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EMR use improves primary care: new study

There seems to be a lot of buzz in the news lately around the question of whether electronic medical record documentation can lead to a higher quality of care.  Last year, a study came out suggesting that this might be true for diabetes care.  More recently, my attention came to an article published in the Journal of the American medical informatics Association in May 2012, Method of electronic health record documentation and quality of primary care.

A group of researchers led by Dr. Jeffrey Linder at Harvard University’s Brigham and Women’s Hospital studied primary care physicians taking care of 7000 patients with coronary artery disease and diabetes over nine months. The study authors assessed 15 quality measures, three of which were found to be performed significantly less by physicians using a typical dictation system for record-keeping as opposed to those keeping records by electronic medical records systems.  Two of the three standards of care measures that dictating physicians were less likely to provide were tobacco use documentation and diabetic eye examinations.
This parallels my own findings as an endocrinologist using electronic medical records. During the period of my early years before I instituted widespread use of templating, I was much less likely to hit all of the quality care measure marks compared with after instituting templates.  It’s actually quite commonsensical that a medical provider can hit all of the marks if they are prompted by the computer.  In a sense, the care goes on autopilot.  No matter how chaotic a given point in the day of a busy doctor might be, it becomes impossible to complete a note without performing all of the prompts unless doing so deliberately.

There has been at least one or two studies that I’m aware of that have doubted or not found the conclusion that electronic medical records improve the quality of care patients receive.  I think that most likely these studies did not find a significant association because they were not properly designed.  When one considers the volume of quality measures pertinent to a typical patient visit with diabetes or coronary artery disease, there are so many measures that unless every physician has the measures memorized and never forgets anything, gets flustered or has to hurry through the visit, there will almost be a guarantee that not all measures will be addressed at a visit.  I’ll take that bet and win every time.

The fact that there are now at least two studies showing a positive relationship between the quality of care given to diabetic patients in the use of electronic medical records documentation is even stronger evidence that this is a real phenomenon.  Personally, I can’t believe that anybody would think that electronic medical records don’t lead to better care, regardless of the degree of such improvement.  That is, unless they’re not using the templating advantage.

October 21, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

How EHR Templating Helps Me Provide Better Diabetes Care

Recently, I guest blogged over at EHR Outlook.  Check out my post How EHR Templating Helps Me Provide Better Diabetes Care.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine and opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.  He blogs at HappyEMRDoctor.com and EHROutlook.com.

October 17, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Lack of motivation of private payers to incentivize EHRs

In his June 30, 2011 post “Private Payers Need to Join Humana, CMS With EHR Subsidies”, Neil Versel wonders where all the private payers are when it comes to providing incentives to doctors for implementing meaningful use of EHRs.  Apparently, Humana is now one company slated to start following CMS’ lead.

This reminded me of an interesting story involving an insider I knew who previously worked for insurance companies.  He once told me an interesting story about the conversations that happen behind closed doors of private health insurance corporate boardrooms.  Alas, it was so long ago, that I honestly don’t remember who it was, or who they previosuly worked for, but it put such an indelible mark on my memory that I couldn’t resist the chance to share it here.  This may be a bit graphic to some, so turn back now if you have a faint heart.

I told my contact that I just couldn’t understand why preventive office visits such as counseling by registered dieticians dealing with weight loss for patients with obesity weren’t ever covered.   Did these patients really need to develop diabetes first before any coverage for such services would be provided by the insurance companies? It just didn’t make any sense to me or others that I had discussed it with.

My contact told me about an example of how insurance companies employ actuaries to mathematically predict odds of a bad outcome.  [For those of you who worship the movie Fight Club, you might find some similarity here to a particular dialog in that film.]  Because the odds are very good that a particular patient will change insurance companies within a few years –happens all the time — there is much less of a chance that insurance company A will have to end up paying for their leg amputation by the time it happens.   Therefore, insurance company A doesn’t provide much in the way of preventive care and counseling visits today.   The odds are with the insurance company that they’ll never have to pay for that operation in the future because the patient’s out the door by then and on to insurance company B.  I know, what a callous and disgustingly money-grubbing view!  Gee, you don’t say.

Now, getting back to this private insurance company incentive plan idea …

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 5, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Bad research? Flawed conclusions from Harvard-based EMR study?

Recently I read a post over at Medwire News citing a that investigated whether the copy-and-paste methodology could have detrimental effects on diabetes control.  Since I previously blogged on this topic, of course I found the study very interesting.  In their study, the authors used a software program to correlate hemoglobin A1c reductions (a marker of diabetes control) with how often copy-and-paste was likely used.  The software guessed at whether parts of a note met enough similarity to previous notes to suggest that they might have originated by copy-and-paste methods.  Because the diabetic patients being followed in the copy-and-paste group did not have lower hemoglobin A1c levels over time, the authors concluded that copy-and-paste had a role in causing bad patient outcomes.

Although interesting, this study is concerning for several reasons.  It places a bad view (real or not) on doctors who use copy-and-paste responsibly and effectively.  Since I do this all the time and have not noted any particularly bad outcomes in my diabetes patients, I have to question whether the conclusion is valid.  There is so much potential for error in this type of statistical correlation research that I think big disclaimers should be noted.  What kind of counseling was being done in the subgroup of diabetics that had an allegedly poorer outcome?  Was that group of diabetics different from the ones with a good outcome?  What approaches to treatment were used?  What years were they being treated?  Who was treating them?  Etc, etc.  Perhaps the most important two questions in my mind are:  Who are the authors responsible for the study?  What are the authors’ personal biases?

The authors conclude that “These results lead us to question whether copied electronic documentation is a reliable representation of patient care,” in a letter to the Archives of Internal Medicine. “If it is not, it could be either an honest mistake or deliberate falsification.  In the latter case, copied documentation that does not reflect the actual events is a serious breach of medical ethics. In either case, it carries a significant financial and legal risk.”  There seems to be such a negative slant here that I have to again ask about the personal biases of the authors and how this may have affected their study design.

What would be my motivation to enter documentation that said I did  things that I didn’t actually do?  That could also be an important question with multiple possible answers.  How much time does the doctor have?  Is the doctor a resident trainee?  How protective of the practice does the doctor feel?  Does quality of electronic notes in general (which is highly varied) directly correlate with patient outcomes?  Maybe, since the data from Brigham and Women’s Hospital suggests falsification in the author’s eyes, they should take a good, long look at the context of their research methodology (who was involved in writing the clinical notes and under what circumstances) rather than relying on a possibly very flawed method to generalize negative study results to all doctors using reasonable and responsible documentation methods.  Or maybe I’m being too rash?

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

June 1, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.