The Efficiency Debate


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The debate over whether EMR's increase or decrease the efficiency of the healthcare system is of extreme importance due to the magnitude of the system.  Some have claimed efficiency gains to be as high as $81 billion, while others believe that adoption will be extremely slow and difficult and won't improve efficiency.  While the technology at stake is not terribly modern or complicated, the magnitude of the implications of adoption make the issue an important and difficult one to resolve.

Pro EMR: Electronic Medical Records are more efficient than paper records 

1.
  Health studies have predicted huge savings from EMR adoption.
The main argument of EMR advocates is that the computerized medical records will save the country a fortune.  An article in The Boston Globe, entitled “Savings seen in computer health records,” published in 2005, cited a study that claimed that efficiency gains nationwide  could be as high as $81 billion per year.  The study was conducted by the RAND Corporation, a non-profit think tank in Washington, D.C.  RAND estimated that each year, $77 billion in savings would come from operating efficiency gains and $4 billion would come from improved safety, thanks to reduced prescription errors.  


The Globe article may be found here:
http://www.boston.com/news/nation/washington/articles/2005/09/15/savings_seen_in_computer_health_records/


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2.  EMRs improved operating efficiency in a case study of VA medical facilities.
The Department of Veteran Affairs has been a large early adopter of EMR technology, and as such, has been used by many as a case study of the costs and benefits of utilizing computerized medical technology.  The VA's EMR system is known as the Veterans Health Information Systems and Technology Architecture, or  VistA. 

In July 2006, the Department of Veterans Affairs was the winner of the "2006 Innovations in American Government Award," which was presented by the Ash Institute for Democratic Governance and Innovation at Harvard University's John F. Kennedy School of Government.  According to the Ash Institute's report, in the last ten years, VistA has helped to improve operating efficiencies by approximately 6 percent per year.  The Institute claimed that, thanks to its EMR system, the Veterans Health Administration now offers "the best care anywhere," which has "set the benchmark in quality of care."

According to the Institute's report, VistA made improvements in a number of areas.  Although it is estimated that nationwide 1 in 20 out-patient prescriptions have an error, the VHA's out-patient error rate is 7 in a million.  VistA has been linked with standardized, real-time summary and performance measurement tools, which gives faster and more reliable information to physicians and allows administrators to more easily evaluate results.  According to RAND investigators, VistA outperforms other health care sectors in all 294 dimensions of quality control in disease prevention and treatment.

The Ash Institute's report can be found here:
http://www.innovations.va.gov/innovations/docs/InnovationsVistAInfoPackage.pdf

An April 2010 Wall Street Journal Blog indicated that by 2007 VistA had already saved the VA $3.09 billion in net benefit.  The blog can be found here:
http://blogs.wsj.com/health/2010/04/06/study-vas-computer-systems-cost-billions-but-have-big-payback/ 

3.  There are many operating inefficiencies and inadequacies of our current system that EMRs could help to fix.
In 2004, the President's Information Technology Advisory Committee (PITAC) published a report entitled "Revolutionizing Health Care Through Information Technology."  The paper listed a number of disturbing statistics that have been the result of paper-based medical systems:
  1. The Institute of Medicine estimated in 2002 that between 44,000 and 98,000 people die each year due to medical errors in hospitals.   
  2. Medication errors are present in 1 in 5 doses given in hospitals, and 7 percent of which were life threatening.
  3. Between 17 to 49 percent of diagnostic laboratory tests are performed unnecesarily because the medical history and earlier test results were not present.
  4. There is no nationwide monitoring system to quickly identify potential epidemics, check for adverse drug interactions, or identify bio-terrorist incidents at an early stage.
According to the PITAC, these problems could be alleviated if we increased our reliance on information technology, such as computerized medical records.  PITAC reasoned that increasing IT would help to give physicians timely patient information, increase the legibility and accuracy of records, and decrease overall medical errors.

The PITAC report can be found here:
http://lazowska.cs.washington.edu/20040721_hit_report.pdf

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Anti-EMR: Electronic Medical Records are less efficient than paper records 

1.  Studies have over-estimated the savings that would result from EMR adoption.While many have proclaimed the great cost savings that would result from EMR adoption, there have been a good number who seem to disagree with the large numbers that EMR advocates are claiming the technology would save.  

For instance, in March 2009, a Wall Street Journal article entitled "Obama's $80 Billion Exaggeration" questioned the huge savings that Obama and others were claiming would result from EMRs.  In the article, authors Jerome Goopman and Pamela Hartband claim that the RAND researchers, who performed the cost savings analysis that was used by Obama and others, did not consider the downsides of EMRs.  According to these authors, the RAND researchers based their cost calculations on 100% EMR compliance across the nation, which is of course unrealistic.  

The authors also state that RAND researchers were not operating according to the scientific method, since they were assuming their hypothesis--that EMRs are cost-reducing--before it had been proven.  According to the authors, "Rather than wrestle with contrary information, the report invokes the success of computer-based systems in saving money in industries like banking, securities trading, and merchandising."  In contrast, the authors argue that, although computer-based systems have been cost-effective in other industries, they have not been proven to be cost-effective in healthcare, and so they should not assumed to be without verifiable proof.

The Wall Street Journal article can be found here:
http://online.wsj.com/article/SB123681586452302125.html

2.  EMRs may not reduce mistakes and may propagate them

Although EMR advocates claim that EMRs will reduce mistakes by standardizing records and eradicating legibility problems, others say that EMRs may in fact cause more mistakes and allow them to easily propagate throughout the system.  

In a report by the American Medical Information Association (AIAA) entitled "Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting, and Duplication" the AIAII investigates whether the copy-paste capability of the computer will cause health professionals and administrators to make a large number of duplication errors.  According to the report, 9 percent of progress notes in the VA's EMR system was the result of duplicated information.  While most copying was fine and time-efficient, the AIAA claimed that other types of copying could be very dangerous and could lead to the propagation of errors throughout an individual's medical record.  The report indicated that high-risk copying took place in 1 in every 720 notes and in 1 in every 10 electronic charts.  In order to combat this practice, the authors recommended "practitioner consciousness-raising and development of effective monitoring procedures." 

They AIAA report can be found here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1480345/

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The bottom picture is from: http://eyemdbilling.com/images/EMR.jpg