Reducing the costs of U.S. health care: the role of electronic health records.

Health Records The United States is spending up to an unprecedented $30 billion on electronic health records (EHRs) through the 2009 Health Information Technology for Economic and Clinical Health Act, colloquially known as the federal meaningful use program (1). This is one of the largest public infrastructural investments made by the federal government in health care or any other industry (2). It is widely believed that wiring the health care system will improve the quality, safety, and efficiency of health care. The evidence behind improvements in quality and safety is solid and growing (3). However, we have little empirical evidence that the costs of health care can be reduced through the use of EHRs. Much of the financial work on EHRs has focused on extensively customized home-grown systems in the inpatient setting or specific elements of EHRs (such as computerized physician order entry) or has lacked rigorous study designs, often relying on expert estimates (4). Relatively little work has addressed the effects of EHRs or other forms of health information technology directly on broad categories of health care utilization and costs. In this issue, Adler-Milstein and colleagues address the relationship between the use of EHRs and the costs of health care (5). They are to be applauded in rigorously analyzing a natural experiment, finding that EHRs in a community-based setting seem to slow ambulatory cost growth, particularly radiology testing. This study has many strengths and raises several questions that would benefit from further inquiry. Studying typical community-based settings rather than academic teaching hospitals and affiliated practices is critically important because most health care is delivered in these settings. Looking broadly at different cost categories of utilization is also important because determining costshifting across categories of care (for example, reducing ambulatory visits but increasing hospitalizations) can otherwise be missed. However, reducing utilization is not always ideal. For example, averting an ambulatory visit that then results in an emergency department visit will not reduce overall health care costs, nor does avoiding a recommended radiologic test, such as screening mammography, that could have detected early cancer. As the literature base on the effects of EHRs grows, it will be essential to look at quality and cost together as markers of health care value. Understanding costs in the absence of concurrent assessment of quality and safety changes limits our ability to effectively understand how to optimize health care delivery. Driving down costs at the sacrifice of quality is not a desirable outcome. Furthermore, we ideally should study health care value over time because short-term gains could result in long-term losses or vice versa. A strength of Adler-Milstein and colleagues’ study was the aggregation of data across 2 commercial payers. Community-based studies that focus on entire populations of patients, including commercially and publically insured ones, will be necessary. The effects of EHRs are likely different for younger patients (for example, the average age of patients in the study was approximately 30 years) compared with older patients or poorer patients, such as those insured by Medicare or Medicaid, respectively. A clear understanding of the effects of EHRs across entire populations is valuable from a societal perspective, given the amount of investment nationwide. Across the country, we are engaging in increasingly standardized use of EHRs through the meaningful use program because it requires certified EHRs and mandates the use of certain functionalities (6). Massachusetts has recently enacted legislation requiring physicians to “demonstrate proficiency in the use of computerized physician order entry, e-prescribing, electronic health records and other forms of health information technology” in order to be eligible for medical licensure (7). How proficiency will be defined is still unclear, but the legislation states that, at a minimum, meaningful use requirements will be a component of proficiency. However, individual physician variation in use of EHRs and health care utilization patterns will persist. Therefore, detailed understanding of how physicians use EHRs and how that use affects health care costs will be valuable. The effects of an EHR system result in part from use patterns but also from myriad other technical, cultural, and organizational factors. Implementation support for the communities in the study was provided by the Massachusetts eHealth Collaborative, an entity similar to federally funded Regional Extension Centers that offer support to health care providers with implementing EHRs (8). The financial savings in the study are probably a combination of the technology used and the support of the Massachusetts eHealth Collaborative. Whether these findings generalize to other communities with different types of EHRs and implementation support is unclear. In addition, teasing out the benefits of EHRs from those of health information exchange (HIE) is essential. Growing evidence shows that utilization patterns can be significantly shifted through the use of HIE (9). In AdlerMilstein and colleagues’ study, the community undertook an aggressive program of EHR adoption and HIE. Therefore, it is difficult to ascribe the financial savings purely to EHRs rather than to the combination of EHRs and HIE. Some physicians accomplish HIE through the direct exAnnals of Internal Medicine Editorial