Clinical Decision-Support Systems and Electronic Health Records

Since 1991, the Institute of Medicine has recommended use of electronic health records (EHRs) as a way to improve the quality of healthcare. Clinical practices using outpatient EHRs report improved clinical decisions and better communication with patients and other providers, more accurate and timely access to medical records, and reduction of medical errors. The American Reinvestment and Recovery Act of 2009 included provisions known as Health Information Technology for Economic and Clinical Health designed to facilitate adoption of EHRs by providers and clinical practices in the United States, increasing use of the technology. However, there has been little evidence associating increased use of outpatient EHRs to improvements in quality of care. Whereas previous studies within specific institutions have shown improvements in quality, recent studies have not found an observational association between EHRs and improved care quality. According to researchers, an EHR function of key relevance to quality is clinical decision support (CDS), a feature that alerts, reminds, or directs healthcare providers according to clinical guidelines. To test their hypothesis that CDS functionality is associated with higher-quality outpatient care compared with use of EHRs without CDS, the researchers used nationally representative, federally collected 2005-2007 data to examine the impact of EHRs on outpatient care in the United States. They reported study results in Archives of Internal Medicine [2011;171(10):897-903]. The analysis included physician survey data on 255,402 ambulatory patient visits in nonfederal offices and hospitals from the 2005-2007 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Using 20 previously developed quality indicators, the researchers examined the relationship of EHRs and CDS to the provision of guideline-concordant care using multivariable regression. The data represented a projected 3.18 billion patient visits nationwide (1.06 billion annually). In 29.6% of all patient visits, EHRs were used; the CDS was used in 56.3% of the EHR visits (16.7% of all patient visits). The use of both EHRs and CDS increased over time. The use of EHRs was more likely in the West (41%) compared with other regions (25%-30%) and in group practices/community health centers (48%) compared with solo practices (16%). Compared with primary care (29%), EHR use was higher for emergency medicine (56%) and lower among specialties (20%). In ambulatory visits where EHRs were used, CDS was more likely to be present in the West (66% of EHR visits) compared with other regions (47%-56%). Compared with other physicians (51%-67%), surgeons (46%) and other specialists (35%) had the lowest CDS use. Of the 20 indicators of quality care used in the analysis, only 1 (diet counseling in high-risk adults) was greater in EHR visits compared with non-EHR visits (adjusted odds ratio, 1.65; 95% confidence interval [CI], 1.12-2.26). Likewise, among the EHR visits, only 1 of the 20 quality indicators (lack of routine electrocardiographic ordering in low-risk patients) showed significantly better performance in visits with CDS compared with EHR visits without CDS (adjusted odds ratio, 2.88; 95% CI, 1.69-4.90). The researchers cited limitations to the study, including the use of the NAMCS/NHAMCS data that limited the analysis to only a sample of patients and excluded those receiving care in federal facilities and nonparticipating practices. Also, the data used may not reflect the current practice patterns. Finally, although the researchers used multivariate analyses to control for variables that are independently associated with CDS adoption and care quality, other factors not available in NAMCS/NHAMCS may be confounders. In conclusion, the researchers stated, “Despite the promise of better quality, the clinical benefits of EHRs and CDS are not evident in our quality indicators. Given the growing institution-specific evidence that CDS use increased the quality of healthcare services, our results raise doubts about past implementation of costly EHR technologies nationally. While EHRs offer substantial administrative efficiency over paper records, current patterns of EHR and CDS use do not appear to translate into better outpatient quality of care.”