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Electronic Letters to:

Jaan Sidorov It Ain’t Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs Health Affairs, July/August 2006; 25(4): 1079-1085. [Abstract] [Full Text] [PDF] [Reprints & Permissions]

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Electronic letters published:

Right On!

Elaine Habig, 317-507-9988   ( 17 July 2006 )

EHRs And Cost Savings -- Term Definitions Are Key

John Haughton   ( 17 July 2006 )

EHRs And Cost Savings

Arvind R. Cavale   ( 26 July 2006 )

Electronic Health Records: Au Contraire

Joan R. Duke   ( 21 August 2006 )

EHRs: Costly And Dangerous To Privacy

Deborah C. Peel, MD   ( 21 August 2006 )

Right On! 17 July 2006
Elaine Habig, Physician & Founder Isprit Systems in Medicine, 317-507-9988 Send letter to journal: Re: Right On! ehabig{at}isprit.com Elaine Habig, et al.	An internist for 27 years, I read your article with interest, and I couldn't agree more on every point. I have used EMRs (EHR) in my office for 25 years and have found that never once did I practice better medicine. Merely recording information on a computer disc did not alleviate the paper trail, nor assist me in my daily tasks. With T1 lines, scanners, and disconnected software, costs increased instead of decreased. When the chronic care epidemic erupted a few years ago, I considered quitting (yes, with an EMR). Instead, I designed an in-office disease management system (acute and chronic), which embeds into a physician's workflow and uses the electronics to make it happen. Now my life with too many patients taking too many pills and having too many diseases is improved, and while not perfect, I do practice better medicine. Funny thing--very few people "get it." Most are engaged with the idea of the expensive, cumbersome EMR and trying to adapt their lives and profession to it. Been there, done that, and found just what you have reported here. We have to adopt technology in health care, but I doubt that we will truly be successful in our efforts until we embrace the same type of disruptive technology as a cell phone--inexpensive, simple, universal, with a purpose in mind: healing.
EHRs And Cost Savings -- Term Definitions Are Key 17 July 2006
John Haughton, CEO / CMO DocSite, LCC Send letter to journal: Re: EHRs And Cost Savings -- Term Definitions Are Key jhmd{at}docsite.com John Haughton	The very nomenclature -- EMR or EHR -- creates confusion. The two terms, often used interchangeably, really encompass a number of functions, some cost savings, and time savings; other have more expense associated with them. (1) EMR -- primarily electronic medical record -- used for documentation. Often sold and touted for its "Coding Calculators"; typically takes time and can increase costs for the health care system, by, for instance, increasing the number of level 4 visits submitted by a primary care provider. (2) EHR -- primarily electronic health record -- used for a "connected" view of the patient as known in the system (either locally or regionally). With the addition of the often included point-of-care decision-support registry function and the population-reporting registry function, these systems save time through decreased need for chart review (summary available) and improve care through measurement of an individual patient's needs and through measuring practice performance. When the Institute of Medicine wrote its Quality Chasm report, the functions described for electronic health systems included neither documentation nor billing enhancement. It did, however, highlight the need for decision support and communication between caregivers, among other needs. In short, the use of "EHR" in Dr. Sidorov's article might be an atypical use of the initials often used to refer to "EMR" functions.
EHRs And Cost Savings 26 July 2006
Arvind R. Cavale, Physician Send letter to journal: Re: EHRs And Cost Savings Arvind.Cavale{at}perfectserve.net Arvind R. Cavale	Jaan Sidorov's article is quite timely. Having personally used and helped develop an EMR over more than 2 years, I find that this article misses the point almost entirely, for several reasons. (1) EMRs [electronic medical records] should not be confused with EHRs [electronic health records] and certainly not with CPOE [computerized physician order entry]. These are quite different entities, and one should not mislead the uneducated reader. (2) Cost savings with EMR use are usually measured by indirect savings such as by improving clinical efficiency, reduction in office costs, etc., as well as reduction in hospitalizations due to preventable errors such as medication errors, etc. (3) Even though the author's reference studies may not have been able to show statistical evidence for the benefits of EMR use, these data sets were collected before the advent and more widespread use of more interactive EMRs. Hence, future studies might show more significant benefits. I would love to see if anyone from the health IT industry would provide evidence contradicting Jaan Sidorov's findings.
Electronic Health Records: Au Contraire 21 August 2006
Joan R. Duke, Managing Principal HCIC, LLC Send letter to journal: Re: Electronic Health Records: Au Contraire jduke{at}hcicllc.com Joan R. Duke	I quote from the study by Jaan Sidorov: "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." I am not sure where the body of evidence is for the increase in cost due to adoption of EHR. I would agree that there is a lack of juried studies of EHR benefits, and there are some number of reports of poor implementation. On the opposite side, there are a number of studies which point to the type of benefits that can be attained and some number of reports from HIMSS Nicholas B. Davies Ambulatory Care Award Winners and other references that demonstrate benefits obtained by ambulatory care practices. That being said, the practices that receive benefits are those that consciously work to obtain the benefits by changing their operations to take advantage of the new technology. It is not sufficient to simply implement an electronic record; a practice must redesign the way it operates and train the staff to be able to function in this new environment. It is also important to aim for an interoperable electronic medical record (EMR). As other readers have pointed out, there is a real difference between an EMR restricted to documentation within a practice and an EHR which captures data external to the practice setting, providing the ability to view a longitudinal record of patient care. Using the Davies Ambulatory Care Award Winners as my guide, I list the following measurable benefits cited by those practices: * Elimination of time required to pull, handle, or file charts * Reduction of paper forms and supplies * Reduction in space requirements * Decreased patient wait time * Reduced number of telephone calls and reduced call turnaround time * Elimination of lab charting * Elimination or reduction of transcription cost * Reduced time for referral letters. * Reduced calls and time for prescription refills * Reduced time to code and more accurate coding * Reduced claims denials * Reduced time for insurance reimbursement Although Sidorov reports that there is little evidence of reduced labor costs and lower staffing occurring "among the 17 percent of practices possessing an EHR," I question the 17% figure as well as the lack of evidence of labor saving. The benefits in these operational sites resulted in reduced cost per patient visit reported to be from 6% to 29%. Some qualitative improvements cited by this same group included: * Ability to monitor yearly mammograms in women at risk * Ability to monitor routine screening (colonoscopy, stress test, etc.) * Ability to track success in reaching the lower ATP III cholesterol goals * Ability to track hemoglobin a1C levels * Ability to track patients who are not at goal for blood pressure * Ability to find lab and other procedures not resulted * Increased immunization rates * Increased staff satisfaction leading to lower staff turnover. Sidorov worries that if "the EHR leads to increases in such interventions, more lives saved will come at a heavy price." It may be true that interventions may result in more costly medications or procedures, but there is a promise that having analytical data will lead to more appropriate interventions and indirect savings from reduction in more costly emergency or inpatient care. My anecdotal experience, from visiting well-planned, -implemented siteswhere EMRs have been operational for some time and mature enough so that the electronic record is linked to other settings of care such as hospitals and testing centers, is that there is increased physician satisfaction based on their ability to have clear, legible records. This could mean that a practice could have higher volumes, but more importantly, it allowed physicians to reduce their time in administrative tasks and thereby facilitate the delivery of quality care and improve customer service. I would agree the documentation of benefits are still scant, but as electronic records become more pervasive and more integrated with data from other care settings, I think we will look back and wonder how we ever allowed paper records to be "gold standard" of care documentation.
EHRs: Costly And Dangerous To Privacy 21 August 2006
Deborah C. Peel, MD, Chair and Founder Patient Privacy Rights Foundation Send letter to journal: Re: EHRs: Costly And Dangerous To Privacy dpeelmd{at}patientprivacyrights.org Deborah C. Peel, MD	Thanks to Jaan Sidorov for puncturing the oft-repeated mantra for rapidly moving the nation into an electronic health system based on EHRs: "money will be saved." Saving money is the key rationale used by Congress to press for passage of legislation to promote health IT and a National Health Information Network (NHIN) this year. Patient Privacy Rights has been working hard to educate Congress and the public about the dangers of forcing Americans into electronic health systems without first ensuring that patients control access to their medical records and ensuring that ironclad privacy protectiions are built into electronic systems up front. The Coalition for Patient Privacy (including 40+ organizations from the Christian Coalition and the Family Research Council to ACLU, USPIRG, and the Privacy Rights Clearinghouse) urged Congress to add basic patient privacy protections to health IT bills, so that consumers can trust their doctors to keep their records private and be willing to participate in electronic health systems. Unless privacy protections are added, compelled inclusion of our medical, genetic, and precription records in the NHIN means exposing the most sensitve personal data on earth to employers, bankers, insurers, government agencies, and educational institutions. For information on the Coalition for Patient Privacy, go to http://www.patientprivacyrights.org/site/PageServer?pagename=PrivacyCoalition Those who want access to the nation's identifiable medical records are already beating the drums to force federal employees to use EHRs. Soon we can expect to be forced to disclose our EHRs in order to obtain medical treatment, get a job, obtain insurance coverage, or to be admitted to schools -- if we do not urge Congress to add basic privacy protections to all health IT legislation. For patients to support EHRs, we must be able to authorize disclosures, be able to segment sensitive records and tests, be able to see audit trails of who accessed our records, be notified when our privacy is breached, and have the right to opt in and out of electronic systems. Patient/consumer input into the design of EHRs has been lacking, as has adherence to state and constitutional law and medical ethics requiring informed consent before disclosure of electronic records (whether identifiable or not). Cost is not the only reason we should move cautiously into the brave new electronic world -- saving privacy is crucial. The American health system must not be turned into world's largest electronic domestic surveillance program for corporate and government use.