Q and A With Dr. John Lumpkin

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Robert Wood Johnson Foundation Health Care Group

The leader of the Robert Wood Johnson Foundation explains how EHRsprovide patients with critical information as well as efficient and effectivecare that costs less.

Healthcare Technology: What do you think are the goals and objectives of electronic health records (EHRs)?

John Lumpkin: I think a key goal of an EHR is improving quality of care and patient safety. I’d like to quote something Daniel Masys said at an Institute of Medicine meeting in 2001: “Current practice depends upon the clinical decision- making capacity and reliability of autonomous individual practitioners for classes of problems that routinely exceed the balance of unaided human cognition.” The rapidly expanding body of medical knowledge essentially means that people can no longer provide high-quality care unassisted. And one of the roles, one of the key roles, of EHRs is to provide them with the information they need to make the right decisions.

EHRs can also provide patients with critical information. The chronic disease model that was developed by Ed Wagner envisions that the best interactions between a patient and a physician occur when the physician and the caregivers are part of a team that’s prepared and responsive, and that the patient is engaged and able to participate in the decision making. And so the ability of an EHR to populate personal health records would enable the patient to be a more active participant in their care. So these are all the enabling areas under quality.

Another key goal of EHRs is to provide efficient and effective care that costs less. For example, an antibiotic would be selected because it is the most effective for what the patient needs, not because it was the most recently detailed by a drug company. You can go down the whole list of rows of treatment, so in some instances where there’s overuse you’ll be able to use resources more appropriately. In other areas there’s under-use, and this underuse tends to lead to higher costs, not necessarily in each individual encounter, but in the overall system. So if you don’t give a patient aspirin after a heart attack, then what you’re going to find is that down the road they are going to have more complications. And as a result, costs for that individual are going to be more expensive.

HCT: We’re trying to understand the roles of different stakeholders in making EHRs happen. What do you think about the roles of various groups, business coalitions, physicians, hospitals, payers and consumer groups?

JL: Well in order to answer that question, it is important to understand the basic economics of EHRs.We have seen from some of the earlier studies that there is a mismatch between who pays for EHRs and who profits from them. The costs for EHRs where they’ve been implemented have primarily been borne by the individual providers — physicians, other caregivers, hospitals, etc. However, the savings that are yielded, the cost savings, don’t actually accrue to them. The savings basically go to those who are paying for the care: the patient, the insurance companies and those who buy the insurance. And so for EHRs to happen, that mismatch needs to be rectified.We can rectify this through a system that enables clinicians to be able to afford and have EHRs. This system would include pay-for-use and pay for performance — those things that really reward clinicians for the outcomes that would result from using EHRs: better adherence to clinical care guidelines and better quality of care.

HCT: What are some of the implementation challenges?

JL: There continues to be implementation challenges associated with standards. We’ve made a fair bit of progress with adoption standards that started with HIPAA. The next important step in developing standards was the adoption of the Consolidated Health Informatics Initiative between the Department of Defense, the Department of Veterans Affairs and the Department of Health and Human Services, which identified standards in 24 different domains. The next phase of important standards adoption is what is being put forward by Connecting for Health, which is identifying standards for health data interchange. Not having a common set of standards and architecture is a major obstacle and creates tremendous challenge. The key part of that challenge is the fact that the true benefits of EHRs will not be yielded until there is an interconnecting system of EHRs. People don’t see just one provider, they see multiple providers, through distance, through time and through different illnesses. If we are to deliver consistent quality care, it’s important to be able to provide clinicians with the information they need to make the right decisions.

HCT: Do you think we’ll have widespread adoption in the next five years?

JL: I think that there are a lot of very positive trends that will lead to adoption. Number one is the belief that EHRs are possible. And this has really been driven initially by Secretary Thompson. Secretary Levitt, if it were possible, has eclipsed Secretary Thompson’s zeal and enthusiasm for EHRs. And then of course the push that has been put on by the president. And now we’re seeing various state governments across the country also trying to create environments where interconnectivity of EHRs will occur through the adoption of legislation that’s supporting the development of statewide networks.

The second important trend is the initiative by the Certification Commission for Health Information Technology. One of the problems in the field is that no one knows exactly what to buy. The promise of CCHIT is that it will put the purchasers of these systems in a position to make reasonable decisions in implementing those systems. So I think that that’s a very important development.

The third is the rise of disease-specific personal health records systems. Here you see individual patients, starting out with those with chronic diseases, who want to be active partners in the delivery of their care and have their medical information available to them. As a result of either health plan or individual provider pressure to provide this electronic information to their patients, they’re recognizing the need to adopt EHRs. Finally, a growing commitment to improving quality of care paired with an increased recognition that EHRs are valuable tools for tracking treatment and standardizing care.

So I think that there are a lot of trends that would indicate we’re entering the logarithmic growth phase of adoption of EHRs over the next couple of years.

HCT: If you had to give a percentage, what percentage of adoption do you think we’ll have in five years?

JL: In five years? If current trends continue, I would predict adoption in the 60 to 75 percent range.