Do EHRs and Clinical Decision Support Improve Quality of Care?

In a January 24, 2011 study published by Stafford et al in the Archives of Internal Medicine, the authors analyzed physician survey data on 255,402 ambulatory patient visits in ambulatory settings (non-Federal offices and hospitals) using 2005–2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data. They concluded that based upon 20 previously developed quality indicators and in relation to the provision of guideline concordant care using regression analysis, they could not detect significant quality differences when EHRs and Clinical Decision Support were used vs. when they were not used based upon 19 out of 20 quality measures.

The authors recognize that there are some limitations to their data analysis including the recency of the data. As the data studied was for the period 2005–2007, it may not reflect current practice patterns. In addition, the use of cross-sectional, visit-level data did not allow for assessment of longitudinal care, one of the areas in which we anticipate EHRs to return greater value.

Are these results surprising? If true, why the massive investment in healthcare IT including EHRs if there is no mechanism to improve quality of care?

Preliminary data from the 2010 National Ambulatory Medical Care Survey (NAMCS) indicated that “Excluding 27 states with unreliable estimates, the percentage of physicians having systems that met the criteria of a fully functional system across the United States ranged from 9.7% to 27.2%.” However when one looks back at 2006–2007, the number of physicians with fully functional EHRs ranged from 3.1% to 3.8%. Meaning that a large majority of physicians with basic or any EHR system lacked the advanced capability at that time to use their systems to manage elements of care that we recognize as quality measures.

The study recommended a need for greater attention to quality control and coordinated implementation in order to to realize the potential of EHRs and CDS to improve healthcare. In an earlier posting on the Patient Centered Medical Home, Dr. Michael Barr recognizes the need for changes in the culture of healthcare delivery as well as the design and implementation of health information technology to facilitate models of care that can be aligned to quality improvement.

EHRs alone will not solve quality issues associated with systemic deficiencies that need to be corrected. A detailed and comprehensive approach will be necessary that brings together the people, processes, and technology as these programs evolve.

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.

Comments:

3 responses to "Do EHRs and Clinical Decision Support Improve Quality of Care?"
  • January 26, 2011
    Michael S. Barr, MD, MBA, FACP (ACP)
    said:

    The lack of a clear, positive clinical effects of CDS on quality has been shown in other studies, too – which raises several questions. Assuming the evidence-basis for the CDS recommendations is well-represented by the clinical decision support system, we should ask:
    1) How are CDS recommendations presented to clinicians and their teams?
    2) Are the CDS recommendations sufficiently adjusted to account for the unique clinical needs of an individual patient and his/her preferences? If so, are the metrics of quality also modified to measure outcomes based on the adjusted and individualized priorities?
    3) Are our measures of quality adequate to discern the effectiveness of the CDS guidance?
    4) Is there a way to appropriately involve patients (and their families/caregivers when appropriate) in the review/implementation of guidance provided by CDS?
    This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.

  • January 27, 2011
    Dr. Alan Brookstone (Cientis)
    said:
  • February 11, 2011
    Michael S. Barr, MD, MBA, FACP (ACP)
    said:

    Dr. Peter Basch posted an interesting response to this Archives of Internal Medicine article on the Health Affairs Blog at: http://healthaffairs.org/blog/2011/02/11/the-case-for-meaningful-use-strengthened-not-weakened/. Entitled, “The Case for Meaningful Use Strengthened, Not Weakened,” Dr. Basch states, “The implications of this 2009 paper for EHR research are abundantly clear. EHRs developed and used within the current “vicious cycle” can all but be guaranteed to show no improvement in quality. The technology was not designed to improve quality, but rather to support documentation and billing.” He then goes on to point out that, “…rather than calling into question the meaningful use program, this study actually supports its use.”
    The post by Dr.Basch puts the Archives article into perspective and highlights the challenges ahead…never mind changing the payment system to anchor those changes – the closing point of his article.

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