EMRs: Airbags for when your doctor crashes you

EMRs have the potential to prevent dangerous medication errors – I certainly have been saved a few times by them – but in this study appear to function mostly as a rescue device once an adverse event has already taken place.

Electronic health records have been purported to reduce the cost of care and to improve the quality of care. Last week, we reviewed an article that cast doubt on the cost-saving effects of EMRs; this week, we discover that current EMR systems do not provide against protection from a wide array of poor quality outcomes.

Hospital-acquired conditions – catheter based infections, iatrogenic injuries, and medication errors – represent patient safety issues and can result in costly complications for patients. Approximately 3.5 percent of Medicare spending goes toward adverse patient events. Nearly one-third of all hospital deaths for Medicare patients involve a hospital acquired condition. Thus is it reasonable to understand why Medicare recently stopped paying for certain hospital-acquired conditions and why Medicaid will soon follow. Elements of the Affordable Care Act known as value-based purchasing will continue this trend of paying for quality instead of simply the volume of services provided.

Researchers sought to explore the hypothesis that EMRs promote quality improvement and cost savings. EMRs are assumed to improve quality through one of 3 mechanisms: (1) by reducing the frequency of adverse events (preventing medication errors), (2) by assisting with the recovery from an adverse event (preventing a hospital acquired condition from progressing or resulting in patient death), and (3) by providing feedback from prior adverse events to promote quality improvement for future patients. Unfortunately, as of 2009, only 1.6 percent of hospitals possessed an EMR that qualified under the “meaningful use” criteria set forth by HHS.

The study explores surgical cases in the United States with a follow up 90 days post-operation. Data were obtained from the Market Scan® Commercial Claims and Encounter Database and the American Hospital Association Annual Survey. Outcomes of importance included adverse events, hospital readmissions, patient deaths, and health care expenses. Multivariate regression techniques were employed to parse out the effects due to EMRs.

Twenty-one percent of surgeries occurred in hospitals with basic EMRs. About 5 percent of these surgeries had at least one of 24 potentially preventable adverse medical events. Hospitals with EMRs were no less likely to have adverse events than hospitals without EMRs, nor were they less likely to have better mortality or readmission rates.

Expenses per patient safety event were $55,810 in hospitals with EMRs compared to $60,093 in hospitals without EMRs. Overall, however, total 90-day spending for surgeries with EMRs was higher ($29,967 versus $29,296 for surgeries without EMRs).

Death rates, while unchanged in the aggregate, did show improvement in patients for whom an adverse safety event occurred. The excess death rate due to patient safety events declined by 34 percent due to EMRs (1.7 percent with EMRs versus 2.6 percent without EMRs). Similarly, readmission rates were not directly affected by EMR systems but did show improvement if patient safety events occurred. The excess readmission rate due to patient safety events declined by 39 percent thanks to EMRs (5.4 percent versus 8.9 percent).

So while the authors concluded that EMRs did not directly impact patient safety or costs prior to the occurrence of an adverse event, these systems did help save lives and money once an adverse event took place. For instance, excess spending due to patient safety events declined by $4,849 (16 percent) due to basic EMRs ($26,448 with EMRs versus $31,297 without EMRs). For every 20 surgical patients, EMRs provided nearly $5,000 in savings. Contrasted with the cost of IT infrastructure, EMRs saved only 55 cents per dollar spent.

Commentary

Undergoing general surgery and driving on the highway both present danger to the involved parties. Collision avoidance systems in today’s automobiles aim to prevent wrecks; airbags and seat belts aim to protect the occupants after a crash occurs.

Based on the above evidence, electronic medical records seem to function similar to airbags and seat belts for surgical patients. While EMRs may not prevent hospitals from wrecking the patient, they do appear to mitigate the damage that might ensue.

However, based on this narrowly focused study, it does not appear that EMRs are necessarily worth the financial investment (from the perspective of profits and losses for hospital administrators). Other studies suggest that greater returns might be possible outside the surgical arena. Previous research shows prescribing errors decline by 66 percent with the use of computerized physician order entry. Exploring the cost savings of EMRs on medical wards might prove valuable. Even if a purely financial reason to implement EMRs does not exist, they do save lives and for those of us in that business, the health of our patients should be reason enough.

Encinosa,W.E. and Bae, J. Health information technology and its effects on hospital costs, outcomes, and patient safety. Inquiry. 2011-2; 48 (4): 288-303.

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Cedric Dark, MD, MPH