Health Affairs, 25, no. 4 (2006): 1079-1085 doi: 10.1377/hlthaff.25.4.1079 © 2006 by Project HOPE	New Online   House Health Reform Bill   Paying for Reform   Vetting AHIP's Report   HIV/AIDS Costs   Brief: Insurance Reform   HA Blog Top 10

This Article Abstract Reprint (PDF) Submit a response to this article Comments: View responses Alert me when this article is cited Alert me when Comments are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (10) Citing Articles via Google Scholar Google Scholar Articles by Sidorov, J. Search for Related Content PubMed PubMed Citation Articles by Sidorov, J. Related Collections Health Reform Hospitals Legal/Regulatory Issues Business Of Health Research And Technology Health Spending Consumer Issues Health Information Technology

Health Tracking

MARKET WATCH

It Ain’t Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs

Abstract

 
Electronic health record (EHR) advocates argue that EHRs lead to reduced errors and reduced costs. Many reports suggest otherwise. The EHR often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the EHR is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the EHR alone.

Or can it? A considerable body of evidence suggests that widespread adoption of the EHR increases health care costs. Although the focus of this paper is on the limitations of the EHR in ambulatory care, ample research shows that this might likewise apply to inpatient settings.

EHR definition and uptake. The Healthcare Information and Management Systems Society (HIMSS) defines the EHR as a "longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting." It does more than store information: It "supports other care-related activities directly or indirectly, including evidence-based decision support, quality management and outcomes reporting."³ According to the National Health Care Survey, EHRs were in use in 17 percent of physicians’ offices, 31 percent of emergency rooms, and 29 percent of hospital outpatient departments in 2003.⁴ In office settings, the 17 percent figure has not changed since 2001.⁵

Cost savings. Given the inflationary $1.9 trillion cost of U.S. health care, 20 percent savings is significant.⁶ A RAND analysis estimated that national adoption of the EHR could lead to "more than $81 billion" in annual savings, while Jan Walker and colleagues estimated that information exchange across providers, hospitals, public health, and payers could save $77.8 billion per year.⁷

The Case For The EHR

Top The Case For The... The Stakes For Physician... NOTES

 
As noted, the EHR’s potential is based on its ability to introduce new efficiencies to health care delivery. Each is examined below.

Worker productivity gains. One analysis showed that the EHR increased documentation time among physicians by approximately 17 percent, while computerized provider order entry (CPOE) increased it by 98 percent.⁸ In a separate study, EHR implementation at Kaiser Permanente resulted in a 5–9 percent decrease in office visits replaced by telephone contacts.⁹ Even if future "smart texts" or automated physician orders correct these inefficiencies, it is unclear whether the EHR enables gains in provider-to-patient ratios. Rather, these studies suggest that a possible outcome is that the same providers would serve the same patients, with fewer office visits, more remote communication, and more documentation.

However, the EHR can enable clerical staff reductions amounting to $13,000 per physician per year.¹⁰ For these savings to be realized, staff employment would need to be completely terminated. Although this is likely in outpatient settings, anecdotes of health care systems (where EHRs are prevalent) offering displaced workers other employment opportunities (including in IT departments) are commonplace enough to dilute these savings.

Ultimately, if the EHR consistently reduced labor costs, lower staffing ratios should enable insurers—representing the "front line" in managing health care costs—to reduce their fee schedules among EHR-enabled providers. The same should be true for participants in consumer-directed health plans. There is little evidence that this is occurring among the 17 percent of practices possessing an EHR.

Billing optimization. Not only are the EHR’s labor savings questionable, but increased billings are another likely outcome. Thanks to underlying decision logic previously only available to large institutions, the EHR can "auto-populate" or scour the record to justify a greater intensity of service. Accordingly, "increased coding levels" account for the return on investment.¹¹ Alternatively, better "capture of charges" and fewer "billing errors" can lead to a five-year $86,400 "benefit" per provider.¹²

Although additional detail may warrant increased payment, the "content" might be unchanged from the point of view of the patient (the end user). Physicians are prone to under-documentation, but these EHR enhancements, appropriate or not, arguably increase health care costs without any corresponding increase in quality.

Medical mistake avoidance. EHR advocates point to "decision support" that reduces errors of omission and commission at the point of care as a critical safety advantage.¹³ The Agency for Healthcare Research and Quality (AHRQ) has endorsed several IT interventions that promote patient safety (such as error tracking and alerts about the timing of tests); however, mention of the EHR is conspicuously absent.¹⁴ In fact, AHRQ’s "20 tips to help prevent medical errors" also fail to mention the EHR, versus interventions such as hand washing or relying on large-volume hospitals for complicated surgeries.¹⁵ The EHR’s failure to pass muster with AHRQ’s evidence-based approach to translating research into practice might explain the necessity of funding a large number of projects to better evaluate the EHR’s role in patient safety.¹⁶

Indeed, the available evidence is decidedly mixed. Examples of omission-type error reductions include alerts about vaccination status among children cared for in the emergency department; inpatient vaccination and anticoagulation reminders; diabetes, hypertension, vitamin B12 deficiency, thyroid and anemia screening in the elderly; health maintenance and counseling in a pediatric practice; and hypertension identification and control.¹⁷ However, EHR decision support has no effect on adherence to primary care guidelines for asthma or angina management; it leads to "variable" and "limited" adherence to diabetes and coronary artery disease reminders; it has no effect on evidence-based interventions for heart disease and heart failure; it causes no change in the care of patients with depression; it leads to "unwieldy" tracking and monitoring of preventive health and chronic illness; and it has no impact on diabetic glucose control.¹⁸

Why such inconsistency? Physicians might resent the loss of professional autonomy or have limited tolerance for on-screen prompts.¹⁹ In one survey, 75 percent of physician respondents admitted ignoring reminder icons, and more than half seldom or never acted on the information.²⁰ The EHR also impedes addressing other immediate patient needs in a time-limited office visit.²¹

EHR advocates also point to errors of commission. For example, important information might be missing from paper records, including radiology or laboratory tests.²² Accordingly, if inaccessible records are responsible for costly retesting, reductions should be readily achievable. This was not the case at Kaiser Permanente, where "use of clinical laboratory and radiology services did not change conclusively" over a two-year transition to the EHR.²³

Excessive testing could be more a function of defensive medicine, ease, or fear of uncertainty.²⁴ EHR decision support tools—including peer management, guideline promotion, and alerts about cost or redundancy—might reduce this.²⁵ However, an EHR-based decision support system that is cost-saving, generalizable, and sustainable remains elusive. Finally, ancillary testing is an important source of revenue. "Profit center" laboratory or radiology departments will not necessarily welcome EHR-based interventions that lead to fewer tests and less revenue.

Storage of other encounter data. Medical records are notoriously vulnerable to damage or disappearance. Hurricane Katrina’s destruction of Gulf Coast physician office practices has been cited as an example of the need for electronic medical information storage.²⁶ Yet Hurricane Katrina’s cost was not factored into any of the previous savings estimates; in fact, the president’s endorsement of the EHR predated this disaster by more than a year. Furthermore, the history remains a time-honored and reimbursable feature of every physician-patient encounter. Aside from the few situations in which patients are too ill to communicate, patients’ recall of past medical facts is accurate across a wide range of conditions.²⁷ It is also far cheaper than remote storage.

Medication error avoidance. Inpatient medication errors can occur at a rate of 142 per 1,000 patient days.²⁸ Both EHR-based decision support and CPOE can decrease these errors and reduce costs.²⁹ Furthermore, ready retrieval of medication lists is an intuitively valuable attribute of these systems.

However, not all reports on CPOE are positive. Its introduction in one pediatric intensive care unit led to an increase in mortality rates that was blamed on delays and increased documentation time, compounded by policies that diminished access to life-saving therapies and hampered communication among team members.³⁰ CPOE might pose other unique threats to medication safety, including fragmented displays, inflexible formats, missed renewal notices, and dosage guideline misinterpretations.³¹

Assuming that CPOE is ultimately vetted, the terms CPOE and EHR are not synonymous. The former can be implemented without the uncertainty of the latter. It also remains to be seen whether hospitals will pass any CPOE savings to health insurers or consumers.

The cost of quality. Cost savings associated with the EHR’s quality-based interventions vary and occupy time lines extending beyond one year.³² For example, influenza vaccination in the elderly costs less than $0 per quality-adjusted life year (QALY). In contrast, beta-blockers in coronary artery disease and hypertension cost up to $10,000 and $50,000 per QALY, respectively.³³ Accordingly, if the EHR leads to increases in such interventions, more lives saved will come at a heavy price.

Malpractice reduction. Physician malpractice premiums are blamed as one reason for rising health care costs. Noting that malpractice suits result from "systems errors," the U.S. Department of Health and Human Services (HHS) has endorsed "voluntary standards necessary to make the creation of an electronic health care record possible."³⁴ Yet no reports link the EHR to a reduction in malpractice suits—they find only that hospital risk managers are "looking" for such a reduction to occur.³⁵ According to a continuing medical education course developed by a major Pennsylvania malpractice insurer, there are too few court cases to assess the EHR’s role in countering malpractice allegations.³⁶

Although hospitals have reason to believe that CPOE or an EHR might lessen their malpractice exposure, liability insurers typically adjust physicians’ premiums by specialty, location, past malpractice experience, obtaining selected education credits, or participating in risk management activities. In contrast, there are no reports yet that many major physician malpractice insurers are prepared to reduce premiums because of the presence of an EHR.

Little wonder. Physicians’ quality of care has less to do with being sued than with having an uninterested demeanor; failing to diagnose or consult; and providing negligent fracture, operative, maternity, or trauma care.³⁷ It is not intuitively obvious how the EHR can alter these. However, two other reasons for malpractice allegations—medication error and failure to document a retrievable informed consent—might be favorably influenced. The EHR has yet to be quantified or consistently used to reduce malpractice premiums or health care costs.

Impact on outcomes. In addition to the EHR’s individual impact, the technology should also facilitate aggregate outcome studies.³⁸ Patient registries could presumably be tapped for population-based, real-world research; quality improvement studies; or cost-effectiveness analyses. Yet the impact on savings is unclear. Gains in avoiding paper chart reviews would be possible only if the savings were greater than the labor and capital costs of setting up a patient registry. It also remains to be seen if new insights from EHR-based research can easily be mainstreamed, since, as noted above, its ability to promote long-established interventions is spotty.

The Veterans Health Administration (VHA) has demonstrated that EHR-facilitated measures of quality can support physician feedback driven by work-unit leadership.³⁹ Given the autonomy enjoyed by non-VHA physicians, behavior changes are less dependent on the EHR than on other factors, including local accountability.

It should also be noted that the prospect of easy access to the EHR partially fueled adoption of the Health Insurance Portability and Accountability Act (HIPAA) in the first place.⁴⁰ Cost burdens associated with HIPAA are considerable. For example, one report documented that HIPAA compliance with a coronary artery disease registry led to more than $8,700 and $4,500 in incremental and follow-up yearly study costs, respectively.⁴¹

The Stakes For Physician Practices

Top The Case For The... The Stakes For Physician... NOTES

 
The fact that the U.S. government spent the considerable sum of $900 million in 2004 to promote health care IT suggests that doubts persist about its marginal utility.⁴² The same is true for retail banking, where similar issues of interoperability persist and data entry remains very much a human task.⁴³ Physicians must ponder the EHR’s estimated start-up and ongoing costs of $44,000 and $8,500, respectively. As previously noted, the "bottom line" rests on recouping the capital outlay by billing more for the same services, while simultaneously lowering personnel costs.⁴⁴ Local market expectations, "branding" advantages, and increased patient volume are other rationales for using the EHR. Despite doubt that quality is served, there may also be income opportunities from pay-for-performance, including efficient patient identification, recruitment, and data reporting.⁴⁵ Yet physicians seem unconvinced. The EHR’s flat uptake suggests that physicians’ inertia is attributable to more than a matter of access to capital or a return on investment. Physicians doubt the EHR’s quality proposition, and income and workflow disruptions from the EHR might be considerable in clinics with high fee-for-service, one-on-one patient throughput.⁴⁶

What is clear is that once physicians’ reluctance is overcome, the EHR’s business case will not necessarily be aligned with the nation’s interest in lowering costs and increasing quality. As the EHR’s installation and maintenance expenses pass to the consumer through increased billings—absent any economic return on efficiency or quality—costs are likely to be accelerated.

PATIENT-CENTEREDNESS, shared decision making, teaming, group visits, open access, outcome responsibility, the chronic care model, and disease management are among the proposals intended to transform medical practice. The EHR’s greatest promise arguably lies in the support of these initiatives, versus the prospect of less efficiency, greater cost, inconsistent quality, and unchanged malpractice burdens resulting from a simple engraftment onto the current health care system. Accordingly, policy might be better served by caution, viewing the EHR as less of an established end and more as an inconsistent means of transformation. Finally, additional research is needed on overcoming the EHR’s limitations and dependably achieving higher quality at affordable cost.

Editor's Notes

 
Jaan Sidorov (jsidorov{at}geisinger.edu) is an associate in the Department of General Internal Medicine, Geisinger Medical Center, in Danville, Pennsylvania, and medical director, Care Coordination, of the Geisinger Health Plan.

The author thanks Kristin Lynn for her invaluable insights in the preparation of this manuscript.

NOTES

Top The Case For The... The Stakes For Physician... NOTES

 

1. White House, "Transforming Health Care: The President’s Health Information Technology Plan," 2004, http://www.whitehouse.gov/infocus/technology/ economic_policy200404/chap3.html (accessed 27 April 2006).
2. U.S. Department of Health and Human Services, "Office of the National Coordinator for Health Information Technology," 23 May 2005, http://www.hhs.gov/healthit/valueHIT.html (accessed 27 April 2006).
3. Healthcare Information and Management Systems Society, "EHR," http://www.himss.org/ASP/topics_ehr.asp (accessed 27 April 2006).
4. C.W. Burt and E. Hing, "Use of Computerized Clinical Support Systems in Medical Settings: United States, 2001–03," Advance Data from Vital and Health Statistics no. 353, 15 March 2005, http://www.cdc.gov/nchs/data/ad/ad353.pdf (accessed 26 April 2006).
5. D. Gans et al., "Medical Groups’ Adoption of Electronic Health Records and Information Systems," Health Affairs 24, no. 5 (2005): 1323–1333.[Abstract/Free Full Text]
6. C. Smith et al., "National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending," Health Affairs 25, no. 1 (2006): 186–196.[Abstract/Free Full Text]
7. R. Hillestad et al., "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs," Health Affairs 24, no. 5 (2005): 1103–1117[Abstract/Free Full Text]; and J. Walker et al., "The Value of Health Care Information Exchange and Interoperability," Health Affairs 24 (2005): w10–w18 (published online 19 January 2005; 10.1377/hlthaff.w5.10)[Abstract/Free Full Text]
8. L. Poissant et al., "The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review," Journal of the American Medical Informatics Association 12, no. 5 (2005): 505–516.[Abstract/Free Full Text]
9. T. Garrido et al., "Effect of Electronic Health Records in Ambulatory Care: Retrospective, Serial, Cross Sectional Study," British Medical Journal 330, no. 7491 (2005): 581.[Abstract/Free Full Text]
10. R.H. Miller et al., "The Value of Electronic Health Records in Solo or Small Group Practices," Health Affairs 24, no. 5 (2005): 1127–1137.[Abstract/Free Full Text]
11. Ibid.
12. S.J. Wang et al., "A Cost-Benefit Analysis of Electronic Medical Records in Primary Care," American Journal of Medicine 114, no. 5 (2003): 397–403.[CrossRef][Web of Science][Medline]
13. L.T. Kohn, J.M. Corrigan, and J.M. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academies Press, 1999); and E.A. McGlynn et al., "The Quality of Health Care Delivered to Adults in the United States," New England Journal of Medicine 348, no. 26 (2003): 2635–2645.[Abstract/Free Full Text]
14. This had more to do with the commission of unnecessary repeat testing rather than the omission of needed testing. Agency for Healthcare Research and Quality, Translating Research in to Practice: Reducing Errors in Health Care, April 2000, http://www.ahrq.gov/research/errors.htm (accessed 29 March 2006).
15. AHRQ, "Patient Fact Sheet: Twenty Tips to Help Prevent Medical Errors," February 2000, http://www.ahrq.gov/consumer/20tips.htm (accessed 29 March 2006).
16. AHRQ, "National Resource Center for Health Information Technology," click "AHRQ-Funded Projects," http://healthit.ahrq.gov (accessed 26 April 2006).
17. See, for example, J.J. Olson et al., "A Reexamination of the Feasibility of the Administration of Routine Childhood Vaccines in Emergency Departments in the Era of Electronic Vaccine Registries," Pediatric Emergency Care 21, no. 9 (2005): 565–567[CrossRef][Web of Science][Medline]; P.R. Dexter et al., "A Computerized Reminder System to Increase the Use of Preventive Care for Hospitalized Patients," New England Journal of Medicine 345, no. 13 (2001): 965–970[Abstract/Free Full Text]; and E. Toth-Pal, G.H. Nilsson, and A.K. Furhoff, "Clinical Effect of Computer Generated Physician Reminders in Health Screening in Primary Health Care—A Controlled Clinical Trial of Preventive Services among the Elderly," International Journal of Medical Informatics 73, nos. 9–10 (2004): 695–703.[CrossRef][Web of Science][Medline]
18. See, for example, M. Eccles et al., "Effect of Computerised Evidence Based Guidelines on Management of Asthma and Angina in Adults in Primary Care: Cluster Randomised Controlled Trial," British Medical Journal 325, no. 7370 (2002): 941–947[Abstract/Free Full Text]; T.D. Sequist et al., "A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease," Journal of the American Medical Informatics Association 12, no. 4 (2005): 431–437[Abstract/Free Full Text]; B.L. Rollman et al., "A Randomized Trial Using Computerized Decision Support to Improve Treatment of Major Depression in Primary Care," Journal of General Internal Medicine 17, no. 7 (2002): 493–503[CrossRef][Web of Science][Medline]; J.C. Crosson et al., "Implementing an Electronic Medical Record in a Family Medicine Practice: Communication, Decision Making, and Conflict," Annals of Family Medicine 3, no. 4 (2005): 307–311[Abstract/Free Full Text]; P.J. O’Connor et al., "Impact of an Electronic Medical Record on Diabetes Quality of Care," Annals of Family Medicine 3, no. 4 (2005): 300–306.[Abstract/Free Full Text]
19. W.M. Tierney et al., "Effects of Computerized Guidelines for Managing Heart Disease in Primary Care," Journal of General Internal Medicine 18, no. 12, (2003): 967–976.[CrossRef][Web of Science][Medline]
20. K. Schellhase, T.D. Koepsell, and T.E. Norris, "Providers’ Reactions to an Automated Health Maintenance Reminder System Incorporated into the Patient’s Electronic Medical Record," Journal of the American Board of Family Practice 16, no. 4 (2003): 312–317.
21. R.M. Epstein, "Time, Autonomy, and Satisfaction," Journal of General Internal Medicine 15, no. 7 (2000): 517–518.[Medline]
22. P.C. Smith et al., "Missing Clinical Information during Primary Care Visits," Journal of the American Medical Association 293, no. 5 (2005): 565–571.[Abstract/Free Full Text]
23. Garrido et al., "Effect of Electronic Health Records in Ambulatory Care."
24. M.L. Dekay and D.A. Asch, "Is the Defensive Use of Diagnostic Tests Good for Patients or Bad?" Medical Decision Making 18, no. 1 (1998): 19–28[Abstract/Free Full Text]; A.M. Epstein and B.J. McNeil, "Physician Characteristics and Organizational Factors Influencing Use of Ambulatory Tests," Medical Decision Making 5, no. 4 (1985): 401–415[Free Full Text]; and A.F. West and R.R. West, "Clinician Decision-Making: Coping with Uncertainty," Postgraduate Medical Journal 78, no. 920 (2002): 319–321.[Free Full Text]
25. E.G. Neilson et al., "The Impact of Peer Management on Test-Ordering Behavior," Annals of Internal Medicine 141, no. 3 (2004): 196–204[Abstract/Free Full Text]; R.S. Evans et al., "A Computer-Assisted Management Program for Antibiotics and Other Antiinfective Agents," New England Journal of Medicine 338, no. 4 (1998): 232–238[Abstract/Free Full Text]; W.M. Tierney, M.E. Miller, and C.J. McDonald, "The Effect on Test Ordering of Informing Physician of the Charges for Outpatient Diagnostic Tests," New England Journal of Medicine 322, no. 21 (1990): 1499–1504[Abstract]; and D.W. Bates et al., "The Impact of Computerized Physician Order Entry on Medication Error Prevention," Journal of the American Medical Informatics Association 6, no. 4 (1999): 313–321.[Abstract/Free Full Text]
26. iHealthbeat, "Officials Say Hurricane Katrina Highlights Need for EHR System," 19 September 2005, http://www.ihealthbeat.org/index.cfm?Action=dspItem&itemID=114778 (accessed 27 April 2006).
27. J.B. Brown and M.E. Adams, "Patients as Reliable Reporters of Medical Care Process: Recall of Ambulatory Encounter Events," Medical Care 30, no. 5 (1992): 400–411[Web of Science][Medline]; L.X. Clegg et al., "Comparison of Self-Reported Initial Treatment with Medical Records: Results from the Prostate Cancer Outcomes Study," American Journal of Epidemiology 154, no. 6 (2001): 582–587[Abstract/Free Full Text]; M.G. Law et al., "A Comparison of Patient Interview Data with Pharmacy and Medical Records for Patients with Acquired Immunodeficiency Syndrome or Human Immunodeficiency Virus Infection," Journal of Clinical Epidemiology 49, no. 9 (1996): 997–1002[CrossRef][Web of Science][Medline]; and M.K. Walker et al., "Validation of Patient Recall of Doctor-Diagnosed Heart Attack and Stroke: A Postal Questionnaire and Record Review Comparison," American Journal of Epidemiology 148, no. 4 (1998): 355–361.[Abstract/Free Full Text]
28. D.W. Bates et al., "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors," Journal of the American Medical Association 280, no. 15 (1998): 1311–1316.[Abstract/Free Full Text]
29. N.C. Dean et al., "Decreased Mortality after Implementation of a Treatment Guideline for Community-Acquired Pneumonia," American Journal of Medicine 110, no. 6 (2001): 451–457[CrossRef][Web of Science][Medline]; D.W. Bates et al., "A Randomized Trial of a Computer-based Intervention to Reduce Utilization of Redundant Laboratory Tests," American Journal of Medicine 106, no. 2 (1999): 144–150[CrossRef][Web of Science][Medline]; and C.M. Birkmeyer et al., "Will Electronic Order Entry Reduce Health Care Costs?" Effective Clinical Practice 5, no. 2 (2002): 67–74.
30. Y.Y. Han et al., "Unexpected Increased Mortality after Implementation of a Commercially Sold Computerized Physician Order Entry System," Pediatrics 116, no. 6 (2005): 1506–1512.[Abstract/Free Full Text]
31. R. Koppel et al., "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors," Journal of the American Medical Association 293, no. 10 (2005): 1197–1203.[Abstract/Free Full Text]
32. M.R. Gold et al., eds., Cost-Effectiveness in Health and Medicine (New York: Oxford University Press, 1996); and M.V. Bala and G.A. Zarkin, "Application of Cost-Effectiveness Analysis to Multiple Products: A Practical Guide," American Journal of Managed Care 8, no. 3 (2002): 211–218.[Medline]
33. K. Kiewra, "What Price Health?" Harvard Public Health Review, Fall 2004, http://www.hsph.harvard.edu/review/review_fall_04/risk_whatprice.html (accessed 27 April 2006).
34. DHHS, "Confronting the New Health Care Crisis: Improving Health Care Quality and Lowering Costs by Fixing Our Medical Liability System," 25 July 2002, http://aspe.hhs.gov/daltcp/reports/litrefm.htm (accessed 27 April 2006).
35. "Risk Managers Looking to EMR Systems for Proactive Reduction of Medical Errors," Performance Improvement Advisor 9, no. 7 (2005): 81–83.[Medline]
36. PMSLIC CME course, "Electronic Medical Records: A Risk Management Perspective" (2005).
37. G.B. Hickson et al., "Obstetricians’ Prior Malpractice Experience and Patients’ Satisfaction with Care," Journal of the American Medical Association 272, no. 20 (1994): 1583–1587[Abstract/Free Full Text]; and R.G. Roberts, "Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk," March 2003, http://www.aafp.org/fpm/FPMprinter/20030300/29seve.html?print=yes(accessed 29 March 2006).
38. See, for example, A.L. Benin et al., "Validity of Using an Electronic Medical Record for Assessing Quality of Care in an Outpatient Setting," Medical Care 43, no. 7 (2005): 691–698[CrossRef][Web of Science][Medline]; M.F. O’Toole et al., "Electronic Health Record Systems: The Vehicle for Implementing Performance Measures," American Heart Hospital Journal 3, no. 2 (2005): 88–93; and J. Powell and I. Buchan, "Electronic Health Records Should Support Clinical Research," Journal of Medical Internet Research 7, no. 1 (2005): e4, http://www.jmir.org/2005/1/e4 (accessed 27 April 2006).
39. S.M. Asch et al., "Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample," Annals of Internal Medicine 141, no. 12 (2004): 938–945.[Abstract/Free Full Text]
40. R.M. Califf and L.H. Muhlbaier, "Health Insurance Portability and Accountability Act (HIPAA): Must There Be a Trade Off between Privacy and Quality of Health Care, or Can We Advance Both?" Circulation 108, no. 8 (2003): 915–918.[Free Full Text]
41. D. Armstrong et al., "Potential Impact of the HIPAA Privacy Rule on Data Collection in a Registry of Patients with Acute Coronary Syndrome," Archives of Internal Medicine 165, no. 10 (2005): 1125–1129.[Abstract/Free Full Text]
42. DHHS, Office of the National Coordinator for Health Information Technology, Directory of Federal HIT Programs, 21 July 2005, http://www.hhs.gov/healthit/federalprojectlist.html#intitiativestable (accessed 27 April 2006).
43. D.U. Himmelstein and S. Woolhandler, "Hope and Hype: Predicting the Impact of Electronic Medical Records," Health Affairs 24, no. 5 (2005): 1121–1123.[Abstract/Free Full Text]
44. Miller et al., "The Value of Electronic Health Records."
45. M.B. Rosenthal et al., "Early Experience with Pay for Performance: From Concept to Practice," Journal of the American Medical Association 294, no. 14 (2005): 1788–1793.[Abstract/Free Full Text]
46. G.A. Loomis et al., "If Electronic Medical Records Are So Great, Why Aren’t Family Physicians Using Them?" Journal of Family Practice 51, no. 7 (2002): 636–641; and R.J. Baron et al., "Electronic Health Records: Just Around the Corner? Or Over the Cliff?" Annals of Internal Medicine 143, no. 3 (2005): 222–226.[Abstract/Free Full Text]

                      What's this?

This article has been cited by other articles:

				E. W. Ford, N. Menachemi, L. T. Peterson, and T. R. Huerta Resistance Is Futile: But It Is Slowing the Pace of EHR Adoption Nonetheless J. Am. Med. Inform. Assoc., May 1, 2009; 16(3): 274 - 281. [Abstract] [Full Text] [PDF]

				M. A. Fischer, C. Vogeli, M. Stedman, T. Ferris, M. A. Brookhart, and J. S. Weissman Effect of Electronic Prescribing With Formulary Decision Support on Medication Use and Cost Arch Intern Med, December 8, 2008; 168(22): 2433 - 2439. [Abstract] [Full Text] [PDF]

				A. Virapongse, D. W. Bates, P. Shi, C. A. Jenter, L. A. Volk, K. Kleinman, L. Sato, and S. R. Simon Electronic Health Records and Malpractice Claims in Office Practice Arch Intern Med, November 24, 2008; 168(21): 2362 - 2367. [Abstract] [Full Text] [PDF]

				G. J.M. Tevaarwerk MD Electronic medical records Can. Med. Assoc. J., May 6, 2008; 178(10): 1323 - 1323. [Full Text] [PDF]

				M. I. Harrison, R. Koppel, and S. Bar-Lev Unintended Consequences of Information Technologies in Health Care An Interactive Sociotechnical Analysis J. Am. Med. Inform. Assoc., September 1, 2007; 14(5): 542 - 549. [Abstract] [Full Text] [PDF]

				J. C. Crosson, P. A. Ohman-Strickland, K. A. Hahn, B. DiCicco-Bloom, E. Shaw, A. J. Orzano, and B. F. Crabtree Electronic Medical Records and Diabetes Quality of Care: Results From a Sample of Family Medicine Practices Ann. Fam. Med, May 1, 2007; 5(3): 209 - 215. [Abstract] [Full Text] [PDF]

				S. M. Davidson and J. Heineke Toward an Effective Strategy for the Diffusion and Use of Clinical Information Systems J. Am. Med. Inform. Assoc., May 1, 2007; 14(3): 361 - 367. [Abstract] [Full Text] [PDF]

				C. Erikson, E. Salsberg, G. Forte, S. Bruinooge, and M. Goldstein Future Supply and Demand for Oncologists : Challenges to Assuring Access to Oncology Services J. Oncol. Pract, March 1, 2007; 3(2): 79 - 86. [Abstract] [Full Text] [PDF]

Comments: