Electronic health record adoption in outpatient settings shows no consistent association with higher quality care, finds a Jan. 24 study printed by the Archives of Internal Medicine. Nationwide adoption of EHRs also varies significantly by region and type of practice, the study adds.

Federal policy heavily encourages medical practices to adopt EHRs through a combination of monetary incentives and promises of future Medicare reimbursement penalties for not adopting them. The Health and Human Services Department estimates that federal incentive payments will total between $9.7 billion and $27.4 billion over a decade.

The study, based on nationwide federal data collected 2005-2007 from private practices and authored by Stanford University researchers Max J. Romano and Randall S. Stafford, examines whether EHR users did any better in performing 20 basic care quality measures, such as measuring blood pressure.

They did so with statistical significance for just one quality indicator, that of giving diet counseling to high-risk adults. EHR users gave nutrition advice 28 percent of the times while only 20 percent of non EHR users did, the study says.

Report authors say they also investigated whether the quality measure results produced by the subset of care givers using advanced function EHRs would be different from those using basic systems, but there was no disparity.

Western state practices are also far more likely to have an EHR than the rest of the country, but the greater level of penetration hasn't affected care quality, the report states. Western outpatients generally got higher quality for two indicators, but worse quality for three.

The study also notes differences in adoption among types of practices, with emergency clinics far more likely to have had an EHR than other specialty types. Hospital or hospital-owned clinics also adopted EHRs in greater numbers than other ownership models--nearly three times more than solo private practices, the study says.  

One motive for the federal EHR adoption push is that EHRs allow easy integration of clinical decision support software into practices. But, the study also finds that of the ambulatory care practices that used EHRs, the presence of the software was likewise not associated with higher quality care.

Of the 20 basic quality care measures, physicians with a CDS in the practice did statistically better with just one, that of avoiding unnecessary electro-cardiography during routine examinations. Physicians with the software did so in 98 percent of visits, versus 93 percent of their counterparts operating without a CDS.

The study findings do raise doubts about whether broad CDS adoption will unilaterally improve outpatient care quality, Romano and Stafford say. The study has a limitation in that it doesn't assess the possible value of EHRs or CDS in patient care over time, since it examines quality indicators on a per-visit basis, they also say.

Alternatively, the study could just suggest a need for greater attention to quality control in implementing EHRs and CDS, the authors add.

Another paper printed in the same edition of the Archives of Internal Medicine suggests that the study could have faults. The medical care practices whose survey data the study used may or may not have implemented the 20 quality indicators selected by Roman and Stafford, say two National Institutes of Health doctors, Clement McDonald and Swapna Abhyankar.

For more:
- download Romano and Stafford's study (.pdf)
- download McDonalds and Abhyankar's comment on the study (.pdf)

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