What are we getting for our national $100 billion investment in electronic medical records (EMRs), or $200 billion, or $300 billion – who knows what the final cost will be? In the primary care ambulatory world, not very much.
It’s not that EMRs are useless, they just don’t help very much. A recent study compared the average hemoglobin A1C levels, which measure average blood sugar levels in diabetics, between clinics that had EMRs and those that didn’t. The EMR clinics’ average hemoglobin A1C levels were 0.26% lower than the paper record clinics. About 5% more patients in the EMR clinics reached blood pressure goals, but there was no difference in cholesterol control. The long-term health improvements of these differences are negligible.
Another study compared the performance of clinics with and without EMRs on quality of care measures for patients taking anti-inflammatory medicines (NSAIDs). There was a 3% difference in the number of patients receiving guideline-recommended care.
Other studies find small positive effects, and others have even found the quality of care is worse with EMRs. Even the most ardent EMR supporters should be disappointed in these results.
Why don’t EMRs have a bigger impact on care quality? There are at least four assumptions of the EMR pushers that should be challenged.
1. EMRs reduce medical errors – They clearly reduce errors with root causes such as illegible handwriting, but those errors are replaced with other errors: system crashes, data entry errors, and software that is built more for capturing billing data than improving clinical care.
2. More information equals better care – Oftentimes more information just means there is more distracting noise for the doctor to process that ultimately doesn’t and shouldn’t influence her medical decisions. A perfect example is the GE commercial where the patient is on the theater stage and the audience of doctors spouts off results of old tests. Information such as the results of a gallbladder sonogram 15 years ago really doesn’t matter today. If the gallbladder was removed because the sonogram showed gallstones, then it’s gone. There is nothing to gain in knowing how big the liver measured or how much stool was in the intestine.
3. Family physicians don’t provide recommended care because they don’t know what to do – Family physicians don’t need reminders of what constitutes high quality care. They need time to deal with all the complexities of patient care, which can’t be accomplished in a 15-minute visit for many patients.
4. EMRs reduce healthcare costs – Many of the chronic care and preventive interventions EMR reminder systems remind doctors to provide increase costs to the healthcare system. Examples include mammograms, some vaccines, cholesterol testing and treatment, and many drugs used for chronic disease treatment. Many analysts have noted the dearth of rigorously collected data measuring the full costs of EMR implementation, or its cost-effectiveness. Estimates by EMR advocates that EMRs will reduce overall healthcare costs can generously be described as an exercise in wishful thinking.
Next week I’ll show how EMRs have harmed primary care.