A study published in the New England Journal of Medicine is among the first to put hard numbers on the benefits of electronic health records.
Researchers looked at four national quality standards, including:
- eye exams,
- pneumonia vaccinations,
- outcome measures such as blood sugar, blood pressure, and cholesterol control,
- patient-driven issues such as obesity and smoking
Nearly 51% of patients in EHR practices received care that met all four quality standards, compared to just 7% of patients at paper-based practices. Nearly 44% of patients in EHR practices met at least four of five outcome standards, compared to about 16% of patients at paper-based practices.
The study is among the first to put hard numbers on the benefits of electronic health records. But as the study's lead author, Randall Cebul, MD, said in an interview this week, "51% is 49% short of ideal."
So what are the next steps? And how can health information technology get us there?
The problem of patient compliance and engagement
One finding of the research was that the benefit of electronic records was greater for care standards than it was for outcomes. And care standards that are largely patient-controlled—such as smoking and obesity—have been particularly troublesome.
"I guess it takes a village to attack all of the more behavioral-related and adherence-related issues that are most relevant to patients when they're living outside of the doctor's office, which is virtually 100% of the time," said Cebul, who is the director of Better Health Greater Cleveland, a nonprofit healthcare alliance focused on improving the health of chronic disease patients in Northeast Ohio.
Personal health records can help, he said.
"The personalized health records in big electronic medical record systems … enable patients to see their results, to see what is needed in terms of either health maintenance or monitoring of a particular condition, to communicate with their provider when in their home," Cebul said. Giving patients access to the ways in which doctors are thinking about their care and the results of their care will help engage them.
Electronic prescribing is another potential tool.
"When we prescribe medicines, we expect or hope that the patient will fill the prescription. In the new world of e-prescribing, there will be mechanisms by which we will be able to determine adherence to medications," Cebul said. "That will help us to recognize reasons for less-than-optimal control of chronic conditions and help engage the patient a little bit more effectively."
Strengthen connections of all kinds
Diabetes patients, in particular, need a lot of services that aren't always provided by their primary caregiver. It's easy to lose track of those visits with paper health records. In fact, it's difficult to track them even with electronic records, since those specialists don't often have EHRs of their own and, when they do, those EHRs are not always connected to the primary care provider.
"The connection between primary care and especially ophthalmology is not as tight as it could be. Most of the practices that we report on do not have ophthalmologists on site. That ends up being a structural barrier to doing better," Cebul said.
"We need to make certain that our ophthalmologist colleagues have electronic health records [and then link] those electronic health records to the practices. The fact that somebody out five miles or even a mile from you where you're practicing has electronic health records is very nice, but if they're not connected then that information is siloed."
If a doc doesn't know a patient has received an eye exam or a foot exam and doesn't document it in the record, he or she can't assume that it's been done, Cebul said. And you don't get credit for improving quality if it's not documented.
Share best practices as well as data
Under National Institutes for Health guidelines, anyone at risk for diabetes should get the pneumococcal polysaccharide vaccine. The MetroHealth System in Cleveland has adopted the standard but was having limited success meeting it, says David Kaelber, MD, MetroHealth's chief medical informatics officer. The organization, which is part of the Greater Health collaborative, got a bump in vaccine rates after it added EMR alerts for docs. The numbers jumped again with some physician education, but MetroHealth still wasn't meeting its goal of compliance in the 90th percentile.
In the end, taking doctors out of the picture was the change that made the difference. Making the vaccine part of the standard orders and empowering nurses to deliver them without asking for a doc's permission pushed MetroHealth’s compliance levels into mid- to high-90s.
Sharing such findings among collaborative members has changed and improved the way individual physicians practice, Kaelber said. Sharing data is important, too.
"Just by reporting quality in a standardized way across many providers and institutions, we are literally a catalyst for improving that quality," he says.
Technology alone isn’t a magic pill for healthcare, clearly. But technology tied to quality standards can help medical professionals and patients alike track care, remain accountable for improvements, and meet society’s goals.