Electronic medical records and pay for performance don’t improve care

Electronic medical records and pay for performance are among the ways health reformers are going to improve patient care.

It’s a fundamental shift in how doctors practice, with more practices adopting expensive EMRs. And with the advent of Accountable Care Organizations, doctors will soon be compensated in part by quality measures.

But will they work? Well, the jury’s still out.

Two articles caught my eye recently.

The first, from the WSJ’s Health Blog, reports on a study from the Archives of Internal Medicine:

[The study looked] at data from outpatient medical visits at nonfederal offices and hospitals between 2005 and 2007 to see how electronic health records correlated with 20 quality indicators. The findings are pretty stark: there was “no consistent association between” better quality of care and electronic medical records or a specific IT tool, clinical decision support.

In fact, EMRs were associated with significantly improved performance in only one measure — giving diet advice to high-risk adults. They didn’t improve performance in things including giving aspirin for coronary artery disease, depression treatment or blood-pressure measurement.

Considering how much money is being poured into the digitization efforts, it’s remarkable that it’s based on so little clinical efficacy. Don’t get me wrong, there’s no question that we should modernize antiquated paper and pen charts, but doing so under the guise of improving patient care is somewhat misleading at this point.

Also notable is the hit pay for performance took in a recent New York Times piece.

The BMJ looked at the NHS, which stuffed general practitioners’ mouths with proverbial gold by offering generous pay for performance incentives. So much so that the average GP in the NHS makes about $175,000 annually (110,000 pounds).

But there’s shockingly little to show for it:

“Pay for performance had no discernible effects on processes of care or on hypertension-related clinical outcomes,” the authors concluded. “Generous financial incentives, as designed in the U.K. pay-for-performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.”

Stephen B. Soumerai, a health policy researcher at Harvard who is also one of the study’s authors, says policy makers should try to evaluate the evidence before they invest substantial sums of money in quality improvement programs that may not work.

Yikes. Considering that every new model, ranging from Accountable Care Organizations to Medical Homes, feature quality incentives, that’s not encouraging.

Again, I’m not saying that doctors should continue to be paid by quantity as they are now. But health reformers need to be careful about overstating the benefits of such reforms to patients. The data isn’t there yet.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • jsmith

    This of course is not surprising to those of us who have done this a long time. EHRs are based on a false premise: The idea is that if we give the system more information, and if we share that information, then the system will improve. It sounds reasonable but it is wrong. Why? Because the system is grossly overloaded. The truth is that there are simply not enough physicians and nurses to assimilate the information already generated, so EHRs just swamp us with more work when we can’t even manage our workload without the EHR. This is easy to explain to a doctor or nurse, but nearly impossible to explain to a politician who knows very little about what we do for a living, or even to an EHR designer who, after all, works alone in a quiet room performing tasks in series while we work in teams and perform tasks in parallel.
    Same with pay-for-performance. We are doing the best we can, given the situation we find ourselves in. If you incentivize us, we will still do the best we can given the situation we find ourselves in. Output change: virtually zero.
    Those who have a false model of reality are often disappointed. The EHR boosters are learning this.

  • pcp

    “doing so under the guise of improving patient care is somewhat misleading”

    So what guise should we do it under?

    • Kevin

      Well, as the studies show, it can’t be under the banner of “improving patient care.”

      I’m open to your ideas. With respect to EMRs, we can point to every other industry that has modernized record keeping beyond pen and paper.


      • jsmith

        On the other hand, Kevin, we are a scientific profession, not an industry. As such, we should be guided by what we believe is the right thing to do, based on our scientific method, not by what others in different lines of human enterprise think. We are the experts here.
        Medicine is very very different from accounting or insurance or car repair. We all know that. If the data in medicine say pen and paper work as well as “modernization,” we should listen to the data, not to what outsiders think.

      • pcp

        A guise (your word) is a “false appearance, or pretense.” The beliefs that EMRs will save money or improve patient care certainly look more and more like guises. I can’t provide an evidence-based reason for their use, and find it disturbing that we’re still looking for one.

        Analogy is not proof, so I’m not sure that the experience in various service industries is relevant to what we should do in medicine. The closest example to health care that I’ve seen (though much smaller and less complex) is the air traffic control system. After countless billions of dollars and three decades, we still have nothing to show for the attempted modernization.

  • fam med doc

    Dear jsmith,

    That was an excellent and quite accurate response.

  • DM

    Despite these findings, “Pay for Performance” makes such a great soundbite as policy makers propose solutions for lowering health care costs. Do policymakers really believe that there are large numbers of physicians who are not working in the best interests of their patients, and thus need financial incentives to do so? Some patients and physicians fear that the real political rationale behind “Pay for Performance” or “Evidence Based Medicine” is a way to give power to governmental administrators to force physicians to ration care according to bureaucratically established guidelines, otherwise face financial punishment. As a patient, I want my physicians to do what they feel is best for me, not what is deemed best for the system, as dictated by governmental bureaucrats.

    • jsmith

      I really think we should distinguish between EHRs, pay-for-performance, and EBM. EBM, done right, has statistical validity. The other two do not. Certainly, EBM has HUGE limitations: irrational extrapolation and the so-called law of small numbers are just two of the many. But it is actually an intellectual advance, albeit over-hyped. EHRs are PPP are simply management fads.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Pay-for-Performance and EMR were designed by non-physicians who do no understand how we physicians practice at Ground Zero in our offices. They are great tools for coders, billers and assorted bean counters. You just can’t point and click your way into higher quality medical care.

  • CWS

    The point of the AIM study on EMRs is that EMRs do not improve patient care. The purpose of an EMR is better documentation – so that insurance will pay for the level of care and protection against med mal suits. We do need to move from a paper and pen system, but “improving patient care” is a false banner to follow.

    I agree with DM, physicians are already working with the best care of the patient in mind. What is missing is the patient’s involvement in their care. The recent health care reform legislation while it addresses concerns about physicians, hospitals and health insurance provides no motivation for the patient to be more involved in their own care. Health care in other countries is lower in cost partly because of the patients willingness to take a preventative approach versus a “give-me-a-pill” approach to their own health. Until this component is addressed, any reform will be not make significant change.

  • Molly Ciliberti, RN

    Physicians need to be paid for caring for patients including listening to them, examining them, educating them and providing the best care possible. We need to stop paying just for procedures and other measures; we need to see the physician patient relationship as a whole and all of the components that provide the patient with good healthcare.

  • Felix Padronas

    I think the consumer will want to be able to take their PHR’s with them where ever they go and that may definitely be an issue in the foreseeable future, but right now we have so many companies that offer PHR services, where no it’s not free but at least they offer a vault, and access via mobile along with reminders, and drives such as companies like medefile.com or even capmedphr.

    While doing my own research I found that a lot of these free companies don’t offer what I mentioned above and instead, I had to put my own information into the database. I really found the free ones to be useless. I don’t mind paying a PHR company to acquire my medical history and having a drive or mobile app with me where ever I go.

  • Richard D. Ball, MD, PhD

    Did it ever occur to anyone that we physicians might already be doing our best job out of pride and ethics? I would like to think that I’m already doing the best job I’m capable of. The EHR, at least in the transition stages, and until everyone has access to a true comprehensive patient database, actually leaves me with less time to study and perfect my craft, even after 33 years of practice. I also have to work more to pay for my EHR, which takes its toll as well. As an IT expert, I can say the the EHR is being introduced in the craziest fashion. It should have been done: 1) Clarify all the HIPAA/HITECH/ACA laws regarding release of information so no one is paranoid about sharing patient info; 2) Build central database servers to connect to and share information with to populate the database, as well as retrieve information; 3) Put EHR clients into medical care “points of delivery”, e.g., Doctor’s offices. Doing it by putting the EHR client in the office first and then sitting around seeing who is going to develop the central database is/was totally idiotic!
    Those doctors in big healthcare systems may get this functionally because all the patients they take care of are in the same system. I would wager that most of us in this country are not in such systems, and our EMRs are still waiting for someone to talk to without worrying about a HIPAA violation.

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