hfm: The Office of the National Coordinator [ONC] for Health Information Technology reviewed more than 150 articles published between 2007 and 2010 to assess outcomes from deployment of various forms of health IT and found that most study outcomes were positive. What should healthcare providers take away from that analysis?

Perlin: In preparation for administration of the HITECH and meaningful use program, the ONC reviewed the literature to determine the quality and financial impact of implementing EHRs. The vast majority of articles reviewed—92 percent—were either positive or mixed-positive; 62 percent were found to be fully positive.a But in the absence of generally accepted approaches to accounting for investments in EHRs and associated technologies, the articles are not directly comparable. None of the studies has used a standard set of assumptions. So in terms of understanding different approaches to implementation, comparing different vendor products, and even understanding the number of FTEs necessary in different environments, it is very difficult to extrapolate from one model to the next. That’s a real problem.

Apart from that important limitation, the literature did support several findings. 

First, the implementation of EHRs was more often associated with improved quality and efficiency. Although new implementations were associated with disruptions to productivity in physician practices, the disruptions were temporary, and productivity almost always went back to baseline performance within six weeks. Physician sentiment was not initially favorable to implementation, but—almost universally—physicians who had gone from paper to electronic systems said they would not go back to paper.

Second, almost all of the studies showed that the benefit of EHRs correlates directly with the completeness of implementation. The higher the HIMSS level—that is, the more features that were fully implemented, be it full documentation, full order entry, full error checking, full communication among different care providers, or more—the greater the benefit. So the literature is telling us that it’s not very efficient to have a foot in each camp. Being part paper and part electronic is less desirable than being exclusively paper or all electronic. Using advanced electronic systems is the best situation of all, in terms of both clinical outcomes and efficiency. 

Did the studies occasionally find that something went wrong or that increased complexity resulted from the use of electronic systems? Of course. But on the whole, considering the lack of productivity gains in healthcare relative to other industries, it’s pretty clear that paper is dangerous and electronic is safer. And there is no way to manage an information-intensive industry with pen and paper and reach the equivalent of aviation safety levels, which is what we owe our patients. Also, when using paper records, the ability to look at comparable processes is extraordinarily limited, both in terms of clinical outcomes and in terms of the effect of different processes on resource utilization. Working electronically, certain information and decision support can be provided, quality can be measured, and cost choices can be made apparent in a way that is generally not possible on paper.

In the past, I have used the metaphor of having one foot on the dock and one foot in the boat as a description of the transition between fee-for-service and the value-based environment of the future. We sense the instability or the challenge of shifting our weight from the fee-for-service world that we’ve always known to the emerging world of value and risk. It’s hard to contemplate shifting that weight safely and effectively without the benefit of EHRs. 


a. Buntin, M.B., Burke, M., Hoaglin, M., et al., “The Benefits of Health Information Technology: A Review of the Literature Shows Predominantly Positive Results,” Health Affairs, March 2011.


For more information, see hfm's Q & A "Jonathan Perlin, MD: Assessing the ROI of EHRs", hfm, November, 2013

Publication Date: Friday, November 01, 2013

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