August 11, 2011
By Shaan Gandhi, PhD
Conventional wisdom dictates that expansion of computerization and information technology into any field would improve quality and efficiency. Our packages and express mail zip around the world at higher speeds and lower costs because of electronic tracking. We can travel to Boston, Bangalore or Brasilia and be assured of having access to funds because of interconnected banking networks. In the face of the ever-increasing costs of health care in the United States, accounting for $7,960 per person in 2009, perhaps an increase in the utilization of information technology in medicine would help us not only bend the cost curve but also keep pace with our peers in terms of health quality metrics, such as life expectancy.
Makes sense, right?
Such is the aim of Health Information Technology for Economic and Clinical (HITECH) Health Act of 2009, part of the 2009 stimulus bill. The HITECH Act aims to encourage the universal adoption and utilization of electronic medical records (EMRs) by health care providers, especially primary care physicians, by 2014. For providers achieving “meaningful use” of EMRs (electronic prescribing, health information exchange, reporting of quality data, among others), federal subsidies are offered to defray the high costs of implementation, which can run up to almost $47,000 per physician, according to a recent study in Health Affairs.
The structure of the subsidies is such that primary care physicians should strongly consider purchasing a system sooner rather than later, as the financial assistance drops the longer a practice waits. Additionally, there are major advantages to the health care system through widespread update of EMR meaningful use beyond increasing efficiency of care.For example, the data collected by the EMRs could potentially be used to improve care significantly and reduce health care disparities.
It sounds like a wonderful idea. So why are only just over half of physicians using at least a basic EMR?
My research through the Primary Care Innovation Collaborative (PCIC) here at the Harvard chapter of Primary Care Progress attempts to answer such a question. A nearby independent practice association (IPA), representing almost 700 primary care physicians, recently implemented a new EMR system in order to meet the 2014 deadline imposed by the HITECH Act. However, daily use of the system has fallen short of expectations. There are several reasons for this. For example, data are often difficult to input into the system with the necessary level of detail. Excess hours are spent every day jockeying with the system to document each patient interaction. Finally, locating pertinent information for patient management is often a drawn-out process.
These concerns are not limited to the practice with which I work. Academic surveys of physicians have documented experiences with poor functionality and integration into practice systems and, perhaps as a result, haven’t utilized the full capabilities of the EMR.
My work through the PCIC has focused on studying the interface of the EMR and its underlying functionality in order to devise streamlined workflows that would empower the physicians of the IPA to offer better patient care. For example, instead of being forced to click through individual windows to add specific diabetes drug dosages and hemoglobin A1C diagnostics repeatedly to manage patients with similar needs, I’ve begun to design templates that, with one click, automatically create prescriptions for the correct drugs and laboratory orders for different types of patients (e.g. a newly-diagnosed patient or a patient with well-controlled diabetes). Such work aims to reduce the number of open windows and clicked buttons to improve documentation efficiency. In addition, I’m working to incorporate deliverables, such as laboratory letters and other health care notes, such that their generation (with any pertinent associated information) can be automated—currently, they need to be written partially in person. Clearly, it isn’t enough to implement such interventions—I need to show that they actually have a salutary effect. So far, the physicians with whom I’ve worked are thrilled with the new tools, and anecdotally, they tell me that they spend less time working on the computer. More quantitative comparisons of time efficiency (documentation time per patient and per day) before and after the workflow changes are underway.
EMRs offer great promise to eliminate inefficiencies in and improve quality of primary care such that providers will be even more able to offer the excellent health care their patients need. Indeed, EMR manufacturers are beginning to realize the diversity of their users and have begun making refinements to their systems to better serve specific types of physicians. The road toward that future, however, is still being paved. Designing EMR systems that are better attuned to the needs of their physician users is a crucial next step.
Shaan Gandhi is a second year student at Harvard Medical School who has interests in health information technology and large-scale quality improvement, particularly in the major chronic diseases and in other complex illnesses, especially cancer. Previously, he completed a DPhil in medical oncology at the University of Oxford on a Rhodes scholarship.
In his free time, he works on policy and financial issues related to preventive health care and in chronic disease management both at Harvard and in the private sector as well as on his badminton game.