EMR use may not save money but can save lives

by Joyce Frieden

Two new studies of electronic medical records (EMRs) have come to different conclusions: one found that they don’t save money or staffing time, but the other suggested that at least one part of EMR — electronic prescribing — does save lives.

In the electronic prescribing study, at a single California hospital, the mean monthly adjusted mortality rate decreased by 20% after implementation of a computerized physician order entry (CPOE) system.

The unadjusted death rate declined from 1.008 to 0.716 deaths per 100 discharges per month (95% CI 0.8% to 40%; P=0.03), according to an article prepared for the July issue of Pediatrics.

“With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame,” Christopher A. Longhurst, MD, of Lucile Packard Children’s Hospital at Stanford University in Palo Alto, and colleagues reported.

“The potential implications of these findings on national mortality statistics in children are dramatic,” they wrote. “Future research should focus on replicating these findings in other inpatient settings and populations, and evaluating the cost-effectiveness of this intervention.”

To determine the effect of CPOE implementation on the hospital-wide mortality rate, the researchers conducted a cohort study using historical controls at the main campus of the Lucile Packard Children’s Hospital.

At the time of the study, the hospital had 271 beds, including 193 on the main campus.

Patients were included if they were admitted between Jan. 1, 2001, and April 30, 2009. Obstetrics patients were excluded from analysis.

The hospital began implementing EMR in 2004, starting with nonmedication, unit-clerk-based order entry. The second phase, activated in late 2007, included CPOE with clinical decision support and comprehensive nursing and support service documentation.

The pediatric intensive care unit implemented the CPOE system about 10 months after the other units; as of the study’s end, only the cardiovascular intensive care unit had not yet been activated. The primary outcome measure was the hospital-wide mortality rate, excluding obstetrics.

The researchers found no significant difference between pre-CPOE and post-CPOE populations on the basis of patient gender (47.4% females versus 48.0% females; P=0.34).

Statistically significant differences were noted for age, severity of illness as represented by case-mix index, and race/ethnicity, with fewer individuals identified as white or of unknown ethnicity and more Hispanic and Asian individuals in the postintervention group.

There are several possible reasons for the decline in mortality following the introduction of CPOE, the authors noted.

  • Standardization of patient orders, which may have resulted in better communication with staff
  • Making orders, vital-sign documentation, and medication-administration information remotely accessible in real time, described as “a fundamental shift in basic care processes”
  • Introduction of CPOE itself, which eliminated the redundant transcription of medication orders by pharmacists, thus improving accuracy and decreasing turnaround times

The authors noted several limitations to their study.

First, they wrote, “it is possible that the reduced mortality rate was simply the result of differences in the preintervention and postintervention populations and is independent of the CPOE intervention.”

Also, they noted, the results cannot necessarily be generalized to other hospitals.

In the economics study, EMR implementation was associated with a 6% to 10% higher cost per discharge in a hospital’s medical-surgical acute units, and it increased registered nurse hours per patient day by 15% to 26%, according to Michael F. Furukawa, PhD, of Arizona State University, and colleagues.

“The results imply that EMR may increase the demand for skilled nurses, which could have implications for nurse labor markets,” they wrote online in the journal HSR: Health Services Research.

“Contrary to expectation, we found little support for the proposition that EMR generates significant cost savings to hospitals through reductions in length of stay and the demand for nurses.”

While interest in EMR adoption is high, little is known about the impacts of the EMR on nurse staffing and patient outcomes in community hospital settings, the authors noted.

To find out if instituting an EMR could reduce length of stay (LOS) and improve efficiency, the authors examined data from the 1998-2007 HIMSS Analytics Databases. The sample included medical-surgical acute units within short-term, general acute care hospitals in California.

Federal government, specialty, children’s, and long-term acute hospitals were excluded, as were hospitals with incomplete financial reports. The final data set included 326 hospitals and comprised 2,828 hospital-year observations.

The authors found that EMR implementation increased significantly from 1998 to 2007. In 1998, only 33.9% of hospitals had at least started implementation of EMR, compared with 80.8% by 2007.

Although EMRs increased costs per discharge across several stages of implementation, costs varied by stage, the researchers found. Later stages of implementation were associated with 5.9% to 10.3% higher cost per discharge, with the cost increases attributable to both higher cost per patient day and higher LOS.

Increases in LOS also varied depending on the state of implementation. Early-stage implementation increased LOS by 2.1%, compared with later-stage implementation, where LOS rose by 3.7% to 4.4%.

All three stages of EMR implementation increased nurse staffing levels, the study showed.

Total nursing hours increased 13.3% to 14.6% in early-stage EMR implementation, compared with 11.2% to 21.6% during the middle stage and 16.0% to 19.4% during the late stage.

The increase in total nursing hours per patient day was attributed to high staffing levels for both RNs and aides, they noted.

The researchers offered several explanations for their findings. The fact that EMR did not decrease LOS suggests that per-diem payments may work against such reductions.

And the association of EMR with increased staffing may also reflect the unintended consequences of poor implementation or cultural resistance to change, they wrote.

The authors noted several limitations of their study, including possible bias from measurement error, quality improvement initiatives that might impact staffing or patient outcomes, and California’s minimum nurse staffing regulation, which mandated staffing ratios for medical-surgical acute units in 2004 and 2005.

In addition, the database is self-reported and primarily used for market research, which might lead to overestimates of actual rates of EMR implementation.

Joyce Frieden is a MedPage Today News Editor.

Originally published in MedPage Today.  Visit MedPageToday.com for more practice management news.

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  • http://nostrums.blogspot.com Doc D

    EMR’s help when the system works.

    There have been reports of 44 injuries and one death due to design defects and programming errors. The Adoption/Certification Workgroup of the federal Health IT Policy Committee testified about this recently. In one case the software recorded patient problem list to the previous patient’s record. In another, the OR system locked up and had to be reconstructed from memory. In one system OR VS records would disappear. In another, data averages recorded by monitors didn’t match with the averages the electronic record software recorded. You can read through example errors here: http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11673_910717_0_0_18/3Shuren_Testimony022510.pdf

    At this point, I think the best approach is to double check everything. It will probably take a few years to resolve all this.

  • jsmith

    EHRs, as currently designed and implemented, are basically a scam, the latest example of business types and think tank docs taking the public and medical profession for an expensive (for us) and lucrative (for them) ride. It has the added plus of being “techy,” thus fooling naive young docs. By the time America wakes up to this, the money will have been made and they’ll be working on the next scam.
    EHRs might someday be useful, they might not. Time will tell. It is also possible that small chunks of EHRs, like prescription entry, are useful and that most of the rest is garbage.

  • r watkins

    Combine the two studies:

    could the reduced death rate at Lucille Packard have resulted from the fact that installation of EMRs required the hospital to hire more skilled nurses?

  • MillCreek

    As a risk manager specializing in ambulatory care, I know there is yet very little data suggesting that EMRs help patient safety in the clinic setting. They can certainly help with the upcoding, though.

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    Newsflash, “Paper and pen decrease mortality in new study”. (jocularity … but then again.. I could see it happening).

    After 13 years in and around the “EMR” industry, I have come to a few conclusions:
    1. EMR / EHR / CPOE / etc. are simply tools. They are not therapies and therefore should not be studied as such.
    2. Medicine is drowning in suboptimal efficiencies of patient diagnostic and therapeutic processes. EMRs first goal should be to improve our efficiency in taking care of patients.
    3. EMRs have, without a doubt, worsened our efficiency.
    4. There is much that can be done that could make EMRs very useful. However, we failed to dissuade our hospital administrators from investing in horribly written software and poorly designed systems.
    5. Now our government has stepped in and injected more money into these same suboptimal products. Thus ensuring that R&D stagnates because we are forced to buy what is already here.
    6. I fear that there is noone out there that has the capital and knowhow to create the disruptively innovative system necessary to move this industry forward.

  • Marc Gorayeb, MD

    “With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame,”

    Sounds like a study with low power, whose statistical conclusions are automatically suspect.
    Can’t read the full study yet, but it’s shaping up to be ridiculous. If we’re talking about 36 or so fewer deaths, why not analyze each and every case resulting in death to determine exactly how or why each death occurred, and therefore whether it was attributable even remotely to presence or absence of EHR?
    Why not? Because it may not result in a conclusion that fits the authors’ pre-conceived notions.

  • LynnB

    Hey, not every EMR comes with CPOE . I know that . My hospital administrator doesn’t necessarily. This article,should be RETITLED CPOE saves lives (at least at Lucille Packard where the staffing ratios may have changed.) Most EMR’s are a piece of c… sold to admins by unscrupulous vendors . I would love to work with a good one but that means moving to the big city.

  • jo

    By the way 10 years ago when I first priced it EPIC was a one million dollar (yes that is right) one million dollar system.

    I think I can clear a couple of things up. The reason why E-presribing saves lives, yet overall EMR use does not is that most EMRs utilize outside e-prescribing software, such as SureScripts, which was developed by another entity, and works and reads and documents very well most of the time.

    Most of the time the rest of the EMR is developed by their ill informed, un-medically educated personnel who have no clue what an actual patient visit looks like or how physicians would document that. When asked to make the notes look like the dictated ones in our charts, they laugh and state that the EMR is not supposed to look like a patient’s paper chart, and boy were they right and no amount of physician customization can fix it.

    When told that their physical exam implemented every specialty’s verbiage instead of one just for primary care, and were asked to use a previous Family Physician’s customization for our template they shook their heads and with a stern, parental tone stated that everyone wanted a different customization and it would be best not to do that and threw in some nonsence about HIPPA compliance to boot.

    So it is the redundant, non-sensical notes are what we and everyone else lives with, with the MAs typing away dictating what the physician states during a visit which increase employees and employee time, but the only way the physicians can use their time for “patient care” a novel idea indeed.

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