Electronic Health Records and Clinical Decision Support Systems Impact on National Ambulatory Care Quality

Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, USA.
Archives of internal medicine (Impact Factor: 11.46). 05/2011; 171(10):897-903. DOI: 10.1001/archinternmed.2010.527
Source: PubMed

ABSTRACT Electronic health records (EHRs) are increasingly used by US outpatient physicians. They could improve clinical care via clinical decision support (CDS) and electronic guideline-based reminders and alerts. Using nationally representative data, we tested the hypothesis that a higher quality of care would be associated with EHRs and CDS.
We analyzed physician survey data on 255,402 ambulatory patient visits in nonfederal offices and hospitals from the 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Based on 20 previously developed quality indicators, we assessed the relationship of EHRs and CDS to the provision of guideline-concordant care using multivariable logistic regression.
Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits. Clinical decision support was present in 57% of these EHR visits (17% of all visits). The use of EHRs and CDS was more likely in the West and in multiphysician settings than in solo practices. In only 1 of 20 indicators was quality greater in EHR visits than in non-EHR visits (diet counseling in high-risk adults, adjusted odds ratio, 1.65; 95% confidence interval, 1.21-2.26). Among the EHR visits, only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS (lack of routine electrocardiographic ordering in low-risk patients, adjusted odds ratio, 2.88; 95% confidence interval, 1.69-4.90). There were no other significant quality differences.
Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

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    ABSTRACT: Objectives To determine whether clinical decision support (CDS) is associated with improved quality indicators and whether disabling CDS negatively affects these. Study Design/Methods Using the 2006-2009 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we performed logistic regression to analyze adult primary care visits for the association between the use of CDS (problem lists, preventive care reminders, lab results, lab range notifications, and drug-drug interaction warnings) and quality measures (blood pressure control, cancer screening, health education, influenza vaccination, and visits related to adverse drug events). Results There were an estimated 900 million outpatient primary care visits to clinics with EHRs from 2006-2009; 97% involved CDS, 77% were missing at least 1 CDS, and 15% had at least 1 CDS disabled. The presence of CDS was associated with improved blood pressure control (86% vs 82%; OR 1.3; 95% CI, 1.1-1.5) and more visits not related to adverse drug events (99.9% vs 99.8%; OR 3.0; 95% CI, 1.3-7.3); these associations were also present when comparing practices with CDS against practices that had disabled CDS. Electronic problem lists were associated with increased odds of having a visit with controlled blood pressure (86% vs 80%; OR 1.4; 95% CI, 1.3-1.6). Lab result notification was associated with increased odds of ordering cancer screening (15% vs 10%; OR 1.5; 95% CI, 1.03-2.2). Conclusions The use of CDS was associated with improvement in some quality indicators. Not having at least 1 CDS was common; disabling CDS was infrequent. This suggests that meaningful use standards may improve national quality indicators and health outcomes, once fully implemented.
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