A recent study by Romano and Stafford in the Archives of Internal Medicine showed that among the visits where the practitioners used Electronic Health Records (EHRs) with clinical decision support (CDS) only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS. It is important to note that this study used data from 2005–2007 and was sampled nationally.
Although this study received widespread notice, many organizations in Minnesota have quietly made significant strides in the effective use of EHRs. This progress was on display this year at the annual winter conference of the Minnesota Medical Group Management Association.
Two local project in particular deserve special attention: the Institute for Clinical Systems Improvement’s High-Tech Diagnostic Imaging (HTDI) Project and local health care analytics firm Evidity’s assessment of the effectiveness of Electronic Health Records in improving the quality of care in Minnesota.
ICSI High-Tech Diagnostic Imaging (HTDI) Project
The Institute for Clinical Systems Improvement (ICSI) reported on a project to improve the appropriate utilization of CT, MRI, PET and nuclear cardiology scans.
Their approach consisted of deploying a common set of appropriateness criteria that would be:
- Available in the physician’s office to provide clinical decision support at the time care is being discussed with the patient and prior to ordering HTDI tests
- Embedded into an electronic medical record (EMR) or made available via a website
- Continually enriched and expanded for improved outcomes.
A simple 1 through 9 rating box is displayed in a provider’s electronic health record when a HTDI test is ordered. The rating box provides an analysis of the level of diagnostic utility of the provider’s selection and carries other multiple benefits including, offering guidance to ordering providers and supporting shared decision making between providers and patients. For those organizations with full EHRs, the patient’s clinical information is loaded automatically into this system which then makes its recommendation based on guidelines from the American College of Radiology and the American College of Cardiology.
When a test of a mid to low range value is ordered, additional information is provided to the ordering physician, who then may choose to continue and order the test or switch to another. All payers in the system have agreed to make payments no matter what level of test is ordered. In some cases, the recommended test is, in fact, more expensive than the test originally ordered.
The ICSI staff’s summary of the benefits of this system over three years among five large medical groups was:
- $84 million savings based on reduction of HTDI scans against projected trend line without decision-support
- 11,000 fewer administrative hours for just one medical group by having electronic decision support accepted vs. calling an Radiology Benefits Manager
- Decreased exposure to radiation, potentially preventing cancers.
EHR Use and Quality
A relatively new health care analytics firm, Evidity, was also at MMGMA and their website shows the power of the new information now available from multiple publicly reported sources.
The Evidity team published a study in August of 2010 which assessed whether the use of Electronic Health Records improved the quality of care in Minnesota. Minnesota Community Measurement data was used and the investigators compared the presence of an EHR to achievement of diabetes care quality measures.
Their analysis showed that compared to clinics that have not yet implemented an EHR, an average of 9 percent more patients met all five of the optimal diabetes care measures when seen at clinics that have the highest degree of EHR use.
These two studies strongly contradict the Romano analysis, which may be due to the time or geographic differences. However, it is clear that the electronic health record is a powerful tool. Do you have other EHR success stories to share? Why do you think there is a discrepancy between the results of the national study and Minnesota’s successes with EHRs? Do you think the use of EHRs could lead to more sophisticated, high-quality, cost-effective care?