This case study, published by BSR’s Center for Technology and Sustainability, examines the environmental benefits and impacts of health IT. Through case studies, the Center for Technology and Sustainability helps companies understand how to apply technology to solve sustainability challenges, credibly measure and communicate sustainability and business benefits, manage change, and successfully implement new approaches.
The introduction of information technology (IT) into a healthcare context continues to radically shift how healthcare is delivered. Patients today expect to be able to communicate with their doctors virtually and to do many of the healthcare tasks online that previously took place in person, such as answering questions, refilling prescriptions, and more. On the healthcare-delivery side, health IT enables the integration of patient records, providing ready access to information for doctors and patients alike.
In addition to the obvious health benefits, research to date shows that health IT can lessen environmental impacts by reducing the need for patient transportation and by reducing the amount of paper used in medical records. In turn, the electronics used in health IT use energy, create waste during manufacturing and end-of-life, and contain a variety of potentially hazardous chemicals and materials.
The Center for Technology and Sustainability supports the development, demonstration, and adoption of technology-based sustainability solutions for a variety of industries.
This case study focuses on technology demonstration, by reviewing and adding to work done by Kaiser Permanente (Kaiser) on the environmental impacts of its electronic health records system. Work to measure the net benefits of IT in electronic health has been limited to date, with Kaiser conducting the first major study in this area.
This case study was based on interviews with Kaiser staff, BSR analysis, and published material related to Kaiser’s activities as well as the broader benefits IT brings to healthcare. With this study, the Center for Technology and Sustainability aims to advance the measurement of environmental impacts and benefits from health IT. With better sustainability measurement, companies in the healthcare sector will be able to make decisions about technology not only based on business impacts, but also on the ability of this technology to drive social and environmental benefits. In addition, companies in the technology sector will be able to quantify the environmental impacts of their healthcare technologies.
Because Kaiser Permanente was an early adopter of electronic health records (EHR) and health IT, the company has already addressed questions other companies are only now facing about the net environmental benefits of such systems. It was clear to Kaiser staff that electronic records reduce the need for paper use, but the members of Kaiser’s Environmental Stewardship Council wondered whether this benefit would be offset by potential negative environmental impacts from increased computer use.
Kaiser’s decision to invest in health IT was made based on rigorous business assessment and a quantitative evidence base. An understanding of the social and environmental impacts was one part of understanding the total cost of these systems.
Kaiser employees undertook a quantitative study to understand these environmental impacts, working with staff throughout the organization and in partnership with Kaiser’s Environmental Stewardship Council.
Because no previous studies of this type had been conducted on health IT, Kaiser developed the model for assessing net environmental benefits over approximately one year, including model development, data collection, internal review, and external review. One staff person led the work part-time, with some additional assistance for field work (such as measuring the weight of charts) and analysis.
Kaiser then published the findings of this study in the journal Health Affairs, in order to help others understand the net benefits of health IT and, if desired, apply Kaiser’s approach to their own organization. This case study focuses on the business impacts of this work and updates the analysis for 2015.
The positive environmental benefits of EHR included avoided paper use, avoided patient transportation, avoided chemical use, avoided plastic waste from x-rays, and avoided water use. The study also highlighted a number of negative environmental impacts such as increased energy use, increase in plastic waste, and an increase in chemical waste.
The study found that, by far, the biggest positive environmental benefit of health IT was the fact that patients needed to take significantly fewer vehicle trips to the doctor’s office. On the other hand, the biggest negative environmental impact came from the increased energy use from computers and electronic systems.
Business benefits seen from the integration of health IT include reduced expenditures on paper use, records transportation, and chemical purchase and disposal. Additional financial savings, such as reductions in patient transportation, are not captured within the Kaiser system but are enjoyed by patients.
Measuring the environmental benefits of a particular technology is a three-step process:1
- Define Scope
- Prioritize Impacts
- Conduct Assessment
1. Define Scope
As an initial step, it is important to identify the purpose and scope of the study. The business processes impacted by the use of information technology must be assessed, along with a qualitative review of the environmental implications of these changes.
To assess the environmental impact of EHR, Kaiser identified four focus areas: (1) reductions in paper use, (2) changes in patient travel, (3) increased use of personal computers and data centers, and (4) changes in x-ray use (from chemical to digital processing).
There are a number of different frameworks used for defining the environmental priorities and impacts of healthcare, including the Global Green and Healthy Hospitals Agenda, Practice Greenhealth’s Eco-Checklist, and the Sustainability Accounting Standards Board’s Health Care Standard. Environmental issues that these frameworks identify as most relevant for the healthcare sector include chemicals, waste, energy, water, transportation, food, and green building. Kaiser used the Eco-Health Footprint, a 2009 report outlining the major impacts associated with healthcare.
2. Prioritize Impacts
An important part of any modeling exercise is determining what to include and what not to include either because data is not available or because the impacts are not significant when considered relative to other aspects of the model. There is often limited data available, especially in early stages of developing an environmental-impacts model, so it is important to start with the most significant impacts.
Kaiser’s study focused on the impact of EHR in four environmental impact areas: (1) greenhouse gases, (2) toxic chemicals, (3) waste production, and (4) water use. Kaiser excluded two environmental impact areas—the use of land for buildings and the emission of air pollutants like ozone, particulate matter, and sulfur dioxide—in order to focus on the four largest and most direct environmental impacts connected to the use of electronic health records.
3. Conduct Assessment
The final step in the model is to quantify the environmental costs and benefits of each business-process change through a combination of primary and secondary data. This should include the documentation of any assumptions made and key areas of uncertainty. Most importantly, it is crucial to assess what decisions can be made or changed as a result of the analysis.
Benefits Depend on Application
One of the most significant findings of Kaiser’s work is that the net environmental benefits of health IT depend significantly on how the organization uses the technology. A system like EHR can be used as a straight one-for-one substitution for paper use, or it can enable significant changes to delivering patient care. Also, an organization like Kaiser Permanente has several opportunities for using EHR for integrated care than would a stand-alone doctor’s office.
The Biggest Benefits Come From Rethinking the Business
If a technology enables significant transformations in how the business is operated or its services are delivered, the environmental benefits can be very large. Instead of thinking of technology as a one-for-one substitution of computers for paper-based records (which represents some modest savings in paper), Kaiser found when they thought more broadly about the transformative role of technology, they found the biggest environmental benefits. For example, adjusting business processes so that patients could interact with doctors online reduced the number of patient vehicle trips. For companies looking to apply technology, understanding the new business processes that the technology enables is a great place to start.
Concrete Measurement Improves Decision Making
This assessment helped Kaiser staff better recognize the environmental impacts, both positive and negative, of its technology decisions. Cost and quality of care are the dominant drivers of its IT systems, but a full understanding of environmental impacts helped increase awareness about these issues within the organization and gave staff a basis on which to make decisions. For example, all patients receive an after-visit summary; after assessing the environmental impacts, Kaiser provided an option for patients to receive this electronically instead of in printed form.
Assessment Requires Both Secondary and Primary Data
Much of the data used in the study already existed in the public domain. However, one challenge in conducting the study was identifying methods to obtain some key source data, such as avoided paper use and avoided patient transportation. These required the collection of primary data, including the number and types of IT equipment, the weights of paper charts, the average distance between Kaiser facilities and patient residents, and more. In addition, Kaiser had published several previous studies on the impact of EHR on the number of in-person patient visits; we used these studies as part of the analysis.
As healthcare is increasingly offered virtually, we will see further environmental benefits, such as a reduced need for clinical space and an even further reduction in patient transportation.
There are two major focus areas to consider for future measurement efforts. First, computers today have lower energy use and environmental impacts than they did in 2011, when the study was conducted.
Second, there is an opportunity to expand the analysis to include other significant impacts of health IT. Aspects that were not included in Kaiser’s initial model, but which may create environmental and other benefits, include the potential to reuse floor space previously utilized for storing paper records, as well as reductions in vehicle use to transport records from site to site. The lack of paper records, for example, means that storage rooms no longer need to be heated and cooled, and being able to reuse space could potentially delay the need for additional building construction.
It is clear that the future of healthcare includes significant technology-based solutions. There is hardly an aspect of healthcare that hasn’t changed as a result of health IT, starting with electronic records but extending far beyond. As healthcare is increasingly offered virtually, we will see further environmental benefits, such as a reduced need for clinical space and an even further reduction in patient transportation. Future assessments of environmental benefits from health IT should look at these wider, more systemic impacts, especially as healthcare organizations become more integrated in the face of a changing business environment and regulatory models.
1Adapted from Global e-Sustainability Initiative (2010), “Evaluating the carbon-reducing impacts of ICT: An assessment methodology.”