REGIONAL/NATIONAL ELECTRONIC HEALTH

RECORDSCOST-BENEFIT ANALYSIS:

A SYSTEMATIC REVIEW

Class 4 aturma4@gmail.com4th June 2012

CONCEPTS: Electronic Health Records

“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

Introduction

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

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Introduction CONCEPTS: Cost-Benefit Analysis

“a method of comparing the cost of a

program with its expected benefits in dollars

(or other currency); 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)

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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

Costs and benefits: economic issues Introduction

Investment budget

Costs versus benefits

- 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 Downsizing personnel

Government incentives for use health IT Pay-for-performance incentives

IT – information technology

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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

Barriers to adoption of EHRs (e.g. South Korea)

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Discussion

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%Lack of capacity to select, contract for, and implement an EHR system 11.1% 2.9%

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Discussion

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

Facilitators of adoption of EHRs (e.g. South Korea)

http://aep.ist.utl.pt/divulgacao/publicacoes/

Research Questions

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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?

Aim

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To review the published literature regarding the

financial costs and benefits of regional or national

Electronic Health Records.

Find out which records characteristics are associated to a bigger

investment return.

Measure the differences relating to the return of investment between

all regions.

With this, we intend to…

Methods

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)

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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 sub-

questions 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.

Methods

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How did we create the queries?

KEY TERMS SYNONYMOUS

EHR

Electronic Health RecordElectronic Medical Record Electronic Patient RecordPersonal Health RecordPersonal Medical RecordComputer Patient Record Computer Health Record Computer Medical Record Digital Health RecordDigital Medical RecordDigital Patient Record

EconomicsFeesFundingFinancingCost

Make an inventory of synonyms of the key terms of the research

Methods

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KEY TERMS SYNONYMOUS

Cost-benefit analysis

Cost-Benefit AnalysesCost Benefit AnalysisCost EffectivenessCost-Benefit DataCost BenefitBenefits and CostsCosts and Benefits

NationalNational Health ProgramsNational Health InsuranceNational Health Services

Regional Regional Health Planning

How did we create the queries?

Combine the terms in the query using Boolean operators.

Methods

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How did we create the queries?

Establish limits on the search

Query with LIMITS

Subject areas

Languages

Timespan

Limit the search to articles in:

English French

Limit the search to the timespan:

1994 to 2012

Excluded articles on: Maths Veterinary Sciences History Anthropology Chemistry Physics

Architecture Geography Linguistics Religion Zoology

Methods

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Collecting articles

DATABASES

851 1312 2199

TOTAL: 4362

Insert queries in three different Databases

Query – PUBMED15

Methods

(("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))

Query – ISI WEB OF KNOWLEDGE

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Methods

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.

Query – SCOPUS17

Methods

(("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 LIMIT-TO(LANGUAGE, "French")) AND (LIMIT-TO(PUBYEAR, 2012) OR LIMIT-TO(PUBYEAR, 2011) OR LIMIT-TO(PUBYEAR, 2010) OR LIMIT-TO(PUBYEAR, 2009) OR

LIMIT-TO(PUBYEAR, 2008) OR LIMIT-TO(PUBYEAR, 2007) OR LIMIT-TO(PUBYEAR, 2006) OR LIMIT-TO(PUBYEAR, 2005) OR LIMIT-TO(PUBYEAR, 2004) OR LIMIT-TO(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 LIMIT-TO(PUBYEAR, 1995) OR

LIMIT-TO(PUBYEAR, 1994))

Collecting the Final Articles – Step by step

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EXCLUSION CRITERIA OF THE FIRST EXCLUSION1st: Not mentioning monetary values/ costs;2nd: Refering to a single hospital/institution;3rd: Refering to a group of services in a certain

hospital.

Methods

Exclude the repeated articles Exclude the non-real articles (ex: letters, conversations, news) First exclusion by abstract with two revisors

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

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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

Collecting the Final Articles – Step by step

Methods

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Selection of the Articles - STEPS

Total of articles only with the real ones

Total of articles without the repeated ones

Total of documents found

2621

2937

4362

Repeated: 1425

Not articles: 316

Methods

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Total of articles after the year 2008

Total of articles included by both revisers

Total of articles

147

306

2621

Selection of the Articles - STEPS

Methods

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Articles included by both revisors

Articles after contact with authors

Full-text articles available

Total of articles after the year 2008

48

111

105

147

Selection of the Articles - STEPS

Variables

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

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Methods

Countries where the systems were implemented

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Results

87.23

2.13

2.13 2.13 2.13 2.13

U.S.A.South KoreaJapanNorwayIndiaU.K.

Date of article publication25

Results

8.51

19.15

42.55

27.66

2.13

20082009201020112012

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Results Institutions involved

6.38

8.5121.28

Hospitals and clinics

Up to 500 hospitals

More than 1000 hospitals

Type of data integrated27

Results

2.13

2.13

2.13

2.13

19.15

Ficancial data

Nurse data

Primary care

Specific area

All data on the pa-tient

User groups28

Results

12.77

6.38

2.13

42.55

Medical Staff

Doctors

Patients and med-ical staff

All hospital services

Financing Agents29

Results

42.55

4.26

2.13

Government

Private institu-tion

Government and private institution

Initial Investment and Cost Savings

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Results

Date of the study

Initial Investment ($/per year) Cost savings ($/per year) ∆ (Cost savings–

Initial investment)2009 60 million

2010 19 000 million

2009 77 800 million

2011 30 000 million

2009 0.034 – 0.039 million

2009 19 000 million

2012 2700 million

2008 2200 – 2900 million 81 000 million 78 800 – 83 900 million

2010 77 000 million

2010 59.2 million

2010 0.011 – 0.033 million

2011 40 – 350 million2010 19 200 million

Initial Investment and Cost Savings

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Results

Date of the study

Initial Investment ($/per year) Cost savings ($/per year) ∆ (Cost savings–

Initial investment)2009 0.0464 million

2010 20 000 million

2011 32 000 million

2010 28 000 million 81 000 million 53 000 million

2009 31.4 million

2009 2 -10 million

2010 0.63 million

2010 130 000 million

2011 20 000 million (public hospitals)30 000 (private payers)

2009 30 – 40 million

2010 32 000 million

2010 17 200 million

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Conclusions

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.

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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

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

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Conclusions

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Conclusion

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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