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A US study showing electronic health records failed to have any impact on outcomes for stroke patients highlights the pitfalls of simply mechanising paper-based processes, says the head of Australia’s e-health authority.
Dr Steve Hambleton, chair of the National E-Health Transition Authority (NEHTA), said e-health was unlikely to be effective if it was simply providing an electronic record of sub-standard care.
“Electronic health records (EHRs) alone — just making a computerised record of what used to be paper — isn’t helpful”, Dr Hambleton told MJA InSight. However, by interrogating the data and applying benchmarks, it’s possible to pinpoint unwanted clinical variation and improve health outcomes, he said.
“If you mechanise medical records by creating an EHR, there will be no change. But if you re-engineer what you do with that information, that’s when we should get some leverage.”
Dr Hambleton’s comments came after the Journal of the American College of Cardiology reported that e-health had no impact on the quality of care and outcomes for ischaemic stroke patients. (1)
The 3-year study evaluated outcomes for 626 473 patients in 1236 US hospitals, including 511 hospitals with EHRs by the end of study period, that had signed on to the Get With The Guidelines-Stroke (GWTG-Stroke) program. (2)
An editorial accompanying the US study described the findings as a “wake-up call” and noted the original “triple aim” of e-health in the US was to improve the quality of health care, the health of populations and the efficiency of health care systems. (3)
“An EHR’s first priority must be support of clinical care, not documentation for billing and reimbursement that adds a burden translatable into neither value nor patient health or safety”, the editorial authors wrote.
Dr Hambleton said the study findings were at odds with the experiences of US integrated managed care consortium Kaiser Permanente.
A review released last year on the introduction of a personally controlled electronic health record (PCEHR) in Australia noted that Kaiser Permanente had recorded a 66% reduction in sepsis-related mortality, a 40% drop in stroke deaths and a 50% reduction in deaths caused by heart attacks since introducing e-health systems. (4)
Dr Hambleton said the foundations were now in place for e-health to make a significant impact on clinical outcomes in Australia. He said two million Australians had a PCEHR; all Queensland, ACT and Tasmanian hospitals were now capable of engaging with PCEHRs; and, by the end of 2015, all NSW hospitals would have this capability. Some hospitals in Victoria, SA and WA were also able to engage with PCEHRs.
He said health care providers now required a clear signal from the federal government on the future funding and the strategic direction of e-health in Australia.
But Alison Verhoeven, CEO of the Australian Healthcare and Hospitals Association, said there was still a long way to go to achieve an e-health system in Australia that effectively met the needs of clinicians, health service providers and consumers.
“Recent reviews have proposed a number of recommendations for system improvement but these are yet to be implemented. We now run the risk of trying to build on a flawed system, based on yesterday’s technology, and not fully informed by either comparative experience internationally or the views and requirements of key stakeholders”, she told MJA InSight.
Ms Verhoeven said e-health systems had been deployed across most hospitals for a range of purposes, but their variability and interoperability with systems used by other health service providers was problematic.
“The requirements of clinicians and consumers, and the goal of improving health outcomes, are not central enough to e-health development”, she said.
E-health systems had the potential to improve information sharing between hospitals and general practice at clinical handover, contribute to better integration between acute and primary care, and to drive greater efficiency in the health system. “But it is unlikely this will be realised under current arrangements”, Ms Verhoeven said.
Last month, the chair of the AMA Victorian section of general practice Dr Michael Levick said poor communication between hospitals and general practices in the state was putting patients at risk. He cited the case of a patient who had died because their GP did not know they had been prescribed warfarin in hospital. (5)
Dr Hambleton said the Victorian case highlighted the importance of sharing information and the need for hospitals to better engage with existing e-health processes.
“It’s all part of the e-health strategy — we have to hand over information. There are 230 000 hospital admissions as a result of medication misadventure in Australia, and 20 000 deaths.”
He said he could not see why we should not target a 90% reduction in medication errors with proper communication and consistent e-health systems.
1. J Am Coll Cardiol 2015; 65: 1964-1972
2. Get with the guidelines: stroke
3. J Am Coll Cardiol 2015; 65: 1973-1975
4. PCEHR Review 2014
5. The Age; 22 April 2015
(Photo: auremar / Shutterstock)
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For the eHealth debate we need to address the following. “Healthcare is seen as a service profession, and a key component of this service delivery is management of information by clinicians. But what does this actually mean? In routine care, clinicians collect data such as patient history, perform physical examination, create reports, access laboratory data, read X-rays results, and then record these data (through the production of notes, operative reports, prescriptions and diagnostic test results). Clinicians also transmit these data through various means: through telephone, paper documents, electronic charts and email. They process this information to arrive at a diagnosis, or deduce a hierarchy of possible diagnoses and initiate treatment(s). ……………… Health, information and management are critically interlinked so ‘there is no health without management, and there is no management without information’. [Taken from Hannan and acknowledgement to Prof W. Tierney, Regenstrief Institute] TJ, Celia C. Are doctors the structural weakness in the e-health building? Intern Med J. 2013;43(10):1155-64. Epub 2013/10/19]
As Coiera stated in 2003, ‘The biggest information repository in health care lies in the people working in it, and the biggest information system is the web of conversations that link the actions of these individuals’. As physicians are a major component of this repository, the current low and inappropriate involvement of physicians in the e-health revolution are major factors in many of the costly failures and adverse outcomes of e-health projects.”
Many pitfalls in the use of eMRs arise from their poor functionality as documentation tools for clinicians. If the system is slower and more difficult than hand-writing on paper (as it almost always is), then it won’t assist a clinician in documentation – we will write less. The real advantages lie in legibility and communication – the ability to share information within and across systems. However, legibility and communication are pointless if the content is poor – “rubbish in -> rubbish out”.
For ease and speed of documentation, there is still nothing easier or faster than pen and paper – no matter how computer savvy you are. It means not having to open screens, save, open and close documents. So, if writing on paper is best for the documenter but electronic is best for legibility and communication, we need to find systems that link the two. Voice recognition or telephone dictation have both been used with success – we need to make them easily accessible.
Some future functions of ehealth which may be actually useful, would be to link and have available to quickly and easily look up using a single programme:
– results from all Australian pathology providers (public and private),
– reports from all medical imaging providers,
– all scripts dispensed by any pharmacy in Australia
This would have huge financial benefits by saving double-ordering of tests, monitoring trends, allowing any doctor to see what medications the patient is really on and when last prescribed (not just their recall), which would also make eliminating doctor shopping much easier.
@ Matthew Yap.
Yes, apart from the disaster of the information blocking and interoperability problems currently being discussed by the US govt (http://www.healthit.gov/sites/default/files/reports/info_blocking_040915…), the key to leveraging eHealth systems is in using the data that’s already there to find and make improvements.
But how is this going to be done without improving healthcare’s expertise in data use? Informatics training in healthcare has been repeatedly reported at many levels, but actual resourcing is missing. Compare this to the Public/Population Health fraternity who have spent over $80 million on data linkage systems, providing the infrastructure and personnel for data-driven policy development. Individual hospitals can’t even link data between adjacent sevice units and clinical staff don’t know where to obtain relevant data to answer their clinical questions about care in their own facility. This is possible now, but try to find a source to fund this – it’s not research, because its infrastructure, but infrastructure grants don’t fund software or IT systems. And it’s not considered part of clinical care either.
Why is Kaiser Permanente able to demonstrate the remarkable improvements mentioned? others eg Intermountain Healthcare also cite clinical benefits realised by eHealth. Look at the structure of their IT services: focuss on patient outcomes & clinician or health sciences led. For example, look at the quals of the authors of papers showing benefit – many have MPH postnomials. It requires clinical epidemiological and health outcomes research skills in the IT space to focus IT development and similar skills at the coal face to leverage the data and eHealth systems.
E-health is promoted as if it is a treatment in its own right. In any capacity in which I have used it, it has resulted in increased medication errors, wrong patient names on scripts, and slower script writing; search capacity is vastly inferior to being able to leaf through a paper file.
Lack of uniformity in software platforms across providers means that there are silos of information which can’t talk to each other, and therefore have NO impact in preventing iatrogenic side effects or improving knowledge of background medical status.
When efforts have been made to standardize a system (eg CERNER in Victoria) the soft ware becomes impossibly cumbersome because of the need to be all things to all disciplines.
I wince anytime anyone talks of the benefits of e-health: at present, e-health is ‘all hat, no cattle’.
So this ‘research’ has found if you implement a system that is made for reporting and record keeping, and one that ignores patient outcomes, there is no effect on patient outcomes?
Could the same not be said for the size of fish tanks in waiting rooms having no effect on patient outcomes?
The remainder of the article covers much more relevant commentary on the usefulness of e-health.
In addition to real-time information sharing about specific patients, e-health has great potential in changing the outcomes of future populations, by way of increased disease and procedure monitoring, and in providing information-rich data for research and clinical service planning. In addition to patient outcomes, such research is likely to have great impacts on economic outcomes also. The big However, however, lies in the need for a well-coordinated, integrated suite of supporting technology and expertise – the scale of which is unlikely to be approached under current systems.
The vision shared by the likes of Ms Verhoeven is the only one that could truly deliver health outcomes for patients and the wider populace. The kind of information sharing needed to prevent medication errors mentioned by Dr Hambleton is one that we should have had yesterday, and still need now.
I have been following the ehealth and similarly named technologies for some time.
Personally I have not found any benefits and many patients very reasonably are concerned about who can access to their records. I know first hand that some very important persons in the USA are entered by false names by their personal doctors.
The benefits are over promoted and I wonder how much the medical profession is being influenced by very large commercial organisations who have real interest in patient care but are reaping huge rewards by overselling technology.