How An Electronic Health Record Can Save Time, Money And Lives
Author: Robert Pearl, M.D.
Across the United States, the potential that electronic health records (EHRs) offer remains largely untapped. Used effectively, EHRs help physicians provide higher-quality, more personalized care to patients—at a lower cost.
But delivering on this promise depends on physicians using EHRs in the right context and culture. Patient outcomes prove superior when medical care is provided through an integrated, multi-specialty medical group, using advanced IT systems reimbursed on a pay-for-value—rather than fee-for-service—basis. In such a scenario, EHRs can be game-changers.
Here I’ll describe examples of success from Kaiser Permanente in Northern California. I offer these, rather than including examples from other organizations, because these are the programs whose details and outcomes I know best.
Unleashing The Potential Of the EHR
Talking about an EHR is similar to asking what a computer or smartphone does. It can serve as little more than a typewriter or telephone—or it can provide functionality beyond anything ever available or imagined. All too often, the EHR is deployed merely as a digitized version of a paper medical record. Under that circumstance, entering and retrieving data takes even more time than with a paper chart, and physicians are frustrated.
In contrast, the EHR can be a tool for multiple physicians from different specialties to coordinate care, communicate critical clinical information, and deliver medical treatment quickly and safely. As with other 21st century medical information technology, what matters most—more than the hardware and applications—is the medical group structure, its reimbursement model and the effectiveness of its physician leadership.
A Case In Point: Lung Cancer
Let’s look at the valuable role EHRs can play in diagnosing and treating lung cancer. Cancer of the lung is the second most commonly diagnosed malignancy in the United States. Each year more people die of lung cancer than of colon, breast and prostate cancers combined. Detecting lung cancer early reduces morbidity and mortality.
Unfortunately, we’ve made little progress nationwide in treating it. More than 50% of patients with lung cancer are diagnosed after the cancer has spread to other organs, by which time surgery, radiation and chemotherapy have minimal efficacy. Sometimes a potentially malignant lesion is identified on a CT scan of the chest during a hospital stay for a different problem. Often it is noted as "an incidental finding" on the radiology report. In both cases, the ordering physician may not notice the radiological reading or follow up.
The Difficulties In Making the Right Diagnosis
Finding lung cancer before it spreads beyond the lung is a critical first step to lowering the death rate from this malignancy. The problem is that as many as a quarter to a half of all lung CTs detect these nodules. As a result, more than one million new nodules are identified annually in the U.S. Of these, only 3.9% are malignant, according to the National Lung Screening Trial.
Why not just biopsy all of them? Unfortunately, the procedures themselves are dangerous and require inserting a needle into the lung under radiologic observation or by performing open-chest surgery. Both have major risks, including death. And because 96% of nodules are benign, more people would be harmed than helped. The key, therefore, is to determine—based on the size and radiologic appearance of the nodule and the presence of risk factors like smoking—the right population for further evaluation. The goal is to identify all of those with cancer, but as few as possible with truly incidental findings.
Spotlight On Innovation
Two years ago physicians across multiple specialties in The Permanente Medical Group (TPMG) began an innovative program to make sure no patient failed to obtain the follow-up needed. Radiologists began placing an identifying marker on all chest CT exams noting whether or not a lung mass was present and their degree of suspicion that the mass represents cancer. This trackable electronic marker, attached by the radiologist with a single click, instructed the computer system to extract key information from the EHR about prior imaging and past medical history.
A user-friendly, single-page report was immediately made available to all physicians involved in caring for the patient, and could be conveniently accessed on the desktop in the doctor's office, in their exam room, and on their privacy-protected mobile device. The result is that patients did not fall through the cracks or have their problem missed by the physicians caring for them. In practice, the radiologist had effectively created an effective, high-quality safety net for patients.
From Information To Action
Next, the TPMG clinical leaders leveraged the EHR as a communication tool to bring expertise into the decision-making process earlier. Traditionally, the ordering doctor reads the report, notices the incidental finding, decides if there is a problem and, if so, refers the patient to a pulmonologist. Post-evaluation, a second consult is sent to a thoracic surgeon, and after the need for surgery is confirmed, a third consult is sent to an oncologist. The result is a series of referrals, all with delays in between, rather than real-time coordination, consultation and consensus.
As a result of using the EHR, the marker placed on the chest CT exam generated a series of computer commands and notified a team of cancer experts in pulmonology, thoracic surgery and oncology. Each had access to the same comprehensive information at the same time, and together they were able to reach a consensus on the best next steps. By bringing together all of the specialists, the patient, rather than hearing conflicting advice from each physician in sequence, was, and continues to be, provided with a clear, expert recommendation for treatment all at once.
Bottom line: use of an EHR in an integrated, multi-specialty medical group eliminates the potential for confusion and medical error, and shortens what otherwise would take weeks to be completed, to less than a day.
Results Speak Volumes
This approach has delivered promising results. Lung cancers are being diagnosed at an earlier stage and treated more quickly. In Kaiser Permanente Oakland, for example, the average work-up time from lung cancer diagnosis to definitive surgery dropped by more than half: from 40 days, the U.S. average, to just 16 days.
In 2011, before this program was introduced at Kaiser Permanente North Valley, 56.5% of patients diagnosed with lung cancer had already experienced the tumor spreading to other organs, consistent with the nationally reported data. By 2014, the frequency of spread beyond the lung had decreased by 7.6% to 52.2%—a significant improvement, and considerably better than the typical program around the country.
The success of this EHR initiative has inspired other clinicians to track and manage a variety of cancers and serious medical conditions. Work is currently underway to expand this program to testicular, ovarian, pancreas, kidney and liver masses, as well as to abnormal laboratory and pathology results for different medical conditions.
The advantages of EHRs abound. They support physicians as they create clinical safety nets, expedite medical work-ups, provide broad expertise and facilitate rapid diagnosis and treatment. Through this process, physicians combine innovation, technology and a team-based approach to achieve highly reliable, superior clinical outcomes.
Empowering The EHR
The EHR can serve mainly as a source of information and documentation, and for many doctors, it’s frequently nothing more than a tool for claims and billing. But it can also add major clinical value and be a powerful force for abbreviating time, eliminating distance and dramatically improving patient care and convenience.
Increasingly, the most important question in cancer care isn’t “Who’s the best doctor for a particular tumor type?” but rather, “Where can I find the best team to identify, diagnose, and treat a specific malignancy?”
Ask yourself: if you had a nodule in your lung, which approach would you prefer? The random, sequential one that is the standard in most of the country? Or one that consistently identifies the problem, assembles a team of experts in fewer than 24 hours, and completes the surgical removal not in two months, but in two weeks?