Why EHRs could increase health costs

Doctors who are fed up with the state of today's electronic health records (EHR) technology have some new friends in a group of six Republican senators.

The senators recently released a report that blasts the federal government's efforts to spur health information technology adoption, warning that "current [health information technology (HIT)] policy may be headed in exactly the wrong direction."

The report cites five major concerns with the Health Information Technology for Economic and Clinical Health (HITECH) Act, a 2009 law that appropriated $35 billion to promote the use of HIT by physicians, hospitals, and other health providers. Those concerns are lack of interoperability among EHR systems, increased costs, lack of oversight, risk to patient privacy, and a lack of clarity on the program's sustainability.

"Nearly 4 years after the enactment of the HITECH Act, and after hundreds of pages of regulations implementing the program, we see evidence that the program is at risk of not achieving its goals and that $35 billion in taxpayer money is being spent ineffectively in the process," the report states.

Rather than focusing on all five of the GOP senators' complaints, we'll explore the one that exacerbates what's already arguably the greatest problem in U.S. healthcare: Its crushing costs when compared with other countries.

The report highlights two aspects of EHRs that could lead to higher health costs: "code creep" and increased medical errors due to copied records.

Code creep: Also known as upcoding, this potential problem received some attention last year when former Centers for Medicare and Medicaid Services (CMS) Chief Donald Berwick, MD, MPP, wrote an editorial in JAMA warning about "coding games" in which providers adjust medical codes to maximize financial returns on patient encounters. The report cites a New York Times article that discusses how EHRs make it easier for users to to automatically and quickly copy and paste detailed patient histories, making it appear that the user conducted a more thorough review than what actually happened.

"Evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services," the Times noted, citing a Rand Corp. study.

The Senate report also cites another JAMA study that found that EHRs were associated with the increased use of clinical services, and, separately, the report suggests that some portion of increased billings to Medicare in recent years can be attributed to more widespread EHR use. Although the report avoids direct criticism of physicians in noting that code creep may be unintentional, it points the finger at CMS for not taking the issue seriously enough.

"While there is currently a lack of conclusive data that can authoritatively answer all relevant questions about the code creep phenomenon, it is clear CMS is not doing enough to address the issue," the report says.

Increased medical errors due to "cloned" records: Here's where EHR's "automated copy-and-paste process" rears its head again. The senators warn that such processes "represent a significant increase in the risk of medical errors by potentially including inaccurate, old, or out-of-date patient information in a patient record that can jeopardize patient safety and increase costs."

The report is careful to note that copying-and-pasting "in not inherently wrong," but the process "deserves careful scrutiny" as a potential benefit and risk of increased EHR use.

"More needs to be done to ensure that the software programs that are sold by government-endorsed vendors and paid for by taxpayer dollars are held to the highest standards and promote the ultimate end goal of safely and effectively sharing health information," it states.

Although it's certainly fair to cite copying and pasting as a concern that needs further study, it's less clear whether copying and pasting actually contributes to medical errors and puts patients at harm. Tellingly, the GOP report cites no research that shows evidence of patient harm as a result of copied-and-pasted EHR records.

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