To the Editor:
Himmelstein et al's article
1demonstrated that the increasing use of electronic medical records (EMRs) during a recent 4-year period did not reduce overall costs and had only marginal affects on quality. This is another useful antidote to the belief that EMRs are a panacea for health care cost and quality.
- Himmelstein D.U.
- Wright A.
- Woolhandler S.
Hospital computing and the costs and quality of care: a national study.
Am J Med. 2010; 123: 40-46
This result is not surprising, given the universe in which it is considered: intra-institutional behavior. The proponents of EMRs point to different sets of reasons for their promised benefits: coordination of multiple provider care to eliminate redundant testing, and external pressures created by the publication of summary data from the EMRs. Neither was present in this study. Another major source of outside pressure is the creation of provider profiles
2from EMRs and the use of these profiles to create reputational incentives to ration health care services.
- McLean T.R.
- Burton L.
- Haller C.C.
- McLean P.B.
Electronic medical record metadata: uses and liability.
J Am Coll Surg. 2008; 206: 405-411
3At the 2010 Society of Thoracic Surgery meeting, we presented data demonstrating that states that use reputational incentives perform significantly fewer coronary artery bypass grafting procedures per capita than states that do not use reputational incentives.
- McLean T.R.
Reputational incentives—how improving transparency can drive hospital competition.
Am Heart Hosp J. 2009; 7: 27-32
More generally, the increased transparency provided by the government's Hospital Compare and soon-to-be Physician Compare websites
4does more than increase patient information. It also makes providers think twice before offering to provide services to high-risk patients. No one wants to be last in their class. Accordingly, providers (who increasingly understand that they are under the microscope of public scrutiny) are seeking to avoid becoming a high-outlier on public report cards by shunning risky patients. But such a rationing scheme is precisely why some health care reformers advocated EMRs. The reformers know that many services, like coronary artery bypass grafting, are over-prescribed; they just cannot figure out which patients should not receive that service. On the other hand, reformers know that the reputational incentives created by the public dissemination of EMR-facilitated provider-specific profiles will motivate providers to prescribe fewer services to high-risk patients. Unfortunately, this will provide the unintended incentive for increasing unnecessary procedures done on healthy patients, which will ensure that the provider has a very low-risk profile.
- McLean T.R.
Big Brother and need for a performance measure integrity and fraud detection act.
Law Technol J. 2009; 42
In short, if Himmelstein et al had included the impact of EMR-facilitated provider-specific reporting on costs in a hospital market rather than individual hospitals, they may have found a significant reduction in overall health care costs because fewer services were provided.
- Hospital computing and the costs and quality of care: a national study.Am J Med. 2010; 123: 40-46
- Electronic medical record metadata: uses and liability.J Am Coll Surg. 2008; 206: 405-411
- Reputational incentives—how improving transparency can drive hospital competition.Am Heart Hosp J. 2009; 7: 27-32
- Big Brother and need for a performance measure integrity and fraud detection act.Law Technol J. 2009; 42
Conflict of Interest: None. Nothing in this letter to the editor is be construed as Department of Veterans Affairs policy or procedure.
Authorship: All authors have contributed to, reviewed, and verified the data.
© 2010 Elsevier Inc. Published by Elsevier Inc. All rights reserved.