The era of meaningful use of information technology has begun in medicine yet is still in its infancy. As electronic health records evolve alongside quality reporting, many expect health care to become safer and more effective.
The “meaningful use” of certified electronic health record (EHR) technology is measured by a set of objectives including breadth of use, extent of use, and quality improvement. The 2011 objectives set by the Obama administration include creating and maintaining medical records in electronic form, display of drug-drug and drug-allergy interactions, and implementation of clinical decision rules. These objectives are posited to achieve significant improvements in care; however there is inconsistency in the empirical research that has been completed.
The authors therefore attempted to examine the effects of EHRs. In particular, they focused on the effects of changes in EHR system capability on changes in specific inpatient processes of quality performance; the specific conditions explored were acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and surgical care infection prevention (SCIP).
They hypothesized that: (1) hospitals that transition to EHR systems capable of meeting the 2011 meaningful use objectives in a given year would have positive gains in process quality in the subsequent period and (2) hospitals with lower baseline quality would see a significant change in quality following transition to an EHR system capable of meeting the 2011 meaningful use objectives.
Of the 3,921 US acute care hospitals in the sample, the proportion of hospitals meeting meaningful use objectives increased from less than 10 percent in 2006 to almost 50 percent in 2010. In the context of delivering care to AMI, HF, and PN patients in all hospitals, the transition to a EHR system meeting 2011 meaningful use objectives was associated with a statistically significant, but clinically modest, gain in process quality. In addition, the low quality hospitals saw significant increases in quality following transitions to such systems, ranging from 1.16 to 1.61 percentage point improvement. This increase correlates with an increase, on average, of 11.6 to 16.1 cases of adherence to recommended treatment guidelines (per 1,000 eligible cases).
An additional interesting finding concerned the transition to EHR systems that surpass the 2011 meaningful use objectives; such advanced system adoption was associated with statistically significant declines in quality for AMI, HF, and SCIP. It was theorized that such a finding was based on undesired operational failures of the new systems or the possibility of longer term benefits that were not able to be examined within this five-year time frame. The authors concluded that implementation of technology alone, though providing some clinical benefit, was not likely to be a sufficient factor in quality improvement.
This analysis provides a very small window into future capabilities of medical technology. It makes sense that lower quality hospitals would be aided by the superior coordination afforded by EHRs. However, so much of the potential of EHRs cannot be visualized with this approach to four inpatient conditions; additional factors must also be analyzed in order to conclude actual impact on process quality. What about processes concerning continuity of care between inpatient and outpatient delivery? If focusing on inpatient conditions alone, I would have preferred to also see an analysis of readmission rates, which would speak to coordination of care for patients and whether adherence to treatment guidelines were of impact over long-term. What about communication between providers throughout a system? What of the impact on adverse events (drug-drug and drug-allergy interactions) that are included within the 2011 meaningful use objectives? As many have argued, the effectiveness of the full implementation of EHR is still unknown. We are far from reaching a conclusion on the benefit of EHRs without assessing these other traditional factors of quality.
Kameron Matthews, MD, JD