The role of clinical information systems in health care quality improvement

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Harrison JP, Palacio C. The role of clinical information systems in health care quality improvement. Health Care Manag (Frederick). 2006 Jul-Sep;25(3):206-12.

This paper discusses the current usage of, and benefits and barriers to the implementation of the EMR and its associated clinical information system. Harrison builds his argument that EMRs are necessary on a foundation of studies that show substandard care in situations where it is not used. He cites a study by McGlynn et al that suggested that only 55% of participants received indicated care, and another study by Asch et al that suggested that 60% of VHA patients (where virtually 100% of patient care involves an EMR) received indicated care vs. only 39% of a national sample. In order to give further evidence of the need for EMRs he cites the 2000 IOM report, and a paper by Bates and Gawande that IT can decrease errors by the use of software to identify ADEs, provide electronic reminders, allow CDS, and CPOE. Ghandi et al suggest that it is a system problem and that simply “exhorting” physicians to do better is not the answer. Other papers are cited that support the use of EMRs with supporting CISs, and in particular the use of “embedded practice guidelines, query functions, prompts, reminders, and messaging”. There is a brief but helpful description of the Veteran’s Health Administration’s EMR, VistA, and notes that the VHA system is Free and Open source Software. In addressing the barriers to implementation of CISs Harrison notes that Valdes et al say that fewer than 10% of all health care systems make significant use of digital technology despite the fact that integrated CISs reduce medical errors and lower cost, and they suggest the use of Free and Open Source Software as a solution to interoperability. Wang et al is cited as showing statistics that demonstrate how woefully behind much of the rest of the industrialized world America is when it comes to the Electronic Medical Record. Several sources are cited that indicate that while the upfront cost of the EMR is high it saves money and lives in the long run. Some of the doctors that are expected to front the cost of EMRs will benefit financially the least from it. Mention is made of the 2005 HIMSS Analytics database where 4000 U.S. hospitals were surveyed about their hardware, software and IT infrastructure. It reported that only 8 U.S. hospitals were using all the components of the CPOE system. Managerial Implications included: 1) The HIMSS data demonstrate that hospitals without CISs may be missing an opportunity to improve efficiency thereby generating cost savings. 2) The more integrated a system becomes (ISDN) the more an EMR is necessary. 3) Barriers include potential downtime, HIPPA requirements, and additional burdens for an already overworked staff. 4) Lack of integration among IT vendors.

Policy implications included: 1) EMRs supported by CIS have the potential to improve both the efficiency and quality of care in both the inpatient and outpatient medical delivery system. 2) There are well-documented shortcomings in the accuracy, completeness, availability, and legibility of paper medical records. 3) Real-time information available at the point of care to multiple users improves health care quality. 4) The VHA and Keiser provide excellent examples of the benefit of EMRs and supporting CISs. 5) A recent HIPAA regulation provided a standard electronic framework for electronic claims submission, thereby encouraging the adoption of CISs. 6) Use of CISs may help reduce malpractice costs. Mark Mench 10/31/06