Transcript Electronic Health Records in Portugal

REGIONAL/NATIONAL
ELECTRONIC HEALTH RECORDS
COST-BENEFIT ANALYSIS:
A SYSTEMATIC REVIEW
21st May 2012
Class 4
[email protected]
Introduction
CONCEPTS: Electronic Health Records
2
 “Media that facilitate transportability of pertinent information concerning
patient's illness across varied providers and geographic locations. Some
versions include direct linkages to online consumer health information that is
relevant to the health conditions and treatments related to a specific patient”
PubMed - MeSH, 2010
 “Electronically stored and transmitted medical record that contains patient
demographics, medical history, lab tests, X-rays, scans, prescription lists, and any
other relevant information” Wulsin, L. and Dougherty, A., 2008
Wulsin, L. and Dougherty, A., Health information technology - Electronic health records: a primer, California State Library, 2008 (http://www.library.ca.gov/crb/08/08-013.pdf)
http://www.ncbi.nlm.nih.gov/mesh/68057286
Introduction
CONCEPTS: Cost-Benefit Analysis
3
“a method of comparing the cost of a program with its
the benefit-to-cost ratio is a measure of total return
expected per unit of money spent.
This analysis generally excludes consideration of factors
that are not measured ultimately in economic
terms. Cost effectiveness compares alternative ways to
achieve a specific set of results.” (PubMed – MeSH, 1976)
http://mavit.kabunzo.com/tag/dolar/
expected benefits in dollars (or other currency);
Introduction
EHR: Why so delayed?
4
It is generally agreed that EHRs hold great promise
for improving healthcare quality and efficiency
But healthcare is decades behind other industries
dealing with Information Technology adoption
There is an urgent need for hospitals to adopt
general EHR systems.
However, the efforts of government and other EHR
advocates have not sufficiently accelerated the
diffusion trajectory.
Lori T. Peterson et al., Assessing Differences Between Physicians’ Realized and Anticipated Gains from Electronic Health Record Adoption, 2009
Introduction
Costs and benefits: economic issues
5
Costs versus benefits
Investment budget
- Activities
- Personnel
- Executive management
- Human resource and finance
- Building
- Supplies
- Electronic health record
- Other operating expenses
Cost Savings
Increased revenue
 Eliminating costs
of a storing paper
records
 Government
incentives for use
health IT
 Downsizing
personnel
 Pay-for-performance
incentives
IT – information technology
Dukyong Yoona et al., Adoption of electronic health records in Korean tertiary teaching and general hospitals, 2012,
International Journal of Medical Informatics 81 (2012) 196–203
Discussion
Barriers to adoption of EHRs (e.g. South
Korea)
6
Barriers
Hospitals with EHR
Hospitals without EHR
The amount of capital needed to purchase and
implement the system
53.8%
76.3%
Uncertainty about return on the investment
33.0%
40.0%
Concerns about the ongoing cost of maintenance
27.3%
36.8%
Finding an EHR system that meets the organization’s
needs
34.4%
35.2%
Resistance to implementation from physicians
22.3%
30.5%
Lack of adequate IT staff
29.1%
27.0%
Concerns about lack of future support for upgrading
and maintaining the system
16.7%
23.3%
Concerns about “hacking”
12.7%
19.2%
Lack of interoperable IT systems in the marketplace
13.4%
18.0%
Concerns about inappropriate disclosure of patient
information
9.2%
10.9%
11.1%
2.9%
Lack of capacity to select, contract for, and implement
an EHR system
Discussion
Facilitators of adoption of EHRs
(e.g. South Korea)
7
Facilitators
Hospitals with EHR
Hospitals without EHR
Additional reimbursement for the use of EHRs
68.1%
62.9%
Incentives for the purchase and implementation of an
HER system (e.g., tax credits, low-interest loans, grants)
61.4%
58.7%
Technical assistance for implementation and process
change
57.0%
31.1%
Objective evaluations of EHR capabilities and
implementation experiences (“consumer reports” on
EHRs)
45.4%
34.1%
Published lists of certified EHR systems to assure the
presence of necessary capabilities and functions
40.6%
36.7%
Changes in the law to protect physicians from personal
liability for “hacking” or for privacy and security
breaches
37.1%
32.4%
Dukyong Yoona et al., Adoption of electronic health records in Korean tertiary teaching and general hospitals, 2012,
International Journal of Medical Informatics 81 (2012) 196–203
Research
Questions
8
 What is the return per unit of money spent on regional or
national EHR systems?
 Is this system financially supported by the government of each
country where it was implemented?
http://aep.ist.utl.pt/divulgacao/publicacoes/
Aim
9
 To review the published literature regarding the financial costs and
benefits of regional or national Electronic Health Records.
With this, we intend to…
 Find out which records characteristics are associated to a bigger investment return.
 Measure the differences relating to the return of investment between all regions.
Methods
10
Systematic Review
A systematic review is a method of identifying, appraising, and synthesising research evidence. The
aim is to evaluate and interpret all available research that is relevant to a particular review
question. In a systematic review, the scope (for example, the review question and any subquestions and/or sub-group analyses) is defined in advance, and the methods to be used at each
step are specified. The steps include: a comprehensive search to find all relevant studies; the use of
criteria to include or exclude studies; and the application of established standards to appraise
study quality.
Lucie Rychetnik, Penelope Hawe, Elizabeth Waters, Alexandra Barratt, Michael Frommer. A glossary for evidence based
public health. J Epidemiol Community Health2004;58:538-545 doi:10.1136/jech.2003.011585. (17/12/2011)
How did we create the queries?
Methods
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 Make an inventory of synonyms of the key terms of the research
KEY TERMS
SYNONYMOUS
EHR
Electronic Health Record
Electronic Medical Record
Electronic Patient Record
Personal Health Record
Personal Medical Record
Computer Patient Record
Computer Health Record
Computer Medical Record
Digital Health Record
Digital Medical Record
Digital Patient Record
Economics
Fees
Funding
Financing
Cost
How did we create the queries?
Methods
12
KEY TERMS
SYNONYMOUS
Cost-benefit analysis
Cost-Benefit Analyses
Cost Benefit Analysis
Cost Effectiveness
Cost-Benefit Data
Cost Benefit
Benefits and Costs
Costs and Benefits
National
National Health Programs
National Health Insurance
National Health Services
Regional
Regional Health Planning
 Combine the terms in the query using Boolean operators.
Methods
How did we create the queries?
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 Establish limits on the search
Limit the search to the timespan:
 1994 to 2012
Timespan
Limit the search to articles in:
Languages
 English
 French
Subject
areas
Excluded articles on:
 Maths
 Architecture
 Veterinary Sciences
 Geography
 History
 Linguistics
 Anthropology
 Religion
 Chemistry
 Zoology
 Physics
Query with LIMITS
Collecting articles
Methods
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 Insert queries in three different Databases
DATABASES
851
1312
TOTAL: 4362
2199
Methods
Query – PUBMED
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(("Electronic Health Record*" OR "Electronic Medical
Record*" OR "Electronic Patient Record*" OR "Computer*
Patient Record*" OR "Computer* Health record*" OR
"Computer* Medical Record*" OR "Digital Health Record*"
OR "Digital medical record*" OR "Digital patient record*")
AND ("Cost-benefit" OR cost OR costs))
Methods
Query – ISI WEB OF KNOWLEDGE
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Topic=((("Electronic Health Record*" OR "Electronic Medical
Record*" OR "Electronic Patient Record*" OR "Computer* Patient
Record*" OR "Computer* Health record*" OR "Computer* Medical
Record*" OR "Digital Health Record*" OR "Digital medical record*"
OR "Digital patient record*") AND ("Cost-benefit" OR cost OR costs)))
Refined by: [excluding] Subject Areas=( VETERINARY SCIENCES OR
HISTORY OR ANTHROPOLOGY OR CHEMISTRY OR PHYSICS OR
ARCHITECTURE OR GEOGRAPHY OR LINGUISTICS OR RELIGION OR
ZOOLOGY ) AND Languages=( ENGLISH OR UNSPECIFIED OR FRENCH )
Timespan=1994-2012.
Methods
Query – SCOPUS
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(("Electronic Health Record*" OR "Electronic Medical Record*" OR "Electronic
Patient Record*" OR "Computer* Patient Record*" OR"Computer* Health record*"
OR "Computer* Medical Record*" OR "Digital Health Record*" OR "Digital medical
record*" OR "Digital patient record*") AND ("Cost-benefit" OR cost OR costs)))
AND (EXCLUDE(SUBJAREA, "CENG") OR EXCLUDE(SUBJAREA, "MATH") OR
EXCLUDE(SUBJAREA, "PHYS") OREXCLUDE(SUBJAREA, "AGRI") OR
EXCLUDE(SUBJAREA, "MATE") OR EXCLUDE(SUBJAREA, "ENVI") OR
EXCLUDE(SUBJAREA, "ARTS") OREXCLUDE(SUBJAREA, "VETE") OR
EXCLUDE(SUBJAREA, "CHEM")) AND (LIMIT-TO(LANGUAGE, "English") OR LIMITTO(LANGUAGE, "French")) AND (LIMIT-TO(PUBYEAR, 2012) OR LIMIT-TO(PUBYEAR,
2011) OR LIMIT-TO(PUBYEAR, 2010) OR LIMIT-TO(PUBYEAR, 2009) OR LIMITTO(PUBYEAR, 2008) OR LIMIT-TO(PUBYEAR, 2007) OR LIMIT-TO(PUBYEAR, 2006)
OR LIMIT-TO(PUBYEAR, 2005) OR LIMIT-TO(PUBYEAR, 2004) OR LIMITTO(PUBYEAR, 2003) OR LIMIT-TO(PUBYEAR, 2002) OR LIMIT-TO(PUBYEAR, 2001) OR
LIMIT-TO(PUBYEAR, 2000) OR LIMIT-TO(PUBYEAR, 1999) OR LIMIT-TO(PUBYEAR,
1998) OR LIMIT-TO(PUBYEAR, 1997) OR LIMIT-TO(PUBYEAR, 1996) OR LIMITTO(PUBYEAR, 1995) OR LIMIT-TO(PUBYEAR, 1994))
Methods
Collecting the Final Articles – Step by step
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 Exclude the repeated articles
 Exclude the non-real articles (ex: letters, conversations, news)
 First exclusion by abstract with two revisors
EXCLUSION CRITERIA OF THE FIRST EXCLUSION
 1st: Not mentioning monetary values/ costs;
 2nd: Refering to a single hospital/institution;
 3rd: Refering to a group of services in a certain hospital.
INCLUSION CRITERIA OF THE FIRST EXCLUSION




1st: Mentioning Electronic Health Records;
2nd: Mentioning Cost-Benefit Analysis;
3rd: Referring to monetary values / costs;
4th: Dealing only with regional and/or national aspects.
Methods
Collecting the Final Articles – Step by step
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 Exclude the articles from previous years than 2008
 Get the full-texts available – search on 7 different
databases (PubMed, Google Scholar, B-On, Scopus, Isi
Web of Knowledge, AtoZ, EBSCO)
 Contact the authors to ask for the articles of interest
that were not available
 Second exclusion reading the full-article, according to
the same parameters as the first one
 Extract data from the articles
Methods
Selection of the Articles - STEPS
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Total of documents found
Total of articles without the
repeated ones
Total of articles only with the
real ones
4362
2937
2621
 Repeated:
1425
 Not articles: 316
Methods
Selection of the Articles - STEPS
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Total of articles
2621
Total of articles included by both
306
revisers
Total of articles after the year 2008
147
Methods
Selection of the Articles - STEPS
22
147
Total of articles after the year 2008
Full-text articles available
105
111
Articles after contact with authors
Articles included by both revisors
48
Methods
Variables
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
Country where the system is implemented

Date of article publication

Institutions involved

What type of medical data is integrated

User groups

Financing agents

Cost Savings

Costs of initial investment

Profit
Results
Countries where the systems were
implemented
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





USA
South Korea
Japan
Norway
United Kingdom
India
Results
Date of article publication
25

2008-2012
Institutions involved







Hospitals
Physician groups
Clinics
Nursing homes
Municipal health station
Community health centers
RHIOs
Results
Type of data integrated
26











Insurance coverage and benefits
Payment remittance advice
Electronic radiology reports
Computerized physician order entry for medications
Electronic physician notes
Data about the patient’s consults
Demographic information
Nursing assessments
Medication lists
Discharge summaries
Laboratory, radiology reports and other diagnostic testing
Results
User groups
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Health care providers
 Payers
 Pharmacists
 Chiropractors
 Doctors
 Physicians
 Patients
 Nurses
 All hospital
services

Results
Financing Agents
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



Government
CNO
Massachusetts eHealth
Collaborative and New York
City Primary Care
Information Project
Other EHR advocates
Results
Initial Investment
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Country
Initial Investment ($)
USA
19 billion
USA
77.8 billion
USA
30 billion
USA (Massachussets and
New York)
36 500
USA
19 billion
USA
2,55 billion
USA (California)
59.2 billion
USA
195 million
USA
19.2 billion
USA
19 billion
USA
20 billion
United Kingdom
32 billion
USA
28 billion
USA
31.4 million
USA
630 000
USA
130 billion
USA
32 billion
USA
17,2 billion
Mean
24 billion
Results
Cost Savings
30
Country
Cost Savings ($/year)
USA (Minnesota)
60 million
Korea
2,7 billion
USA
81 billion
USA
77 billion
USA
667 896
USA
46 400
USA
1,2 million
USA
81 billion
USA
6 million
USA
20 billion
USA
30 billion
USA
35 million
USA (Rhode Island)
42 000
Mean
22 billion
Conclusions
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
In terms of cost savings, we studied them per year.

The investment from government or other entities was,
in mean, 24 billion dollars, being the highest value
from the USA, 77.8 billion dollars and the lowest
36500, also from USA (Massachusetts and New York).

Our data related to cost savings came from 13 articles
that referred values varying from 81 billion dollars to
42000 dollars.

In mean, 22 billion dollars were saved per year with EHR.

With two exceptions (Korea and UK), all of this was
related to USA medical institutions.
Conclusions
32

From this point of view, EHR appear as
advantageous. However, when compared to
the mean of investment, which is 24 billion,
we observe that this is not that linear.

In terms of profit, the target articles almost
didn’t contain this type of information. Just
some of them stated that the profit was
11billion, 20-30 billion, 1-2 million or 154,900
per year.
Conclusions
33

One of the main limitations to our project was the
lack of relevant information in the final articles
selected

The access to the full-text of many articles was
denied and when asking the authors to provide us
their articles, the majority did not answer us

The variables related to monetary values, such as
initial cost investment, cost savings and profit, did
not gathered information in every article
Conclusion
34
From our systematic review, because the major barriers
to adoption of EHRs are financial, we suggest that
hospitals in better financial position with regard to
liquidity, profitability and human resources efficiency
will be more likely to adopt EHRs.
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