Are EHRs Truly Improving the Quality of Healthcare? A Closer Look.
I’ve often heard people say that they don’t know much about art, but they recognize good art when they see it. The value of a particular work of art is subjective. But when it comes to healthcare, we can’t afford to be subjective in our assessment of value. We’re in a rapidly changing healthcare environment where it has become more important than ever to define and measure value objectively.
When discussing healthcare value, I like referring to the Porter equation where value is equal to quality over cost. We know that healthcare costs are increasing.
Defining Healthcare Quality
It’s one thing to say we need to improve quality. But what does that really mean? Defining healthcare quality can be a challenging task, but there are frameworks out there that help us better understand the concept of healthcare quality. One of these was put forth by the Institute of Medicine in their landmark report, Crossing the Quality Chasm. The report describes six domains that encompass quality. According to them, high-quality care is:
- Safe: Avoids injuries to patients from care intended to help them
- Equitable: Doesn’t vary because of personal characteristics
- Patient-centered: Is respectful of and responsive to individual patient preferences, needs and values
- Timely: Reduces waits and potentially harmful delays
- Efficient: Avoids waste of equipment, supplies, ideas and energy
- Effective: Services are based on scientific knowledge to all who could benefit, and it accomplishes what it sets out to accomplish
Intuitively, we might think that spending more money would drive these quality goals forward. But the evidence suggests this isn’t the case. Higher-cost care isn’t necessarily higher quality. For example, a group of hospitals in southwestern Pennsylvania were paid an average of $18,000 to perform heart bypass surgeries, while others were paid as much as $35,000 for the same procedure. In the same area, charges for heart valve surgery ranged from a low of $24,000 to a high of $54,000. What is significant is that the lowest-priced hospitals had lower mortality and readmission rates —better quality—than the highest-priced hospitals! Examples like this really undermine the notion that we have to be investing huge amounts of money to realize higher quality.
EHRs: An Investment in Healthcare Quality?
One thing that everyone agrees on is that advances in technology can contribute greatly to our attempts to improve quality and value in the healthcare system. And this is where electronic health records (EHRs) come into the picture. The EHR is the instrument at the center of most organizations’ plans to drive lower cost, better care. In fact, huge amounts of money have been invested in these EHRs, and organizations are understandably concerned about what their return on investment will be.
The adoption of the EHRs in clinical systems should help drive the quality agenda. But it’s important to recognize that EHRs alone may not be sufficient to deliver data intelligence, to really deliver data to clinicians in a meaningful way that will help them improve value.
A January 2013 article in The New York Times suggested that EHRs have not been the cost-reducing panacea they promised to be a decade ago. The article cites a RAND report from seven years earlier that forecasted $81 billion in annual U.S. savings from EHRs. But the article points out that evidence of the technology’s impact on healthcare efficiency and safety are mixed, while annual healthcare expenditures have grown by $800 billion.
Texas Children’s Hospital’s Approach: EHR, Processes and an Enterprise Data Warehouse
At my organization, Texas Children’s Hospital, we were determined to create a system-wide strategy that would leverage the EHR to help us drive value. We’re committed to developing clinical effectiveness guidelines to deliver the highest quality care possible, and we do this in a systematic fashion.
We devised what we call our clinical systems integration strategy. Our objective was to build a comprehensive, integrated and evidence-based quality and safety program that would result in measurable improvements in process and quality care. We would implement an enterprise-wide data management infrastructure that would leverage our current clinical systems, starting with clinical data from our EHR and data from our financial systems.
We quickly realized that we couldn’t just rely on our EHR for this robust, integrated data. We determined that the right approach for us was to aggregate clinical, financial, patient satisfaction and other data into a healthcare enterprise data warehouse (EDW) to serve as a single source of truth for our organization.
Identifying and Reducing Clinical Waste
By having all of this data available to us in a sophisticated but easy-to-use infrastructure, we were able to start tackling the problem of how to improve quality and lower costs—drive better value—in our organization. We decided to focus on the fifth item in the definition of quality I mentioned above: high-quality care is efficient. It avoids waste of equipment, supplies, ideas and energy. We knew that our data could reveal to us areas of inefficiency and waste that tied quite clearly to cost.
Using an advanced analytics application to analyze our data, we discovered that 10 care processes accounted for 53.2% of our organization’s variable cost. This knowledge helped us prioritize our improvement efforts. We knew exactly which care processes—such as asthma care, appendectomy and more—gave us the greatest opportunity for reducing variability and waste.
This data-driven focus has enabled us to achieve measurable improvement in both process metrics and outcomes metrics. Here are just a few examples:
- We’ve decreased length of stay in over 10 disease processes
- We’ve decreased our readmission rate for asthma patients
- We’ve decreased unnecessary chest X-ray utilization.
For a more complete look at what we’ve been able to accomplish, I invite you to watch the webinar I recently presented. By pairing our EHR with an EDW, we are realizing care improvement, waste reduction and cost savings—and we’ve really only just begun. The combination of the two is very powerful and is proving key to our strategy to drive better healthcare value.