In the past decade, academics and industry experts have published conflicting reports on whether electronic health records (EHRs) actually save money. Recent studies based on large, historical data from diverse providers suggest that EHRs haven[i]’t decreased costs[ii][iii] – contrast this with cost benefit analyses published back in 2003 that predicted EHRs would save around $15,000 to $20,000 per primary care physician per year[iv][v]. In addition, multiple vendors, academics and industry experts have published positive case studies on how EHR provides a positive return on investment or saves money in areas such as billing and staffing costs.
So why the divergence? Are providers simply not achieving what we expected in 2003? Are the positive case studies overly selective? Is it a case of what’s true for some is not true for all?
EHRs actually enable more productivity and satisfy more demand, and this is what drives cost. For providers, this also means driving up revenues.
Supply and Demand
One reason healthcare costs have not uniformly decreased is that more (efficient) supply from EHRs leads to more demand.
Firstly, consider the Jevons Paradox: energy efficiency leads to greater consumption (e.g. as air conditioning becomes more efficient and affordable, more air conditioners are purchased.) Taking a healthcare analogy, data center capacity has grown exponentially and EHR functionality has improved in recent years. In response, providers are storing larger amounts of detailed patient data and accessing greater capabilities. For example, providers are integrating IT and medical devices for real time patient data monitoring, storage and beyond. Additionally, a 2012 study supports this theory in that physicians ordered 40 percent to 70 percent more radiology exams with EHRs than with paper records. The efficiency and capability of EHRs (supply) have driven up the demand.
Secondly, I’ll paraphrase Parkinson’s Law: work expands to fill the time available. Demand for services in (public) healthcare will always outstrip the supply. This is because there is a backlog of patients waiting for currently available services and once this backlog is cleared, expectations of what should be provided will increase. It is therefore important to recognize that current health care reforms may not automatically decrease costs with EMRs in place, as demand will then increase too.
Increased demand means increased cost.
So if cost doesn’t uniformly decrease with EHRs, does anything improve? Productivity does. A 2009 Wisconsin Medical Journal Study[vi] found that physician productivity increased about 20 percent and remained at that sustained level of productivity following EHR implementation. This means that more patients were seen on a given day. Not bad, considering the average wait time to see a physician in the U.S. is 20 days.
Increased productivity, however, leads to increased costs.
Payers vs. Providers
Another way to explain the divergence may lie in who we’re actually talking about. Do we mean payers like Medicaid/Medicare or providers like primary care physicians or hospitals? Studies often reference cost but fail to discuss revenue increases that an EHR system delivers to providers. Seeing more patients means more revenue to providers. In addition, providers with integrated EHR and billing benefit by eliminating billing errors and enabling better revenue protection. Payers, however, don’t share these financial benefits as more procedures means their costs are rising. Indeed, payers may not realize the full cost savings of EHR until providers move away from pay-per-procedure to quality based payments. Quality based payments of course, are next to impossible without the enabling reporting capabilities of EHR systems.
So when we talk about the cost of EHR systems, it’s important to distinguish who we’re talking about. In addition, when comparing pre- and post-EHR situations, instead of simply asking: “What’s the cost?” we should also be asking “What do we get for this cost?”
David Farrell is an IT strategy specialist at PA Consulting Group, focusing on project management and strategy for healthcare providers. He has worked with accountable care organizations and county-run hospitals on both U.S. coasts, assisting clients in building business cases, managing project benefits and forecasting the long term infrastructure impact of EHR.
By the time the market is ready to move, the technology they’ve been told to move to won’t exist as it has been depicted.
This is much the same thing as technology that has been developed that upon its arrival has been pronounced dead. An example of this was the iPad. Before it hit the market analysts and naysayers said the technology – which I don’t have to tell you is essentially a hand-held, touch screen computer – was worthless. No one had a need for PC that one could carry about wherever they went; we had laptops after all. But they failed to see the upside.
For example, iPads are the ideal technology for busy physicians (as you well know) making rounds jumping from patient to patient throughout a practice, as well as have had a profound effect on the treatment and education of individuals with autism and other developmental disabilities.
For example, tablet devices have opened the door for children with special needs, many of whom use them easily and effectively. Not only have they become a learning tool for many of these children, they have also become communication devices. According to Mashable, students using an iPad advance more quickly than those who did not use them. Even in education, there are currently more than 2 million tablets, like iPads, being used and the number will increase dramatically as the technology becomes more accessible and affordable.
As of December 2012, there are more than 20,000 apps for mobile devices that teach communication, speech, language, motor skills, social skills, academic skills, behavioral skills and more than 900 apps for students with disabilities, including autism.
I believe something similar will happen to the patient portal market. Heavily pushed on physicians by EHR vendors for the last three years, this has led to their increased popularity. Meaningful use hasn’t hurt either.
However, by the time the market adjusts to their availability and the reasons for their existence – bill administration, appointment scheduling, viewing records (in some cases) and communicating securely with physicians – the technology as we now know it will no longer exist.
Monique Levy, vice president of research for Manhattan Research recently made an interesting point about the future use of patient portals and I think it’s hard to disagree with her: Today, patient portals are most commonly used for scheduling appointments, viewing medical results and sending messages to doctors or nurses, Levy says. But many more advanced features are not only possible, but are available and waiting to be implemented. This includes access to video chat with a healthcare professional, pre- or post-operative care instruction videos and consolidation of all of a patient’s medical data from multiple sources in one place.
For instance, mobile health technologies will feed patient data directly to the patient portal to improve care and treatment options.
In a lot of ways, this sounds a lot like a Hootsuite interface that used to collate and track all of our social media channels. For example, I can track my Twitter feeds and Facebook pages as well as can interact, post and broadcast content through it. Patient portals are likely moving in this direction and will end up being so much more than the base model systems currently being implemented.
Most likely, the standard bi-directional portals that current vendors produce are likely going to be passé in short order and new systems and interfaces are likely to crop up and take over the market, changing the landscape once again.
Simply stated, perhaps it’s best not to believe all that we’re being told. It may benefits us to think about where our decisions regarding technology investments take us.
To follow the belief that the stale portals of today will match what in the future will most likely be vibrant interfaces may be similar to denying the viability and importance of devices like tablet PCs in healthcare and beyond, though, many thought them worthless at the point of issue.
Guest post by Stein Soelberg, director of marketing, KORE Telematics
As a provider of machine-to-machine (M2M) wireless networking services specifically designed for connecting mHealth solutions, KORE is approached every day with new use-case scenarios where telemedicine can provide life-saving or quality-of-life improving solutions for patients.
Currently, there are many health conditions that are being positively affected by the growth of mHealth applications; however, the top five health conditions for telemedicine treatment are active heart monitoring, blood pressure, diabetes, prescription compliance and sleep apnea.
1. Active heart monitoring. For at-risk patients, wireless heart monitoring devices have already proven to reduce hospitalization through early detection of heart failure. In addition, these devices are able to limit the time that physicians spend looking at data that is not pertinent, since they only send notifications with information that is outside an acceptable range.
2. Blood pressure. Wireless sensor nodes have become cost-effective, compact and energy efficient, which allows for continuous cycle reporting and electronic dispatch in urgent situations. It is important, however, to distinguish in this category between “critical monitoring” and “convenience monitoring.” The former are able to account for stress, eating habits and other external triggers more completely and pinpoint life-or-death issues. The latter are iPhone Apps for the health conscious consumer.
3. Diabetes. Wireless glucose monitoring devices can send alerts to patients and doctors alike when values move outside an acceptable range. These devices can also monitor for dietary intake to help impact a patient’s lifestyle choices.
4. Prescription compliance. On the surface this is an easy one. Patient health risks — and the risk of hospital admission — get greatly reduced by patients taking their medications as directed. But there is also a need to ensure that people take entire drug courses and eliminate the potential for re-prescribing. Literally billions of dollars each year reach their expiration date in patient’s medicine cabinets. Additional intangible benefits include fewer provider phone calls, and even shorter wait times in provider offices, by eliminating visits from improper prescription utilization.
5. Sleep Apnea. The thing that is really interesting about telemedicine devices for sleep apnea is that they can handle both investigatory and direct treatment. The two-way nature of the device can report on sleep patterns, body position and breathing to refine research and treatment course for any given patient. There is a direct cost saving here as well, since the devices directly eliminate the need for expensive Polysomnography exams and limit the need for overnight hospital stays, on an ongoing basis.
These mHealth applications are helping to promote more efficient use of medical equipment and resources, ensuring that devices and medication are being used as prescribed, improving patient outcomes by providing real-time data, improving patient quality of life, decreasing treatment costs and minimizing travel to and from offices and hospitals to allow for ease in care. Overall, the rise of mHealth/telemedicine will drastically and positively affect the lives of patients with a wide variety of health conditions.
Stein leads a team whose responsibility is to own the branding, advertising, customer engagement, loyalty, partnership and public relations initiatives designed to propel KORE into the 21st century. With more than 15 years of technology marketing experience in the business to business software, Internet services and telecommunications industries, Stein brings a proven track record of launching successful MVNOs and building those brands into leaders.
Guest post byRobert Oscar, R.Ph., founder of RxEOB.
Mobile technology has changed the way we live in dramatic fashion. Now it’s changing the way we access healthcare and medical information. In fact, the popularity of health-related smartphone apps as on-the-go tools has skyrocketed. Our smartphones and other mobile devices have made health and wellness choices simple and convenient.
More people than ever before are finding physicians, managing weight, controlling allergies, looking up symptoms, making doctor appointments and even checking into the hospital through their smartphones. For the house-bound and people living in rural areas, this technology can actually save lives by greatly improving connectivity and access to care, and streamlining self-management of such chronic diseases as diabetes, asthma and high blood pressure.
Health apps can also make medical-financial tasks easier, such as integrating financial data from high-deductible health plans or comparing prices between pharmacies. Furthermore, health apps can help streamline the flow of information between health plans, physicians and patients — making communication easier, quicker and more informative.
At work, employees can take greater control of their own health and work more closely with in-network healthcare providers. This is especially true for those who are looking to save money and reduce their out-of-pocket healthcare expenses.
Today, health-related apps are used mostly for accessing information, with some mobile devices making one-on-one interaction possible. As more hospitals and doctors begin to use apps, they will be able to reach more people with greater efficiency. Along these same lines, apps designed for physicians will become better at connecting to patients’ clinical records so that information can be easily shared — where and when it is need.
The impact of the mobile app revolution is expected to grow. In fact, a recent study found that nearly 17 million consumers were accessing health information on mobile devices in 2011, according to American Medical News, representing a 125 percent increase from 2010. These statistics have experts predicting that healthcare and medical app downloads will reach 44 million this year, and 142 million by 2016.
Consider the example of a large shipping company that participated in a pilot project involving a new mobile health app. Early reports showed that 42 percent of employees who used the app saved money on their prescription drug costs, according to Employee Benefit News. These employees had easy access to prescription drug plan information via their desktop and smartphones. End result, a whopping 71 percent of the participants said they’d recommend the service, and the company savings ranged between $174 and $366 per user per year.
Ultimately, health-related apps and the wealth of information they provide help patients become more engaged in their health so that they can make better choices, cuts costs and, eventually, help ease the strain on the US healthcare system.
Robert Oscar, R.Ph., has more than 25 years of experience in healthcare. Throughout much of his career, Oscar has developed and implemented successful programs to effectively manage pharmacy benefit risk including pioneering work in the Medicare HMO market. Before founding RxEOB more than a decade ago, Oscar worked in the medical information systems industry, designing, developing and implementing several different claims analysis tools. Licensed in Virginia and certified in pharmacy-based immunization, Oscar is a graduate of Ohio Northern University.
I may be preaching to the choir, or, perhaps, I’m speaking to myself. Here I am, a member of the both the health IT community and a member of the PR community. One of my tasks is to help educate and inform those within and those on the outside of the healthcare community about the benefits of technology that’s designed and created for the betterment of physicians, caregivers and patients.
Being in my somewhat unique position, where I publish a site dedicated to healthcare technology and my role as a PR professional, I get to see things from both sides of the fence, in many cases several times in a given day.
I do a lot of pitching to media sources, sending stories and ideas that have been developed by my clients to best educate the community about a plethora of subjects to the media. I live by a credo established by myself to approach the media only with topics I feel are specific, educated and advance the overall conversation about a certain subject. Never do I blindly pitch ideas simply for the sake of landing coverage in obscure outlets.
Perhaps Electronic Health Reporter is an obscure outlet. I’d like to think not. Nevertheless, I get pitched by fellow PR practitioners a lot. More than you might think; several times a day. As regular readers of this site know, I tend to focus on healthcare information technology and it peripheral topics. But, that’s more than I receive from my colleagues for story ideas.
Some of the topics in my inbox are enlightening and some are entertaining; some of completely off topic and some should never have been sent. So, why is this important; why take the time to dedicate to a post about the subject?
Perhaps I’m a purist. Maybe I have a sense of self importance, but I tend to think that the conversations taking place with the media, things that are being positioned for the press by leaders in the HIT community, just might not be what the market – those serving patients and others in the practice of healthcare – really need, want or like.
At its very base, this is the sort of thing that makes me wonder just how much “innovation” there is because those in the position of creating a product for the purpose of selling it to make money are convincing those that are counting on them for the newest products to advance their mission in the field according to innovation and need.
I’m often called a cynic. It’s true. I’m suspicious of a lot of things. It’s something that I developed during my days as a reporter when, like now (as a site publisher and blogger), I get pitched a lot of stories that were not worthy of my time.
I’ve got to admit, I’m surprised by this disconnect. It’s somewhat eye opening to me that the vendors serving the healthcare community seem so far from synched up with those actually providing the care.
If I’m wrong, I hope you’ll let me know. If I’m right, I promise not to be part of the problem.
According to a recent report issued by KLAS Research, “Patient Portals 2012: The Path of Least Resistance,” published by HIT Trends health systems and practices are turning to patient portals more than ever before. Meaningful use is an obvious reason, but convenience and “the ease of integration that comes from having an established relationship with an EHR vendor are the primary factors providers use to choose a patient portal.”
In light of the expanding need of patient portals, the KLAS study focused on solutions that providers use, and what role the portals play in the long-term strategies each organization for patient engagement. The report included respondents from a mix of health systems, hospitals, and clinics.
“Providers are feeling increased pressure to engage with their patients at deeper levels than ever before. About one-half of interviewed providers already had a portal in place, primarily from their current EHR vendor. Providers needing to connect a number of disparate EHRs were the only group more likely to opt for a best-of-breed solution.”
“The existing EHR vendor relationship appears to be more important than any other factor when choosing a patient portal,” said report author Mark Allphin. “While functionality and ease of use are important to providers, they take a backseat compared to providers’ desire to manage fewer vendors and interfaces.”
Although many providers are choosing to stay with incumbent EHR-based patient portals, KLAS did report significant interest and engagement with third-party vendors.
Access to the patient clinical record is the most implemented function. Other functions in place or planned include: appointment scheduling, provider messaging, bill pay, online registration and patient education.
Of those interviewed for the report, 57 percent of providers surveyed report a patient portal in place.
According to Michael Lake, publisher of the monthly healthcare IT newsletter, HIT Trends sums up the report this way: “Providers are putting patient portals in place to meet meaningful use requirements for access and messaging. Some are looking at kiosks and mobile solutions, too. In single EHR organizations, using portals from their current vendor makes tactical sense. Niche solutions may fare better when providers look at long-term strategies and required functionalities.”
From my perspective, and probably yours, serious portal conversations have taken place for about the last three years, and with the mandates of meaningful use, it was only a matter of time before they started to proliferate the market.
Even as practices look to engage their patients more, portals will likely be the first tool considered to do so. As the report suggests, the biggest question here may be whether to add a portal from your current vendor or to find a third-party solution.
Are you going through a portal implementation? What’s your strategy going to be?
Having spent most of my career on one side of a note pad while looking at a source on the other, I’ve often wondered if others have felt the way I have about trying to connect with the story tellers I’ve come to rely upon for my professional endeavors.
As professional reporter and freelancer, I’ve spent much of my life trying to connect with and extrapolate information from those who have it to give and turn that information into compelling stories for the world to read. And, in many cases, even as a public relations professional who worked for an EHR vendor to tell stories to the media about our technology and how physicians used it to improve practice efficiencies and establish their electronic health records, I asked myself the same question: Am I connecting with those I’m speaking with while I work to paint their pictures with my words.
Even now, as a blogger and freelance PR professional I continue to ponder the same question. And, I’ve wondered, if I feel this way when I’m writing a story and the only thing coming between me and my source is a pad of paper, how must it be then for physicians that are now using computers to take notes and build cases histories for their patients during their exams?
One day this argument will be settled as a new generation of docs enters the workplace and take over practices left by their predecessors as they will never know an exam room without some sort of technology – computer or mobile device – but one can’t but help feel (at least now in the infancy of the true EHR days) that there has been a change in the way your physician practices now that he or she has a computer next to your exam table in the exam room.
I’ve noticed that the doctor seems to be some great distance away from me as if I’m having a conversation with someone 1,000 miles away. It’s the same thing as when you are in a conversation with someone while you are toying around your iPhone or Blackberry. You’re there physically, but in mind you are a long way away.
The same can be said for drivers who chose to talk on their phones. Clearly, the individual is behind the wheel letting their body’s muscle memory carry them through the task of shifting, steering and turning, but their cognitive thoughts are in the place of purgatory somewhere between the road in which they are driving and the person on the other end of the line.
With this in mind, just how much is being conveyed and captured by the physician who’s tapping away at their keyboard while their trying to guide you through the eight-minute office visit?
Speaking from the perspective of a professional journalist who has made a career of trying to capture the facts, figures and stories of those sitting next to me while I’m typing or writing away, I can safely say that much is being lost. This is especially true since shorthand and transcription is a skill not being taught at our top medical schools and residency programs throughout the United States. Heck, we can’t even get our young med students trained on using electronic health records prior to graduating into real life so why should we expect our doctors to have the skills of a professional journalist or court reporter.
So, if I still have problems at times with connecting to sources even with nearly 15 years of experience, I can guarantee you that physicians, who don’t make a living at capturing the heart of a story or even its most important elements, that not all of a patient’s most important information will end up in their health record.
Guest post by: Sarah Armstrong, a consultant at ARRYVE, a strategy consulting firm.
A recent study published by the RAND Corporation indicates that implementation of electronic health records (EHR) has not yielded the cost reduction predicted in 2005[i]. Their study identified process efficiency and patient safety savings as two primary outcomes of EHR implementation, leading to a forecasted $81 billion annual drop in healthcare costs. Instead, costs have risen significantly. RAND cites a number of reasons for this: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of healthcare providers and institutions to reengineer care processes to reap the full benefits of health IT.
While the latter can be attributable to the inability or unwillingness of care providers to change, the former places blames on the institutions’ IT departments and software companies. These parties know that disparate EHRs leave a significant gap, but providers are not empowered to bridge the gap. Furthermore, software companies may struggle to differentiate themselves should they modify their product to be compatible with that of a competitor. Assuming either option presented a real possibility, modified software products and altered care processes lie years down the road at best.
If something breaks, you fix it. Fixing this problem will not be easy, however, and many opinion pieces point to our federal government as the catalyst required to affect change. But instead of a major, time-consuming overhaul by the producers and users of health IT, I propose we consider incremental ways to mitigate some of the effects of the problem. I see great opportunity for 2013 to be a year not of rigorously planned change, but of simple workarounds. Specifically, these workarounds would be performed by the people most affected by 1) poor or nonexistent interoperability of EHRs and 2) their caregiver’s inability to effectively use the technology: patients.
Consider the primary problem that arises from non-interoperable health IT systems: incomplete patient data. This problem manifests itself in many ways. For patients, treatment options may be redundant, medicines prescribed may counteract each other, and they may find themselves repeating information they already gave another provider. For providers, if their patients seek care outside their facility and do not fully report their medical history, the current state of health IT does not afford them a way to see the full picture. Additionally, the quality of a provider’s aggregate patient data diminishes.
I would argue that incomplete patient data has long been a problem associated with paper medical records. So why the recent finger pointing at EHRs? Could the problem be attributed to behavioral changes on the part of both providers and patients? Within the past five years, I have changed primary care physicians twice. I have listed the names of my previous physicians, but neither has asked me to obtain my old records. Because I have not been asked to procure these, I have not troubled myself with the task.
A patient unfamiliar with health IT or health information privacy laws might think that listing their previous physician’s name (or current specialists’ names) automatically transfers their medical record. Unless a patient signs for a record transfer, caregivers must rely on what is optimistically a factual and complete patient history form that is often filled out during the minutes before an initial visit. Years of medical care are rewritten according to one’s ability to recall vaccinations, test results, and allergies, as well as the accuracy of a data analyst inputting the record into the patient’s brand spanking new, and likely abbreviated, EHR.
Patients want the best care and we look to our caregivers to tell us what to do. We may not always listen (e.g., quit smoking, exercise, etc.), but people consistently identify their physician as the person they trust most. A simple but powerful mitigation plan for addressing incomplete patient data could be to involve patients more closely in their care:
In addition to obtaining high-level health information in the intake form, ask new patients to procure their old records. Evaluate the records and input the most important details into the EHR.
When calling with appointment reminders, ask patients to bring all current medications and supplements to the medical center. An easy task for many, it can only help providers diagnose and suggest treatment options.
During the visit, ask if the patient has sought care elsewhere. A simple question, it would likely jog one’s memory that, yes, they did see the eye doctor for an annual exam or received a flu shot at the pharmacy since their last visit.
Providers would also benefit from involving patients more closely in their care. Not only do they have countless reasons to deliver care based on complete data, but many also want to publicize to prospective patients that they provide quality care. Complete patient data helps legitimize providers’ quality claims. For example, by asking all female patients about recent cancer screenings, they can truthfully state the percentage of patients who are current on these screenings. Without asking this question, a primary care clinic might report a lower percentage of current screenings among its patients than is accurate, since they would not take into account those performed by outside providers (e.g., OB/GYN, dermatology, etc.).
When discussing the ineffectiveness of EHRs, invite all affected parties to the table. I have confidence that behavior modifications aimed at mitigating the side effects of a rapidly evolving landscape, keeping the best interests of everyone at heart, will serve us all well. I dare say that the cumulative effect of millions of small modifications will reach further and quicker than one major change by software manufacturers or Uncle Sam.
Sarah Armstrong is a consultant at ARRYVE, a strategy consulting firm, with a diverse mix of industry experience ranging from healthcare to software. Healthcare engagements have encompassed strategic planning, process design, revenue cycle, compensation planning, market analysis, quality management and regulatory compliance at academic medical centers, children’s hospitals, and both primary care and pediatric practices.
[i] Arthur L. Kellerman and Spencer S. Jones, What It Will Take To Achieve The As-Yet-Unfulfilled Promises of Health Information Technology, Health Affairs, 32, no. 1 (2013):63-68