Thursday, February 3, 2011

EMRs and Pay for Performance: Stay the Course

Consider: When people must choose between changing an ingrained behavior, or proving why they don’t need to change their behavior, they will put their energies into the latter. Depending on what that behavior is will determine how much conflict there will be, and how uncomfortable the situation will get.

We fear that those who see no future in health IT or pay for performance will use lots of energy to convince others. One analysis study published in the Archives of Internal Medicine, one IT survey from Thomson Reuters/HCPlexus, and one pay for performance study published in BMJ suggest that physicians have no need to change behavior.

“Don’t spend any more money on this foolishness,” they are saying.

In our mind, is the question about the technology, or about change management?

In the Archives study, researchers from Stanford University pored over 255,402 non-hospital patient visits that occurred between 2005 and 2007 to non-federal treatment facilities. The authors looked at the role of electronic medical records (EMRs) and clinical decision support software (CDS) in assessing whether patients received better care, using 20 quality indicators as benchmarks. EMRs and CDS only exceeded one benchmark, the authors concluded.

"These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality," they wrote.

In the IT study, 3,000 MDs were queried as to whether EMRs would help patients: 39 percent said yes, 37 percent said there would be no effect, and 24 percent said the effect would be detrimental.

But could it be that some doctors aren’t tech-savvy, or that they just don’t have the time to learn how to use the system? We do not think the former, but it's true EMRs will likely,at least in the beginning, take them away from their patients. But over time, that should pass. 

Maybe it's all in the way IT is approached.An analysis study highlighted in FierceHealthIT showed that using IT, along with clinical guidelines, cut down on imaging studies for lower back and headache MRIs, and hence the costs. Yet another study in the same article noted that improvements came about when “healthcare organizations wholeheartedly embraced the technology and customized it to maximize performance.”

The operative word here: wholeheartedly.

Writes FierceHealthIT: “Physician complaints about computers detracting from patient encounters show that many doctors don't yet know how to use EHRs properly. …While today's health IT leaves much to be desired, doctors must make the effort to meet computers halfway if they expect the technology to help them improve care.”

In the BMJ pay for performance study, the researchers chose 470,725 hypertensive patients to follow between 2000 and 2007. The point: to see if their physicians could improve their patients’ numbers, earning money if they did. Nada.

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

It’s very possible the researchers chose the wrong disease. After all, hypertension doesn’t have any initial symptoms. Patient adherence could have been an issue.

On his blog, KevinMD writes that health reformers need to “be careful about overstating the benefits” of IT and pay for performance. “The data isn’t there yet,” he says.

Our point exactly. These studies have older data. Let's see what newer data can tell us before hardline decisions are made.

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