By Ashly D. Black, Josip Car, Claudia Pagliari, Chantelle Anandan, Kathrin Cresswell, Tomislav Bokun, Brian McKinstry, Rob Procter, Azeem Majeed, Aziz Sheikh
PLoS Medicine
January 18, 2011
Editors’ Summary
Background
There is considerable international interest in exploiting the potential of digital health care solutions, often referred to as eHealth — the use of information and communication technologies — to enhance the quality and safety of health care. Often accompanied by large costs, any large-scale expenditure on eHealth — such as electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems — has tended to be justified on the grounds that these are efficient and cost-effective means for improving health care. In 2005, the World Health Assembly passed an eHealth resolution (WHA 58.28) that acknowledged, “eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research,” and urged member states to develop and implement eHealth technologies. Since then, implementing eHealth technologies has become a main priority for many countries. For example, England has invested at least £12.8 billion in a National Programme for Information Technology for the National Health Service, and the Obama administration in the United States has committed to a US$38 billion eHealth investment in health care.
Why Was This Study Done?
Despite the wide endorsement of and support for eHealth, the scientific basis of its benefits — which are repeatedly made and often uncritically accepted—remains to be firmly established. A robust evidence-based perspective on the advantages on eHealth could help to suggest priority areas that have the greatest potential for benefit to patients and also to inform international eHealth deliberations on costs. Therefore, in order to better inform the international community, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery.
What Did the Researchers Do and Find?
The researchers divided eHealth technologies into three main categories: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. Then, implementing methods based on those developed by the Cochrane Collaboration and the NHS Service Delivery and Organisation Programme, the researchers used detailed search strategies and maps of health care quality, safety, and eHealth interventions to identify relevant systematic reviews (and related theoretical, methodological, and technical material) published between 1997 and 2010. Using these techniques, the researchers retrieved a total of 46,349 references from which they identified 108 reviews. The 53 reviews that the researchers finally selected (and critically reviewed) provided the main evidence base for assessing the impact of eHealth technologies in the three categories selected.
In their systematic review of systematic reviews, the researchers included electronic health records and picture archiving communications systems in their evaluation of category 1, computerized provider (or physician) order entry and e-prescribing in category 2, and all clinical information systems that, when used in the context of eHealth technologies, integrate clinical and demographic patient information to support clinician decision making in category 3.
The researchers found that many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence. The evidence base in support of eHealth technologies was weak and inconsistent and importantly, there was insubstantial evidence to support the cost-effectiveness of these technologies. For example, the researchers only found limited evidence that some of the many presumed benefits could be realized; importantly, they also found some evidence that introducing these new technologies may on occasions also generate new risks such as prescribers becoming over-reliant on clinical decision support for e-prescribing, or overestimate its functionality, resulting in decreased practitioner performance.
What Do These Findings Mean?
The researchers found that despite the wide support for eHealth technologies and the frequently made claims by policy makers when constructing business cases to raise funds for large-scale eHealth projects, there is as yet relatively little empirical evidence to substantiate many of the claims made about eHealth technologies. In addition, even for the eHealth technology tools that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. Therefore, in light of the lack of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, the authors say that future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology’s life cycle, and include socio-technical factors to maximize the likelihood of successful implementation and adoption in a given context. Furthermore, it is equally important that eHealth projects that have already been commissioned are subject to rigorous, multidisciplinary, and independent evaluation.
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000387#pmed.1000387-Garg1
Comment:
By Don McCanne, MD
Digital health care solutions, or eHealth, include electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems. These researchers performed a systematic review of the systematic reviews of eHealth published since 1997, providing us with a perspective of the impact that eHealth has had on the quality and safety of health care.
What did they find?
“Our systematic review of systematic reviews on the impact of eHealth has demonstrated that many of the clinical claims made about the most commonly deployed eHealth technologies cannot be substantiated by the empirical evidence. Overall, the evidence base in support of these technologies is weak and inconsistent, which highlights the need for more considered claims, particularly in relation to the patient-level benefits, associated with these technologies. Also of note is that we found virtually no evidence in support of the cost-effectiveness claims.”
This is of particular importance right now as health care providers and institutions are gearing up to establish accountable care organizations (ACOs), as called for in the Patient Protection and Affordable Care Act (PPACA). Although various models of ACOs are being developed, all of them have in common interconnectivity through eHealth. In fact, the simplest form is the so-called virtual ACO which is nothing more than isolated, independent practices connected through eHealth.
Since eHealth provides the fundamental framework through which ACOs function, it is important to be sure that we have it right. But w
e’re not certain. The authors report that eHealth systems have proven to be beneficial when carefully designed in house for a handful of large institutions, but the evidence is simply not there for most systems in use today.
The reason that our politicians included ACOs in the PPACA is that theoretically they would help to control health spending primarily through the transparencies, efficiencies and error reduction of eHealth. Yet there is “virtually no evidence in support of the cost-effectiveness claims.”
We have to get health care costs under control. Maybe someday eHealth will help with that, but we’re definitely not there now. It is certainly fine to continue with studies of ACOs and eHealth, but for cost containment, we should move immediately to policies that have been proven to be effective – a single payer national health program, aka an improved Medicare for all.