The patient who had come to see Dr. Eduardo Haddad had complicated problems — he was obese and diabetic with pulmonary hypertension. As Haddad reviewed the 50-year-old man’s medications, reading from a long list saved in the patient’s electronic health record, a window popped up on Haddad’s laptop. Two of the drugs, when taken together, could make the patient drowsy, it warned.
Haddad, an independent nephrologist in a two-doctor office in Lawrence, calls himself “old-fashioned.” He still keeps a bank of paper records in the receptionist’s office, but the electronic records system he uses each day is advanced. There are tools to screen for adverse drug interactions like this one and prompts to help him make choices about tests and treatments.
Haddad bought the “Cadillac system” last year, after trying a more basic system, and joined a growing body of physicians adopting the new technologies. One in 10 doctors who work outside hospitals in the United States began using electronic health records in 2011, helped along by the promise of $27 billion in incentives from the federal government.
As of the end of last year, 35 percent of such doctors had a system that performed at least basic functions, including ordering of prescriptions and storing doctor notes and test results, according to one in a series of studies on the topic published in the latest issue of the journal Health Affairs.
The technology is spreading, the result of years of fierce, well-funded advocacy aimed at soothing doctors’ concerns about the hassle and cost of the systems. To date, $146 million in incentive payments have been distributed to doctors and hospitals in the state to help pay for installation, training, and upkeep, according to Bridget Scrimenti, spokeswoman for the Massachusetts eHealth Institute, part of an independent state agency working on the issue.
Now, some involved in health information technology say it is time to focus more attention on making sure the systems are safe.
“In 2012, the debate cannot be: Should we or shouldn’t we” use electronic records, said Dr. Ashsh Jha, associate professor of health policy at Harvard School of Public Health and an author on one of the Health Affairs studies. “The new question is: How do we do it well? How do we not cause harm? . . . That’s the more compelling question and one for which we essentially have no data.”
Doctors in Massachusetts have been quicker than those in many other states to accept the new systems, with about 44 percent of physicians outside hospitals using them as of last year, according to an analysis of federal data by Jha and colleagues. Adoption among community hospitals in Massachusetts more than doubled in 2011 to 35 percent. And 37 percent of teaching hospitals in the state had at least a basic system last year, up from 23 percent in 2010.
Electronic health records are expected to improve health care by making it easier for doctors to keep track of patient histories and to monitor groups of patients to find those who are due for preventive care or need more assistance in managing chronic conditions.
Some studies have indicated electronic health records already are having such effects, though much of the research has been at facilities with more advanced systems. Just 8.7 percent of hospitals in the country had a comprehensive system last year, according to a Health Affairs report led by Catherine M. DesRoches, senior researcher at Mathematica Policy Research in New Jersey.
Other research has pointed to problems that electronic records could introduce into health care, including glitches in ordering tests or medications, or errors that result from disrupting a physician’s normal workflow.
While a senior resident, Jha said, he had two patients under his care with similar names and ordered an antibiotic using the computer system for the wrong one. Haddad’s system has a warning for that, he said. But again, few doctors have such advanced systems.
“Do I think that’s a common problem?” Jha said. “I do.”
Some say there has been a hesitancy to look at such problems out of fear that they will dissuade doctors from adding an electronic system to their own practice.
“The sensitivity that people feel about it reflects, I think, their concern that we could stop the momentum and that we won’t get to the point that most of the Western world has gotten to, where the electronic systems are routine,” said Dr. David Blumenthal, former national coordinator for health information technology and now chief health information officer at Partners HealthCare.
When Dr. Danny McCormick of Cambridge Health Alliance and his colleagues published a study in March suggesting that doctors using the systems might be more likely — not less — to order costly imaging tests, such as CT scans, critics were quick to dismiss it.
McCormick’s paper used old data, from 2008, not applicable to modern systems, critics said. Dr. Farzad Mostashari, who succeeded Blumenthal as national coordinator, wrote on a blog that the study “tells us little” about how the systems work.
McCormick acknowledged that some critique was warranted, particularly about whether the study did enough to account for variations among doctors and patients. But the reaction, McCormick said, was “not an inquisitive one.” The study “hit a raw nerve,” he said.
Dr. Stephen Soumerai, professor of population medicine at Harvard Medical School, was critical of McCormick’s study design, but he was also dismayed by the reaction.
Researchers must be able to ask, “What if all these machines aren’t good? What if they’re bad?”
Blumenthal said the decision in 2009 to set aside about $27 billion in stimulus money to create a federal program to promote electronic records was “socially correct.” But he said he has concerns about safety, too. While in his federal role, he commissioned a study by the Institutes of Medicine on that topic.
The report, released in November, recommends requiring makers of the systems to report patient injuries or deaths related to the technology to a national database. Jha, who was a member of the panel, said that some vendors now have doctors and hospitals sign gag clauses to prohibit them from reporting problems.
The panel also called for more research, acknowledging a dearth, and an independent body to investigate when something goes wrong, in much the same way the National Transportation Safety Board investigates aviation accidents. If the private sector does not take actions to ensure the systems are safe, the report said, the US Food and Drug Administration should regulate them.
The Office of the National Coordinator for Health Information Technology is taking comments on proposed rules that, if approved in the final version, could establish the reporting database, said David Muntz, principal deputy in that office. And the office is developing a plan for creation of an investigative board, he said.
“We have played a strong role in having the conversation” about safety, Muntz said.
Electronic records are “no magic bullet,” Jha said. “But try to figure out how to improve population health and deliver higher quality and more efficient care without electronic health records. Good luck.”
Making the systems work in ways that protect and promote patient safety will take more than luck, he said. It will take good information.
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