Electronic health record use and the quality of ambulatory care in the United States

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Introduction/Question – The authors used data from the National Ambulatory Medical Care Survey (NAMCS), to determine if there is a correlation between the use of an electronic health record (EHR) and the quality of ambulatory patient care. NAMCS collects information from U. S. non-federally funded, community, office-based practices.

Methods: The authors completed a retrospective analysis of data from the 2003 and 2004 NAMCS, calculating EHR usage across the U.S. and checking for an association between this usage and 17 ambulatory care quality indicators, such as medical management of common diseases, anti covered medical management of common diseases, antibiotic prescribing, preventive counseling, screening tests and other services. Quality indicator performance was equal to the percentage of applicable visits receiving the recommended care.

Main results: This extensive study showed no consistent correlation between EHR use and quality of ambulatory care. EHR use was associated with higher quality care in only 2 of 17 indicators, while EHR use made no difference in performance on14 quality indicators. For one indicator, that of statin prescribing for high cholesterol, EHR use was associated with poorer quality.

Conclusion

This study showed no association between the use of EHRs and improved quality of ambulatory care. However, the EHRs used in the community practices covered in this study may have been less robust and lacking in clinical decision support features found in benchmark institutions whose systems have been shown effective in improving quality of care. Also, the physicians studied may not have been using decision support even if available. Study limitations include a relatively small sample size for some of the indicators; results dependent on accurate coding on the NAMCS; possible negative confounders hiding a correlation between EHR use and quality care; and variation among the survey participants in the definition of an EHR.

Commentary

This carefully done study by leaders in the field was reported by some in the media as indicative of the failure of computerized patient records to improve quality of care (1). However, the authors here show a lack of correlation between EHR use and quality, but not necessarily causation. The study may simply be demonstrating how inadequate decision support implementation or lack of usage incentives can result in little or no impact on quality of care. Since many past studies have demonstrated the positive effect of such systems on error rate and practitioner performance, it is likely that as the authors indicate, their results “are not a refutation of previous studies”, but suggestive that as EHR use increases, one cannot assume automatic improvement in quality of care. Informaticians and decision makers need to consider all the steps necessary to ensure that these systems will have the desired effect.

References

  1. Sarasohn-Kahn, J..“EHRs, Media and Statistics: Misinterpreted Results Skew Understanding,” iHealthbeat, California Healthcare Foundation, July 31, 2007. Available from: http://www.ihealthbeat.org/articles/2007/7/31/EHRs-Media-and-Statistics-Misinterpreted-Results-Skew-Understanding.aspx?ps=1&authorid=1572