Are EHRs for Population Health or Individual Health?

what-is-a-group-of-cows-called_d87d5c1c-8102-4634-baea-c03e5bd8784f

Each of these cows has a BMI > 30.  One of them is a body builder.

There’s a difference between treating the health of a population and treating the health of an individual.  I’m honestly not sure if that’s a commonly held perception/understanding or not.  Every time someone decries that BMI shouldn’t be used as a general health indicator, this difference between treating populations vs. individuals seems to go unnoticed.  Sure, when looking at an individual the BMI is only one of many variables taken into account when assessing their overall health, but in creating health policy and wondering which part of the population to target for specific initiatives, BMI is a pretty good indicator of who might benefit from such initiatives.

Population Health is concerned with the treatments and behaviors that benefit most of the population, say 80%.  Individual Health, is just concerned about you.  While that last sentence subconsciously made you like the term “Individual Health” more, I can assure you that both are equally important.  Population Health, which we could also call Epidemiology, Public Health, etc. susses out the general patterns that effect health.  Treating individuals based on these generalities provides a level of granularity and deeper understanding that not only helps the remaining 20%*, but also feeds back in to those Population Health recommendations to improve and refine them.  As a quixotic aside, just like over half of drivers feel they are better than average, I’m pretty sure 80% of people feel they are in the 20% of the population where general health recommendations don’t usually work for them.

I’ve long contended that the major benefits of EHRs are really in terms of Population Health.  The whole point of the secret/evil/dastardly/conspiratorial plot by the government to incentivize EHR use was to collect Population Health data more efficiently and potentially create a better pathway to implement Population Health recommendations.  And while one could certainly argue about how well this goal is being achieved and the methods of which are being used, it’s hard to argue that this initiative isn’t having a standardization of care and data collection effect.  The same information is now being collected in the same format from all participating providers and hospitals. Additionally, providers and hospitals are focusing more on improving quality scores from a defined set of quality measures which are all based on public health recommendations.  If there is an overall uptick in these quality scores (and theoretically that means the health of the general population is improving too), that would be a clear indicator that EHRs are a good infrastructure addition for Population Health.

But what about Individual Health?  What have EHRs done at this level?  There isn’t any evidence to show that when your doctor uses an EHR to treat you as an individual, you will be healthier.  That in itself has a little to do with the nature of how statistics work, but it also has to do with the fact that EHRs aren’t really built for how to treat patients when deviating from general recommendations.  Templates, rules, and order sets are all created as general applications, not individually tailored ones.  What EHRs certainly have not been shown to do is to improve the volume and quality of information exchange between the patient and the provider.  Having a more complete picture of the patient and the condition allows a provider to better determine if the course of treatment should be the same as what’s best for the general public or something that deviates to a certain degree.  The modicum of improvement in communication created by the ability for patients to send messages to their providers is a start, but certainly not enough.

If I were to rewrite an article I wrote a long time ago about the hurdles to EHR implementations (and part 2) I would add that it’s going to be a hard sell to your patients that your shiny new EHR is going to help them as individuals.  As a people; as a populous, sure, you can show measurable benefits.  To the individual in the treatment of their own health though?  Not only is that harder to prove, but the aspects of being treated in a healthcare setting that a person notices, namely the quality of communication or the effectiveness of their treatments, hasn’t necessarily improved as a result of an EHR.  In other words, EHRs are kind of like flu shots.  Can your doctor tell you with absolute certainty that you won’t get the flu this year if you get your flu shot? No, but they can tell you with certainty that instances of flu will be down this year if the majority of the population does get their flu shots.  Therefore, when talking about the benefits (potential or realized) of EHRs, I think it’s an important distinction to say Population Health instead of Individual Health or a patient’s health.  Until they are shown to improve communication between a patient and their provider, EHRs will continue to be misunderstood as a tool to improve an individual’s health instead of infrastructure to assist in improving the population’s health.

 

*These percentages are, of course, rough estimates and alluding to the Pareto Principle.  In this example, 80% of all healthcare costs come from 20% of the population and it’s that 20% that either general health recommendations don’t work for them due to other factors or they aren’t following them.  Nowhere near a perfect allusion, but I’m nowhere near perfect. 

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  1. […] the fundamental misunderstanding that EHRs are the solution to taking better care of patients.  EHRs are the solution to gathering better data to develop public health policy.  That’s it. Technology that solves communication and resource allocation problems, which […]



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