Electronic health records and clinical decision support systems: impact on national ambulatory care quality.
BACKGROUND
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, USA. mromano4@jhmi.edu
Max J
MJ
Romano
Randall S
RS
Stafford
D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000379:methods* / Q000706:statistics & numerical data; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D020000:Decision Support Systems, Clinical / Q000458:organization & administration*; D057286:Electronic Health Records / Q000458:organization & administration*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D016015:Logistic Models; D008297:Male; D016347:Medical Records Systems, Computerized / Q000458:organization & administration; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D015397:Program Evaluation; D058996:Quality Improvement; D012189:Retrospective Studies; D014481:United States
J Am Med Inform Assoc. 2009 Jul-Aug;16(4):457-64
19390094
N Engl J Med. 2008 Jul 3;359(1):50-60
18565855
Med Care. 2008 Dec;46(12):1267-72
19300317
J Healthc Inf Manag. 2010 Winter;24(1):4-5
20077915
N Engl J Med. 2010 Feb 4;362(5):382-5
20042745
Arch Intern Med. 2007 Jul 9;167(13):1400-5
17620534
Inform Prim Care. 2009;17(4):231-40
20359401
J Gen Intern Med. 2008 Apr;23(4):379-82
18373133
N Engl J Med. 2003 Jun 26;348(26):2635-45
12826639
Qual Saf Health Care. 2010 Oct;19(5):e15
20427312
Milbank Q. 2005;83(4):843-95
16279970
J Am Med Inform Assoc. 2006 Jan-Feb;13(1):106-12
16221936