Health information technology is expected to reduce costs, save the environment, and improve the quality of care. Some evidence exists supporting health IT as beneficial to processes of care; more evidence is needed on outcomes.
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has encouraged health care organizations to improve quality of care by implementing and optimizing electronic health records (EHRs). One study reported an increase in EHR adoption of almost 57 percent and that a majority of providers plan to apply for HITECH’s meaningful use incentive program.
The authors of this study aimed to find any direct evidence either supporting or refuting their hypothesis that EHR use in underserved settings could improve quality outcomes. They performed a comprehensive literature review on studies of EHRs and quality in underserved communities with the aim of highlighting current knowledge and synthesizing lessons learned.
Underserved settings were defined based on the Institute of Medicine definition of safety-net settings whose providers “organize and deliver a significant level of health care and other related services to uninsured, Medicaid, and other vulnerable patients.” EHRs were defined by each publication, but had to include basic features such as note writing and medication lists.
The search strategy included Medical Subject Headings (MeSH) and and related text words. Inclusion criteria were as follows: (1) some percentage of the patients had to be underserved or in an under-resourced area. (2) The study must have been conducted in the United States. (3) The intervention studied had to utilize an EHR. (4) Results or discussion of outcomes had to include improved quality or the quality improvement process.
The literature search yielded 330 articles published between 1976 and September 2011, of which 52 articles were selected for full-text review and 17 articles were selected for final inclusion.
The articles were descriptive studies (11), quasi-experimental (5), and one randomized trial. Most descriptive studies (5) were completed in rural settings, while all quasi-experimental studies (5) were conducted in urban settings. Seven studies were conducted in urban areas; six were performed in rural settings; four were done in multiple settings.
The authors found evidence to support that EHR use in underserved settings improves quality of care. Five studies demonstrated improvement in documentation of the medical encounter. Improved process measures were supported by ten studies. To a lesser extent, improved outcome measures were supported by only three studies.
EHR use for diabetes care improvements and child health were well represented in the sample. EHR with clinical decision making features worked well to improve safety, medication appropriateness, and guideline adherence. Focus groups and interviews confirmed that there was an expectation that EHRs would improve quality and accessibility of medical information. EHRs did not always improve process measures. There was little evidence to support that EHRs improved outcome measures.
The reduction of health disparities will take the coordination of numerous interventions. Health information technology, specifically electronic health records (EHRs), is just one tool that may contribute to better health outcomes. The Medicare and Medicaid EHR Incentive programs offered through HITECH provide incentives to eligible providers and hospitals, including critical access hospitals, for implementation and demonstration of the meaningful use of certified EHRs. In addition to improving quality of care, EHRs are expected to lower health care costs, reduce paperwork, and decrease administrative burdens.
The trend of fewer providers accepting Medicaid and Medicare may soon see a decline or even a reversal, if adopting EHRs can prove to buttress profit margins for health care providers serving these patients. Along with the impending expansion of Medicaid, an increase in Medicaid providers would allow better access to care for low-income Americans and greater opportunity to decrease disparities in health and health care. Could widespread adoption of EHRs help the US achieve a goal of health equity?
Renée Volny, DO, MBA