Electronic health records (EHR) are supposed to improve quality of patient care and increase cost savings. That’s the promise for the $36 billion of the federal stimulus package infused into health care industry earlier this year for a national network of computerized health records. That promise comes after 40 years of pushing computerized health records and where recent studies show that only 9 percent of hospitals and 17 percent of doctors use EHR.
Even in those unpromising numbers, EHR dominates large, centrally administered health care organizations such as Kaiser Permanente, the Mayo and Cleveland Clinics, U.S. Veterans Administration, and Intermountain Health Care. In these organizations, doctors are salaried rather than being paid under fee-for-service plans and collaborate on patient care to become the models to copy in the health insurance legislation ricocheting through the U.S. Congress in the past six months.
A recent report of a decade’s experience with EHR and $100 million investment in hardware and software at the Cleveland Clinic, however, has mystified medical administrators that no cost savings have occurred. The investigative journalist cited the example of one patient who could now step on a scale at home and prick a finger for blood and the results were recorded on his EHR at the Clinic where his physician could monitor his diabetes without seeing him face-to-face. Beyond one reported case, the journalist heard from Clinic doctors that the quality of diagnoses and decreased errors in medical decisions added up to improved quality of care in their hospitals. But not cost savings—one of the oft-repeated objectives of EHR initiatives. Advocates of technology again gnash teeth and shake heads in dismay at yet another disappointment in curing ills in the health care system.
One disappointing report from an investigative journalist, however, will hardly slow the federally-fueled momentum to get more doctors and hospitals to use EHR as a way of improving quality and cutting costs. Moreover, using technology daily is a way of life in the cell phones we use, the ipod music we hear, the YouTube videos we watch, and the latest gadget that promises us more, faster, and better ways to enjoy and live a full life. So champions of EHR will continue their march through the health care industry.
The take-away point in the Cleveland Clinic study is not about the failure of EHR to contain ever-escalating costs—for the successes of implementing these technological innovations may, indeed, cost more in the short run—yes, a decade of EHR use in Cleveland Clinic is the short run; the point is that reformers attribute far too much to technological innovations accounting for improved quality in care. Consider that in July 2009, shortly before the above report was completed, the Clinic embarked on a five-year study of 85,000 surgical patients using 34 million EHR documents to determine whether quality has improved.
No surprise that research follows changes in practice rather than the reverse. Giving too much credit to new technologies for organizational outcomes and well before studies support the claims is not peculiar to EHR and medical care. It applies to public schooling as well.
Consider reports about technological advances improving quality schooling using test scores as the primary outcome for Chugach, a small district in Alaska and Union City in New Jersey. Technology advocates have continually boosted both districts, enrolling largely poor minority students, as sterling models of places where extensive purchase and use of computers by students and teachers have led to substantial gains in test scores.
What is often omitted from these accounts, however, is that each district launched system-wide reforms in curriculum, teaching, and accountability 3-5 years before schools were wired, computers bought, and technical assistance provided. Yet gains in academic achievement were attributed to computers, not the deep structural and curricular reforms introduced years earlier. Nor was there any mention of whether the costs for hardware, software, and technical support to achieve these supposed gains rose and stayed higher than average for district or regressed to normal operating expenditures.
Boosters continue the tainted practice of falsely attributing gains in quality health care and cost containment or district test scores to technological innovations without having data in hand. Moreover, when that data comes up short, then the next step—not yet taken in these examples—but historical studies are filled with such instances–blame is distributed—not to the policymakers who make flawed, data-free decisions nor vendors who shamelessly boost every new gadget–but to the practitioners who work in hospitals and school.