The Lessons Thus Far From the Transition to Digital Patient Records

The New York Times Blogs (Bits)

July 29, 2014

The use of digital patient records has not led to overbilling, as feared, according to a new report; but it has not yet delivered efficiency gains or improved care, either.

Soon after the financial crisis hit, the Obama administration decided to toss into the economic stimulus package a carrot to accelerate the computerization of health care. Within the roughly $800 billion pump-priming project, the health technology initiative could be seen as a modest down payment on the future: about $20 billion in incentives spread over several years to encourage doctors and hospitals to move from paper records into the computer age. The Bush administration had championed the cause, and, seizing a crisis-created opportunity, the Obama administration put up the money.

But ever since, the government-promoted drive for electronic health records has been assailed as everything from a handout to greedy tech companies to the advance guard of socialist medicine. In an editorial in February 2009, the Wall Street Journal called the program a "stalking horse for government-run health care." Forecasts and studies of the impact of the incentive program have been similarly varied. Some predicted big dollar savings and improved care, while others came to the opposite conclusion, seeing higher costs and medical errors induced by complex technology.

At first glance, a new research paper, published in this month's issue of Health Affairs, only adds to the confusion. The research paper found no evidence that hospitals adopting electronic health records were systematically using them to drive up their billings. The research by Julia Adler-Milstein, an assistant professor at the University of Michigan School of Public Health, and Ashish K. Jha, a professor at the Harvard School of Public Health, would seem to contradict an analysis done in 2012 by the New York Times and a similar one by the Center for Public Integrity, a nonprofit investigative journalism group. Both those analyses found higher costs for Medicare patients at hospitals using electronic health records.

In an interview, Dr. Jha said his research with Ms. Adler-Milstein did not refute the findings of the Times and the Center for Public Integrity. Certainly, Dr. Jha said, there were cases of doctors, nurses and clinic assistants using the automated point-and-click and cut-and-paste features of computerized health records to change the billing codes for treatment to patients and to charge more. But the new research, Dr. Jha said, covered a broader slice of data, including inpatient hospital billing as well as the emergency room reimbursements that, along with visits to doctors' offices, were the main focus of the Times analysis.

The research with Ms. Adler-Milstein, he noted, also included a control group to adjust for factors like digital-record users being more likely to be larger institutions and teaching hospitals, which are more effective at billing and may be sent more seriously ill patients.

The researchers did not find systematic higher Medicare billing in hospitals that was attributable to electronic health records. "The bottom line," Dr. Jha said, "is we didn't see it."

The Health Affairs article refers to the Times analysis, which "pointed to an association between E.H.R.s and higher payments" as helping to fuel concern about the potential for fraud and abuse. Dr. Jha said the Times analysis also prompted his research with Ms. Adler-Milstein—to look for how widespread the problem might be, or not.

Dr. Jha said he was surprised they did not find systemic higher billing, but Ms. Adler-Milstein, a former graduate student of his at Harvard, said she was not. Her assumption, she said, was rooted in simple economics. Hospitals in general operate on slender profit margins, she observed, so "lots of resources are devoted to maximizing coding using all available information in the paper or electronic record."

The concerns raised have also brought government scrutiny to the potential for using digital technology to overbill and inflate costs.

Dr. Jha has been studying the impact of digital health records for years. A research paper he published in late 2009, as the federal government was about to embark on the incentive program, cast doubt on how much hospitals that had already adopted electronic health records had achieved lower costs and improved care.

Today, Dr. Jha says he remains skeptical. Some things have changed markedly. In 2008, 9.4 percent of the nation's hospitals were using basic electronic health records, according to the American Hospital Association. By 2013, the percentage had soared to 59.4 percent, propelled by the federal incentive program.

"So far," Dr. Jha said, "we've mostly spent a lot of money to transition from paper to electronic records."

No one thinks a modern health care system can cling to paper records. But the policy goal of the federal incentive program was to use digital technology to curb costs and improve care. The legislation was called the Health Information Technology for Economic and Clinical Health Act. And there are examples of health care providers that use digital patient records effectively—mostly large medical groups, like Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic and the Marshfield Clinic, that have worked with the technology for years.

But Dr. Jha said there was "certainly not yet" evidence of a payoff nationally from the federal incentive program.

That is hardly surprising. The economic dividend from any technology, from steam power to the electric engine to the computer, takes time to appear, as people figure out how to make the best use of the new tool. In 1987, when the personal computer revolution was more than a decade along, Robert M. Solow, a winner of the Nobel in economic science, mordantly observed, "You can see the computer age everywhere but in the productivity statistics." By the 1990s, the impact on productivity became evident.

The principle of the technology-payoff time lag is true in many industries. But in health care, there is a case for special vigilance as well as for patience. The more digital patient records and decision-support software become part of diagnosis and treatment, the higher the stakes: In health information technology, there are no clinical trials or tests with randomized controls, as there are for drugs, for example. True, digital data does not go into the body, but it can increasingly guide what does.

That is why the Food and Drug Administration, in cooperation with the National Coordinator for Health Information Technology and the Federal Communications Commission, is developing what the government calls a "risk-based regulatory framework" for digital health technology. It is also a reason Dr. Jha says he believes the federal incentive program, which got under way in earnest in 2011, will be stretched out to eight or 10 years rather than the five years of the original plan.

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