No Quality Benefits Seen with Electronic Health Records

BOSTON -- Electronic health records (EHRs) have yet to lead to quality improvements in health care promised by the technology's supporters, according to a review of national statistics.

BOSTON, July 9 -- Electronic health records (EHRs) have yet to lead to quality improvements in health care promised by the technology's supporters, according to a review of national statistics.

Comparing use of electronic health records and changes in 17 quality indicators for ambulatory care, investigators found no change in 14 indicators, improvement in two, and deterioration in one, according to a report in the July 9 issue of Archives of Internal Medicine.

As currently implemented, electronic health records do not improve the quality of health care, concluded Jeffrey A. Linder, M.D., M.P.H., of Harvard, and co-investigators at Harvard and Stanford.

Patients in the U.S. receive about half of recommended health care, the authors stated, and health information technology, particularly electronic health records, has been touted as a means to achieve cost-effective, sustainable improvements in quality of care.

However, they said, results to date have been inconsistent and much of the research comes from four benchmark institutions with internally developed EHR systems.

To determine the impact of health care technology in the broader community, Dr. Linder and colleagues reviewed ambulatory care data from the National Center for Health Statistics (NCHS) for 2003 and 2004, a period comprising approximately 1.8 billion patient visits.

During those two years, the NCHS' National Ambulatory Medical Care Survey (NAMCS) included a question about use of electronic health records (other than for billing). On the basis of responses to that question, the investigators found EHRs were used in 18% of patient visits.

The 17 quality indicators analyzed came from a set previously validated in the NAMCS by Stanford researchers Jun Ma, M.D., Ph.D., and Randall Stafford, M.D., Ph.D., co-investigators in the current study. The indicators can be grouped into five categories:

• Medical management of common diseases,
• Recommended antibiotic use,
• Preventive counseling,
• Screening tests, and
• Potentially inappropriate prescribing in elderly patients.

Performance on the quality indicators was defined as the proportion of visits in which patients received recommended care.

Overall, electronic health records did not improve quality of care compared with patient visits in which EHRs were not used, the investigators concluded.

The two indicators that improved with use of electronic health records were avoidance of benzodiazepines for treating depression (91% versus 84%, P=0.01) and omitting urinalysis as a routine screening test (94% versus 91%, P=0.003). The one indicator for which performance deteriorated with use of electronic health records was statin therapy (33% versus 47%, P=0.01).

In a secondary analysis limited to visits to primary care physicians or cardiologists, there was improvement in one other indicator with EHR use: Smoking cessation counseling was given more frequently (39% versus 25%, P=0.03).

Use of electronic health records was not influenced by patient age, sex, race, ethnicity, or insurance status, or by physician specialty or office type. Solo practitioners were less likely to use electronic health record systems compared with other types of practices (13% versus 21%, P=0.01).

Electronic health records also were used less often in physician-owned practices versus those in which physicians were employees or contractors or had some other employment status (16% versus 25%, P=0.003).

Use of electronic health records was significantly more common in practices owned by health maintenance organizations (60%) or other health care corporations (36%) compared with physician ownership (17%) or some other type of ownership (19%, P=0.003).

Dr. Linder acknowledged several limitations to the study including the fact that the sample size was small for some of the quality indicators, self-reporting of data in the survey, and the fact that because the survey is cross-sectional, causality cannot be assumed.

He also noted that there is a problem with the definition of an electronic health record. Although the term was pre-tested, not all products bearing that name allow for clinical decision support, necessary for optimal quality improvement.

Dr. Stafford said the results do not minimize the value of electronic records but instead emphasize the need for greater commitment to improving quality of care.

"We need to be cautious about the assumption that electronic health records are going to solve problems around health care quality by themselves," said Dr. Stafford. "It's not sufficient to have an electronic health record system that provides readily available patient data and decision-making guidance. Physicians have to be receptive to that input and willing to act on that input."