Dr. Bates, Middleton and I have been asked to respond to a letter in the Washington Post. Our response, including links to the appropriate studies/evidence, is today's blog.
Dear Editor:
As Harvard Medical School faculty and experts in healthcare information technology, we wish to respond to the March 17, 2009 article "Bad Bet on Medical Records" By Stephen B. Soumerai and Sumit R. Majumdar. Our response is below:
"Soumerai and Mejumdar’s critique of electronic health records and the investment being made in them in the U.S. by the Obama administration does not present a balanced view of the evidence. The U.S. already lags behind virtually every other industrialized nation with respect to Health Information Technology (HIT) adoption, especially outside the hospital. The evidence suggests that investing in HIT will pay for itself.
Their first point is that several randomized controlled trials of decision support for one particular area (management of a few chronic conditions) did not show benefit (Article 1, Article 2, Article 3) That is accurate. However, they have not included multiple other studies that show that there is benefit for other conditions like diabetes and heart disease (Article 4, Article 5, Article 6) The data about the benefits of HIT for chronic diseases are more mixed than for other areas, but clear benefits have been demonstrated.
Their next assertion is that health IT does not save money. There are numerous studies showing that it does (Article 7, Article 8, Article 9, Article 10, Article 11). For example, a detailed case study of the cost and quality benefits of EHR at Family Care of Concord, NH found net benefits per clinician per year of $30,324. Another study of hospital-based provider order entry identified net savings of $1.7 million per year from drug dosing guidance, nursing time utilization, and error prevention.
Soumerai and Mejumdar also suggest that information technology makes care less safe. They present data from Children’s in Pittsburgh, which found that children transferred in for special care had an increased mortality rate. They do not mention that this hospital implemented the system poorly (as has been well documented) and made many workflow changes that resulted in delays in care for sick children. Badly implemented software can certainly yield negative results. Other hospitals, including Children’s of Seattle, have implemented exactly the same vendor system, following best practices for implementation, and experienced a trend toward a lower mortality rate.
The authors refer to “modest” error reductions. In fact, the level of medication error reduction with computerization of prescribing seen in multiple studies is over 80%. That is more than modest.
Doing research takes years, years that we do not have if we are to avoid slipping even further behind the rest of the world in this key part of the economy. While we do need research in this area, it should focus on how to improve care, not whether or not to implement electronic health records. That is already clear. Physician and nurse-practitioner teams represent a good idea, but they will be much more efficient if they are supported by the right information technology. Furthermore, health information technology, once implemented, keeps delivering benefits which will grow over time, while approaches like physician-nurse teams require ongoing support.
If we are to deliver high quality care for patients with chronic conditions, electronic records with decision support are needed to help providers track all the many things that need to be done. These records should include tools that enable providers to manage populations of patients with certain conditions like diabetes, and to track their progress. Patients should have tools that allow them to access their records and more actively participate in their care. Finally, we need to provide economic incentives for delivering better care, which will get providers to focus on these issues.
If patients are to have high-quality, safer, lower-cost care, we must move to a digital world in healthcare. Doing so won’t ensure that care gets better by itself, but it is a pivotal step in the right direction.
David Bates MD, MSc is Professor of Medicine at Harvard Medical School, and Professor of Health Policy and Management at the Harvard School of Public Health.
John Halamka MD, MSc is Associate Professor of Medicine, and the Chief Information Officer at Harvard Medical School and Beth Israel Deaconess Medical Center
Blackford Middleton MD, MPH, MSc is Director of Clinical Informatics R&D, and of the Center for Information Technology Leadership, at Partners Healthcare."
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