Kaiser Study on EHR Efficiency: We Are Not The World

A study that shows how the use of electronic health records and connectivity with patients has made Kaiser Permanente more efficient also points to something of equal importance: why EHRs might not add much efficiency to the rest of the U.S. healthcare system unless it's restructured.

Published in Health Affairs, the study measured the impact of implementing an EHR in the Hawaiian division of Kaiser Permanente, which has about 225,000 members. (Nationally, the giant group-model HMO covers 8.6 million people.) Between 2004 and 2007, the office visit rate in Kaiser's Hawaii region dropped 26.2 percent. During the same period, "scheduled telephone visits" increased more than eightfold, and secure online messaging, which began in late 2005, rose nearly 600 percent.

The major reason for the decrease in office visits to both primary care doctors and specialists, says co-author and senior Kaiser consultant Louise Liang, is that, with complete patient information available to them in the EHR, physicians can respond to patients' questions about minor problems without seeing them in person. They can do this either online, if patients send questions through the HMO's secure e-mail system, or on the telephone, when they respond to patient calls at a scheduled time. These modes of patient contact don't lower either patient satisfaction or the quality of care, the study found.

When examined more closely, the drop in office visits had as much to do with these communication methods as with the use of an EHR. In 1999, nearly all doctor-patient contacts occurred in the office setting. In 2007, however, office visits accounted for only 66 percent of total contacts. Telephone "visits" represented 30 percent, and online consultations accounted for the remaining 4 percent. The decision of Kaiser to provide physicians and patients with the tools they needed for these alternate modes of contact directly affected how they communicated with each other.

One other point: The percentage of Kaiser members who seek online contact with their physicians is rising: Liang says that it is now 11-12 percent nationwide. One reason why more patients are e-mailing their doctors is that all Kaiser physicians respond to them, says Liang. Altogether, 31 percent of Kaiser members use its KP Connect online system for messaging with physicians, prescription refills, appointment requests, or viewing lab results, she adds.

So what are the lessons for the rest of the country? First, as Liang notes, most non-Kaiser physicians in the private sector are unlikely to use EHRs in the way that Kaiser does, because their financial incentives discourage non-visit care. In fact, when fee-for-service physicians contact patients outside of visits, they lose money. So a very low percentage of doctors are online with their patients or on the phone with them.

Also, as the Congressional Budget Office has pointed out, large, integrated systems like Kaiser and the VA system reap the benefits when physicians use EHRs to increase efficiency, not only by reducing office visits, but also by avoiding redundant tests and writing more prescriptions for generic drugs. Even if EHR adoption increases markedly, other physicians will not necessarily benefit from increased efficiency; instead, payers will benefit. So it's an open question how much health IT is going to reduce costs or improve quality in the fragmented, fee-for-service world in which most health care is delivered in America.