Wait – Health IT Increases Costs?

By Kim Bellard, November 29, 2012

Two recent reports challenge the prevailing conventional wisdom that increased spending on, and use of, electronic medical records and other clinical health IT will help control costs.  If these are true – and it’s too early to be sure – it may be because we’ve approached health IT in the wrong way.

Kaiser Permante looked at their experience in their Colorado plan for five years, comparing the utilization of 44,000 users of My Health Manager, Kaiser’s patient portal, to 44,000 non-users.  Pretty much across the board -- from office visits to ER visits and even inpatient stays, among other measures – the online users had higher utilization, and their utilization went up after gaining online access.  Kaiser’s portal allows for email consultation with their physician, but not only did that not deter some of these increases, the online users’ telephone calls per member were still actually higher than non-users.  

There’s more bad news for health IT proponents.  The New York Times recently reported that their analysis of Medicare data indicates hospitals are collecting more than $1billion more in 2010 than five years prior, in part because of how they have changed billing codes in the emergency room.  The Times associated many of these increases with introductions of electronic medical records in specific hospital systems, and asserts that some physicians outside the hospital setting are also using their EHRs to maximize billings.

The belief is that the EHRs can prompt physicians to code their documentation in ways that maximize payment, or to “cut and paste” documentation from other patient visits which might not accurately represent the services the patient received.   Some of these practices would be fraudulent, while others are just part of the ongoing arms race over up-coding.  Either way, the EHRs may be helping.

Raising yet another red flag, the HHS Office of Inspector General just issued a report warning that CMS does not have appropriate safeguards in place to monitor the EHR incentive program, either prior to the incentives being paid or once they’ve been paid.  The outcome could be fraud and/or less meaningful use than anticipated.

Meanwhile, a study on e-visits by Dr. Attev Mehrotra and colleagues had more mixed results.  It looked at visits for sinusitis and UTI for 4 primary care practices.  Their results found the e-visits resulted in significantly fewer tests being ordered for UTIs, but also a higher rate of antibiotics prescribed for both conditions.  The rate of follow-up care – a rough proxy for misdiagnosis -- was similar for e-visits and office visits.  The authors did not look directly at costs but their estimate was that e-visits may have led to lower costs per visit, taking into account the lower reimbursement for the e-visit itself.

For better or worse, EHRs would seem to be here to stay.  A recent survey by The Commonwealth Fund illustrates this.  CWF surveyed primary care physicians in 11 countries, including the United States.  Between 2009 and 2012, use of EHRs went up from 49% to 69% in the U.S.  Of course, seven of the other countries still are ahead of the U.S. in adoption rates, by as much as 30 percentage points.  And only Canada started from a lower point. 

More disappointingly, the U.S. ranks in the middle of the pack for “multifunctional HIT capacity,” with only 27% having EHRs that allow them to generate patient or panel information, or to give them clinical decision support.  We rank in the lowest third for ability to exchange patient information or test results with doctors outside their practice, with only 31% of U.S. primary care physicians having that ability.   We’re certainly not living up to EHR’s potential.

Consumers certainly appear ready for the new world.  OptumHealth recently found that three-fourths of consumers want online access to their records, although only 40% currently report such access, and 60% want to communicate with their physicians online.  Similarly, Manhattan Research found that 73% of American adults use online health information and tools, and 54% of online consumers are using the online resources in their choices of providers, treatments or services.  This is most pronounced for newly diagnosed patients.  This is good news, I think, although I’m still skeptical about how good the information is by which consumers may be making these choices.

Which leads me back to the Kaiser study and the NYT analysis.  The Kaiser results suggest to me that more engaged patients are taking advantage of the online resources, and at this stage of EHR evolution it doesn’t surprise me that those engaged patients are care-seeking.  As for the alleged up-coding the NYT warns of, to the extent the EHRs are prompting physicians to be more thorough, that’s a good thing; to the extent it is facilitating fraud, it must be fought.  The proof of the pudding is in the eating; in this case, how are patients faring with their treatment(s)?  This is where only EHRs offer us hope to give us better information, and why we can’t give up on them just yet. 

Many providers have embraced EHRs and health IT to improve their delivery of care, while others are still gamely trying to figure out how to do so.  Any provider that is not trying to re-engineer their processes may have a tough time in the coming years, so kudos to the ones aggressively taking advantage of technology to help patients.  Why taxpayers need to subsidize this kind of re-engineering, though, I’m less sure. 

It strikes me that the HITECH stimulus has compounded the provider-centric focus of our health care system.  It does, after all, pay providers for provider EHRs, and Meaningful Use for consumers is essentially only an after-thought.  The current incentives could mean that patients end up with access to disparate records at their various providers, and if they are lucky some of those provider systems may share data.  We should be expecting more than that.

We continue to think about patient data incorrectly.  A case in point was reported recently by The Wall Street Journal.  Long story short, Medtronic defibrillator devices now produce significant amounts of data wirelessly once implanted.  Medtronic shares the data with the patients’ cardiologists, and is now trying to further monetize the data through sales to payors or other entities, but does not see the patients as either customers or even entitled to the data.  That data is generated from those patients’ chests, mind you.  Medtonic and some physicians see the data as too complex for patients, but maybe they’re not thinking hard enough about how to make it useful to those patients.

Instead of HITECH, perhaps what we should have done was to stimulate the patient health record industry, transforming it from simple medical records to virtual health assistants.  These online assistants would take information from various providers’ EHRs, from the ever-increasing number and types of monitoring devices available, and from patient inputs, plus offer patients features like dashboards that summarize their health, suggestions for improving/maintaining their health, and assistance with choosing appropriate treatments and/or providers when necessary.  I bet IBM would see a potential role for Watson here.

A patient-centric health system would start an EHR initiative by analyzing what information patients need, and then determine what information was needed from the providers’ records to support that information.  Instead, we have provider-specific EHRs that can’t talk to each other and that patients often can’t understand – when they are fortunate enough to get access to them. 

As long as EHRs and health IT continue the provider-centered, provider-siloed approach of our current health system, I’m not holding my breath for them to really bend either the cost or quality curves.

Comments

[Kim]

Another article on the lack of demonstrated savings: http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html?_r=0