Wednesday, March 15, 2017

This Is A Question We Need To Ask, Just The Same As They Are in The US.

This appeared a few days ago.

Why it’s time for EHRs to make an impact on healthcare costs

Published March 09 2017, 4:36pm EST
Earlier this year, Monmouth University conducted a survey to determine which issues were most important as the country transitions to a new presidential administration. Among all the potential concerns Americans now face, the issue that rises to the top is healthcare costs.
How acute a concern is this? It’s significant enough that, when asked the open-ended question, “turning to issues closer to home, what is the biggest concern facing your family right now?” 25 percent of respondents made it their No. 1 issue.
“It’s also worth noting that issues that have been dominating the news, such as immigration and national security, rank very low on the list of items that keep Americans up at night,” said Director Patrick Murray of the politically independent Monmouth University Polling Institute.
The concerns Americans are voicing about the affordability of care are certainly not misplaced. Overall healthcare costs rose more last August than they have during any month since 1984.
Why do healthcare costs continue to climb?
The answer is complex, as healthcare economics are complex, but certainly Obamacare and industry consolidation and drug prices and a host of other issues can be factored in. Still, one input outweighs all others, according to a recent New York Times piece.
“The real culprit of increased spending? Technology,” health economist Austin Frakt writes. “Every year you age, healthcare technology changes—usually for the better, but always at higher cost. Technology change is responsible for at least one-third and as much as two-thirds of per capita healthcare spending growth.”
To be clear, Frakt is talking about all technology, not just healthcare information technology. Indeed, in the sheer tonnage of medical technology that currently exists, IT probably makes up a relatively small share, but it does get lumped in the larger group when looking at the direct relationship between tech and costs.
Lots more here:
The point here is that if Health IT did indeed save money and make a real difference to care surely someone would have come up with evidence by now and no-one would be asking the question any more.
They are however! The ADHA has to start to be hard-nosed about the public’s money is spends without any evidentiary justification. It has gone on too long as partially demonstrated by the most recent poll.
See here:


Bernard Robertson-Dunn said...


I completely agree with your observation: "The point here is that if Health IT did indeed save money and make a real difference to care surely someone would have come up with evidence by now and no-one would be asking the question any more."

But we still get assertions like this, from the article:

"Healthcare IT in general and EHRs in particular offer a unique opportunity to help moderate costs and provide a host of clinical, organizational and population health benefits by improving processes."

Where's the evidence?

It's pretty self evident that more health IT will cost more. More Health IT may well (and usually does) improve outcomes through better diagnoses and better treatment. But save money?

And it's not just a matter of evidence, it's a matter of logical and credible changes to (in the language of Information System architecture) business processes.

Terry Hannan said...

I have many more studies on this topic
1. Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA. 1993;269(3):379-83. Epub 1993/01/20.
2. Tierney WM, Overhage JM, McDonald CJ. Demonstrating the effects of an IAIMS on health care quality and cost. J Am Med Inform Assoc. 1997;4(2 Suppl):S41-6. Epub 1997/03/01.
3. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med. 1996;124(10):884-90. Epub 1996/05/15.
4. McDonald CJ, Tierney WM. The effect of electronic health records on test ordering. Health Aff (Millwood). 2012;31(6):1365; atuhor reply 6. Epub 2012/06/06.
5. Tierney WM, McDonald CJ, Martin DK, Rogers MP. Computerized display of past test results. Effect on outpatient testing. Ann Intern Med. 1987;107(4):569-74. Epub 1987/10/01.
6. Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med. 1990;322(21):1499-504. Epub 1990/05/24.

Terry Hannan said...

This may be old technologies (evolving and adapting) but there is evidence for cost and quality benefits.
1. “To date, this program has demonstrated such dramatic Improvements in clinical and financial outcomes, as well as Remarkable acceptance by physicians, that it has been
Requested and installed in additional inpatient and outpatient Facilities in our integrated health care delivery system.” The New England Journal of Medicine -- January 22, 1998 -- Vol. 338, No. 4 A Computer-Assisted Management Program for Antibiotics and Other Antiinfective Agents. Scott Evans, Stanley L. Pestotnik, David C. Classen, Terry P. Clemmer, Lindell K. Weaver, James F. Orme, Jr., James F. Lloyd, John P. Burke
2. Conclusions: displaying the charges for diagnostic tests significantly reduced the number and cost of tests ordered, especially for patients with scheduled visits. The effects of this intervention did not persist after it was discontinued. WILLIAM M. TIERNEY, M.D., MICHAEL E. MILLER, PH.D., AND CLEMENT J. McDONALD, M.D. (N Engl J Med 1990; 322:1499-504.)
3. At Brigham and Women’s Hospital,Receivables dropped from 100 days in 1983 to 59 days in 1988. Outstanding debts in the outpatient clinics were reduced by more than $6 million during a period when the cash collected from outpatient revenues increased by 45%. International Journal of Medical Informatics 54 (1999) 183–196 The CCC system in two teaching hospitals: a progress report Warner V. Slack , Howard L. Bleich
James B, C. The Quality Measurement and Management Project (QMMP). Chicago: 1989 1989. Report No.

Bernard Robertson-Dunn said...


Dividing health industry applications into three:

1. Administration/business i.e. the fact that it's health is not relevant, it's a service business, like most others of that type.

2. Pathology and other types of tests e.g Blood tests, XRays, MRI, fMRI etc

3. Clinical, point of care support systems that manage patient data in the context of a current, acute and/or chronic health problem.

4. Long term health records that contain primarily summary documents relevant to the patient's health care/history. They may also contain un-curated/un-managed lists of a patent's prescriptions and interactions with health professionals.

I haven't read all your references in detail, but it would appear that they all fall into one or more of the first three categories.

My Health Record is of the last type and I have never been able to find any research or reports that provide any evidence that they deliver any significant value to most patients. I have found unsubstantiated claims that they will deliver major benefits, but I have never seen real evidence that they do.

The Royle review leaned very heavily on this:
"Using 21st Century Tools to overcome the ‘fear of frying’ and build success"
Which is little more than a set of assertions.

And this is an early one that set expectations but its predictions have not been achieved.
"Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs"

RAND, who sponsored this paper agree (I emailed and asked) that the "promise" of benefits haven't eventuated. They haven't done any follow up research to find out why.

IMHO, their big mistake was in assuming that health care was like other industries such as manufacturing and finance. It isn't. If ADHA make the same mistake, they'll get the same results. Or more specifically, the same non-results.

IMHO, the question is not, can Information Technology and Systems be used in health care to improve outcomes (I believe it can) but are the current efforts that are focused on a records management approach to health data delivering or are likely to deliver significant value to patients?

Bernard Robertson-Dunn said...

While we are looking for evidence and research, here's a paper you (and ADHA) might want to read.

"National electronic health record systems as `wicked projects': The Australian experience"
Karin Garrety, Ian Mcloughlin, Andrew Dalley, Ping Yu
July 2016

This is the conclusion

"The story of NEHRSs in Australia is far from over and new enthusiasms for the use of "big" and 'open' data to drive innovation in the healthcare sector suggest that the digital health record is a thin end of a much larger digitalization 'wedge'. It remains to be seen whether the proposed shift to an opt-out model and financial incentives for use by GPs will help to evolve the Australian MyHR system into a more useful tool that is valued by those delivering and receiving healthcare.

Regardless of what happens in the future, we now have 15 years of experience of attempts to build a workable NEHRS. It is timely to reflect on the consequences of the decisions that have been made and the processes that have been undertaken, in order to ascertain what might he learned about the development and implementation of ICT in the healthcare sector. Examining major policy 'blunders' in the UK, including the ill-fated attempt to introduce NEHRS in the English NHS.

King and Crewe suggest that the inherent complexity of these often 'hyper-ambitious' endeavours is beyond the competence of the politicians who initiate them and the civil servants who advise them. Moreover, the projects typically progress in the absence of appropriate means of tracking progress and allocating accountability, with the consequence that the scale and gravity of the 'blunder' usually emerges slowly and only after most of the damage has been done.

As they go on to suggest, one set of lessons revolves around getting the 'right people in the room" when decisions to initiate large-scale projects are made and seeking ways to ensure that an 'operational disconnect' does not emerge between the realities of the problems facing healthcare and what might assist in tackling them, and the 'magical' properties all too often associated with ICT by politicians."

Anonymous said...

Interesting publication Bernard. Personally I would like to see the designs to tackle the issue of the content. As you and others point out, the govHR is a document store, not a content store. Minister Hunt I ask, before you make anymore commitments to the MyHR you get the ACS to come in and review and explain the constraints.

The concept is fine, the purpose of the tool is not, it is not to late to change design. I am sure some will see you as easy prey coming from such small portfolios, I say that makes you perfect, untainted leadership, which the PM needs.

The ADHA has a design and innovation division, let us see what they think.

Anonymous said...

A view of a future Tim and co want -

The slow removal of those who understand this level of computing and the placement of technically less savvey yes people should be of great concern.

I am not against this, but the tax payer, patients and healthcare professions should be represented by real professionals who know what they are talking about. Would any buy a scalpel from a blacksmith?

Bernard Robertson-Dunn said...

March 18, 2017 9:02 AM

"The concept is fine..."

If you mean that health records and health data should be better curated, managed, organised and made accessible to value creating applications, then I agree with you.

Unfortunately, the big mistake NEHTA made was to come up with a solution that created a centralised, secondary, summary, government owned database.

The alternative, to take a health information perspective and to build upon and extend existing distributed systems close to point of care would have been a much more useful and flexible approach.

But they were only looking at the owner's requirements, we have been told. Pity about the poor patient, who also foots the bill and takes the privacy risks.