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REGIONAL/NATIONAL ELECTRONIC HEALTH RECORDS COST-BENEFIT ANALYSIS: A SYSTEMATIC REVIEW Class 4 4 th June 2012.

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Presentation on theme: "REGIONAL/NATIONAL ELECTRONIC HEALTH RECORDS COST-BENEFIT ANALYSIS: A SYSTEMATIC REVIEW Class 4 4 th June 2012."— Presentation transcript:

1 REGIONAL/NATIONAL ELECTRONIC HEALTH RECORDS COST-BENEFIT ANALYSIS: A SYSTEMATIC REVIEW Class 4 4 th June 2012

2 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/ pdf) 2

3 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) 3

4 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

5 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 SavingsIncreased revenue  Eliminating costs of a storing paper records  Downsizing personnel  Government incentives for use health IT  Pay-for-performance incentives IT – information technology 5 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

6 Barriers to adoption of EHRs (e.g. South Korea) 6 Discussion BarriersHospitals with EHRHospitals 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%

7 7 Discussion FacilitatorsHospitals with EHRHospitals 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)

8 Research Questions 8  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?

9 Aim 9  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…

10 Methods Lucie Rychetnik, Penelope Hawe, Elizabeth Waters, Alexandra Barratt, Michael Frommer. A glossary for evidence based public health. J Epidemiol Community Health2004;58: doi: /jech (17/12/2011) 10 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.

11 Methods 11 How did we create the queries? KEY TERMSSYNONYMOUS EHR Electronic Health Record Electronic Medical Record Electronic Patient Record Personal Health Record Personal Medical Record Computer Patient Record Computer Health Record Computer Medical Record Digital Health Record Digital Medical Record Digital Patient Record Economics Fees Funding Financing Cost  Make an inventory of synonyms of the key terms of the research

12 Methods 12 KEY TERMSSYNONYMOUS Cost-benefit analysis Cost-Benefit Analyses Cost Benefit Analysis Cost Effectiveness Cost-Benefit Data Cost Benefit Benefits and Costs Costs and Benefits National National Health Programs National Health Insurance National Health Services RegionalRegional Health Planning How did we create the queries?  Combine the terms in the query using Boolean operators.

13 Methods 13 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

14 Methods 14 Collecting articles DATABASES TOTAL: 4362  Insert queries in three different Databases

15 Query – PUBMED 15 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))

16 Query – ISI WEB OF KNOWLEDGE 16 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=

17 Query – SCOPUS 17 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))

18 Collecting the Final Articles – Step by step 18 EXCLUSION CRITERIA OF THE FIRST EXCLUSION  1 st : Not mentioning monetary values/ costs;  2 nd : Refering to a single hospital/institution;  3 rd : 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  1 st : Mentioning Electronic Health Records;  2 nd : Mentioning Cost-Benefit Analysis;  3 rd : Referring to monetary values / costs;  4 th : Dealing only with regional and/or national aspects.

19 Methods 19  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

20 Methods 20 Selection of the Articles - STEPS  Repeated: 1425  Not articles: 316

21 Methods 21 Selection of the Articles - STEPS

22 Methods 22 Selection of the Articles - STEPS

23 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 23 Methods

24 Countries where the systems were implemented 24 Results

25 Date of article publication 25 Results

26 26 Results Institutions involved

27 Type of data integrated 27 Results

28 User groups 28 Results

29 Financing Agents 29 Results

30 Initial Investment and Cost Savings 30 Results Date of the study Initial Investment ($/per year) Cost savings ($/per year) ∆ (Cost savings–Initial investment) million million million million – million million million – 2900 million million – million million million – million – 350 million million

31 Initial Investment and Cost Savings 31 Results Date of the study Initial Investment ($/per year) Cost savings ($/per year) ∆ (Cost savings–Initial investment) million million million million million million million million million million million (public hospitals) (private payers) – 40 million million million

32 32 Conclusions per year.  In terms of cost savings, we studied them per year. 24 billion dollarshighest value 77.8 billion dollars  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 dollars. 22 billion dollars were saved  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.

33 33  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, billion, 1-2 million or 154,900 per year. Conclusions

34  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 34 Conclusions

35 35 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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