR:

• Financial
• Quality
• Patient Satisfaction
• Clinical Research
• Community Leadership

Not a bad list of reasons to consider for those people on the fence about adopting an EMR.

Today, I decided that I’d ask people to share a benefit they’ve received from an EMR (or seen received if you’re an EMR vendor) that you didn’t expect to happen when you implemented an EMR.

I’ll start off with one unexpected benefit of an EMR: audit logs.

There’s so many things you can do with audit logs. It resolves so many issues with accountability for a record. You just run a quick report on the audit logs and you know exactly when someone did something in the EMR. This is also true for patients when we check to see for things like when a patient checked in and when they were seen. The audit logs can tell you a lot about your clinic. Plus, it just feels so much more secure knowing that everything that’s being done in the EMR is being audited.

Not really relevant, but I got free breakfast thanks to the audit logs. HIM found a mistake in the EMR that needed to be corrected. One of our Directors went on and on about the breakfast this person would have to bring for making this mistake. She started listing off what she wanted for breakfast. I pull up the audit logs to identify the offending party: sure enough it was the Director who was going on and on that made the mistake. She corrected the mistake and brought a full breakfast.

Ok, now lets hear what EMR benefits surprised you.