FWD: emr (a conversation with my brother about the RAND study on EHR adoption and quality improvement)

I received this e-mail from my brother, who is an (excellent) ophthalmologist practicing in a fee-for-service environment:

Hey ted,

Just saw this on the net, kinda confirming what my conversations have been with doctors (though can’t speak for hospitals).  The study didn’t address cost savings though, as I’m sure some duplication of tests can be avoided.

There has been some (very slow) integration of emr into offices here.  My main contention is still the focus on data collection by the govt,


what do you think?

As I mentioned in my last post about conversations with my brother (FWD: More on HIT and cost saving (NOT!), Arizona is a long way from Washington, DC, and as I have always said, the reality of health care is what happens where the patient is.

He was referring to the study recently released by folks at RAND. I reviewed it, provided some commentary, and here was his response.

I agree with you, that the cost savings and quality improvements depend on implementation.  The few docs I know that are going emr, are in it for the govt discount, and of course, chose the cheapest, most basic system that is clearly worse than paper charts at this point.

Also, a good point with the duplication of tests.  Even though a test was normal 3 days ago, we’re still legally liable to repeat it.

Integration with physicians is surely the way to enhance our health care delivery; as long as it’s done right.

There were some doctors elected to the new congress.  Hopefully, that will help.

So what did I think?

I think the article makes a good argument that an EHR by itself is not transformative (you can read commentary on it here). There’s an important clue embedded within:

Sixth, our study may not have been long enough to fully estimate the relationship between EHr adoption and quality improvement. Institutions with “homegrown” EHrs that have been developed and refined over decades typically report that their EHrs have significantly improved clinicians’ adherence to recommended practices. In fact, our analyses are some- what illustrative of this phenomenon, as we observed that hospitals that had a basic EHr in place at the outset of the study realized significantly higher gains in heart failure quality scores.

In other words, there’s the data, and then there’s what you do with it. Quality does improve with leadership experience, and that will happen over time.

Not just technology, leadership, Kaiser Permanente, Tualatin, OR

Look at the data in this study – the first of its kind – showing the impact of measuring and introducing “care gaps” into clinical practice, at Kaiser Permanente, Northwest. The study looked at 13 different care recommendations and found that after 20 months, the PST improved performance from 72.9 percent to an average of 80 percent.

That’s a very different conclusion. Why? Look at the photograph on the left. You could only understand how an EHR helps by physically going to the place where it is used. When you do, you discover all the things in the environment around the technology that makes it work, like leadership and commitment. And it does work, with results to show for it. You can read more about my experience here: The ability to know – Population care facilitated by health information technology at Kaiser Permanente Tualatin, Oregon.

I suggest looking beyond the data, just like the design thinkers do – the value of observation.

I don’t want to imply that the hospitals studied in the RAND article lack leadership or commitment – referring back to what my brother asked, it’s the goal of EHR implementation to open the physician and patient community to the commitment they have always had, enabled by great tools.

In Conclusion, I don’t know what to tell my brother, yet

I need to sip my own champagne and “observe what people don’t do, listen to what they don’t say,” so I’m going to shadow my brother in his practice of medicine, where his patients are. 🙂

I’ll report back; in the meantime, what would you tell him?


Ted Eytan, MD