The Relationship between Electronic Health Record Use and Quality of Care over Time
These are systematic review of the article entitled “The Relationship between Electronic Health Record Use and Quality of Care over Time” by Li Zhou
- 1 Abstract
- 2 First review
- 2.1 Methods
- 2.2 Results
- 2.3 Discussion
- 2.4 Conclusion
- 2.5 Comments
- 3 Second Review
- 4 References
- 5 Related Articles
- Objective: Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability.
- Methods: The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care.
- Results: The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses.
- Conclusions: In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.
Electronic health records(EHRs) have a great likelihood to enhance the quality of health care by offering real-time access to patients’ health information, tracking patients over time to make certain that they obtain guideline-recommended care, and offering decision-support mechanisms to minimize medical errors. However studies suggest that that simply having an EHR may not be adequate enough to improve quality and safety of health care. Additionally, it is possible that quality and safety benefits of EHR adoption and use may be time-dependent, perhaps taking several years after implementation to take place, as users become more knowledgeable about EHR applications. This article evaluated how the quality of care delivered in ambulatory care practices varied according to duration of EHR adoption and usage.
The study design involved two data sources: (1) a statewide survey of physicians’ adoption and use of EHR and (2) statewide data on physicians’ quality of care as indicated by their performance on widely used quality measures.
Statewide Survey of Physicians’ Use of Electronic Health Records
1,181 respondents were surveyed for this portion of the analysis. Respondents specified how long they had been associated with their main practice and if their main practice had an EHR. If a practice was presently using an EHR, respondents specified when their practice first began using it and designated which EHR features were available and, if available, the degree to which they used each feature. Also, in order to evaluate financial considerations, respondents were asked to signify whether their practice’s income or their personal earnings were eligible for incentive payments for quality of care, patient satisfaction, adoption of health information technology (HIT), or actual use of HIT.
Statewide Data on Physicians’ Quality of Care
Four years of data was collected on 445 physician respondents pertaining to n six previously defined clinical categories of quality from 2001-2005. If a physician pointed out in the 2005 survey that a feature was available in his or her EHR system, the author assumed that the feature had been available since the time when the practice first began using an EHR. The same theory was also applied to the extent of usage of the EHR feature. Based on these assumptions, projections for EHR adoption and availability and use of EHR core functions by year were obtained.
Characteristics of Survey Respondents
Physicians practicing in a metropolitan setting and in groups with more physicians were found to be more likely to have an EHR.
EHR Adoption and Use of EHR Functions
137 physicians provided the year in which their practice first began using an EHR. By 2005, the average duration of using EHR in this study population was found to be 4.8 years. Also, the availability and use of core EHR functions increased over time from 2000 to 2005
Quality Performance and EHR Adoption
Quality performance between EHR users and non-users regardless of when their EHRs were implemented was evaluated. For all 6 clinical conditions categories, there was no found difference in performance between EHR users and non-users.
Financial Considerations Regarding EHR Usage and Quality of Care
It was found that having an EHR was not associated to physicians’ reported financial incentives for patient satisfaction or clinical quality.
This study examined the relationship between EHRs and health care quality, particularly taking into consideration the changes in association over a period of time. No confirmation that quality of care improved with a longer interval of EHR usage was found. The results imply that merely implementing EHRs is unlikely to result in enhanced quality. Other approaches, such as paying more for higher quality care and ensuring that physicians are using EHRs to their full capacity through education and workflow renovation may be necessary. However, several studies have demonstrated that decision support delivered through electronic records can improve quality of care. For this study, usage of decision support among EHR users was quite low at only 23.5% in 2005, compared to its availability, which was 65.0% amid EHR adopters. As a result, it was agreed that quality of care improvement is achievable when EHRs are coupled with other system supports such as decision support and order entry. Several limitations were found to be of significance in this study:
- Unknown factors may have masked true associations.
- Even though the measures used in this study have been extensively used by researchers and other healthcare related entities, they are derived from claims data. Actual clinical data may provide a more precise representation of the quality of physician care.
- EHR adoption and usage were self-reported by physicians, and social prestige bias may have led physicians to overrate actual EHR usage.
- The survey was carried out in a single state therefore generalizing the findings to the rest of the United States may be inadequate.
There was no found association between length of time using an EHR and quality of ambulatory care. Also, EHR use was not linked with improved quality of care. Strategies to increase the efficient use of [clinical decision support] and other potential tools to improve quality of care should be considered. Future studies may be needed to re-evaluate the relationships between the quality of care and EHR use over time.
This study provides a straightforward qualitative and quantitative analysis of whether or not EHR usage provides improved quality of care over a period of time. Despite a few limitations to the study, it is evident that an EHR use alone will not necessarily enhance quality of care. Rather, the incorporation of system support tools such as clinical decision support and computerized physician order entry leads to better quality improvement outcomes. However, more research needs to be done in order to fully assess the benefits of EHR system tools in improving quality of care over a period of time.
Electronic health records EHR have the possibility to increase the quality of care provided to a patient by allowing care providers quick access to detailed patient information, keeping track of patient’s health history over a length of time, and reducing medical errors. However, very few studies have been able to show a direct correlation between the use of EHRs and an advance in quality of care. A study was done to examine how the quality of care in an ambulatory practice changed with the adoption and use of an EHR.
In 2005, physicians in Massachusetts were surveyed about their EHR adoption and use. A total of 1,181 practices were used and one physician from each practice was randomly selected to be included in this study. A longitudinal analysis was used to view the trend of EHR adoption and use and to assess the correlation between the quality of care and duration of EHR use.
It was found that the physicians most likely to have an EHR were those who were younger recently graduated from medical school, and practiced in an urban setting. The amount of physicians who adopted and used EHRs doubled between 2000 and 2005. However, there was no difference in the performance of physicians who used EHRs compared to those who didn’t.
There was no correlation found between the use of EHRs and improvements in quality of care. More studies are needed on this topic to examine if EHRs could improve quality of care in the future with use of key features such as clinical decision support CDS.
Simply speaking this study has identified that EHRs are not the magic bullet solution to the US healthcare system problems.
- The Relationship between Electronic Health Record Use and Quality of Care over Time. DOI: http://dx.doi.org/10.1197/jamia.M3128 457-464