regional/national ele ctronic health records cost-benefit analysis: a systematic review
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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
24
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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