A large RAND study of nearly half the acute care hospitals in the U.S. calls into question the value of electronic medical records, saying that except for basic systems used to treat congestive heart failure patients, EHRs are not improving process of care measures for many large hospitals that have them.
"The lurking question has been whether we are examining the right measures to truly test the effectiveness of health information technology," says Spencer S. Jones, a RAND scientist and lead author for the report. "Our existing tools are probably not the ones we need going forward to adequately track the nation's investment in health information technology."
Jones and authors write that their "results should temper expectations for the pace and magnitude of the effects of the Health Information Technology for Economic and Clinical Health (HITECH) legislation. The challenges and unintended consequences of EHR adoption are well documented."
Federal aid amounting to $30 billion is stimulating a national push to adopt EHR in healthcare settings, but Jones' report says that data demonstrating that the technology improves quality comes from a few large teaching hospitals and may not be representative of hospitals at large.
The study looks at 17 process measures for three common illnesses, heart failure, heart attack, and pneumonia between 2003 and 2007. Also, the number of hospitals using basic or advanced EHR grew from 24% to nearly 38% during that period.
Those 17 process measures included whether clinicians gave aspirin to patients who arrived in the hospital with an acute myocardial infarction, an ACE inhibitor or ARB for left ventricular systolic dysfunction to patients with heart failure and an oxygenation assessment to patients admitted with pneumonia. The measures did not include any outcomes.
Quality of care at all hospitals improved overall regardless of whether they had EHR over this time, but with the exception of patients with CHF, it did not improve faster at hospitals with EHR than at hospitals without it.
"Adoption of advanced EHR capabilities was associated with significant decreases in quality improvement for acute myocardial infarction and heart failure," the authors write.
RAND used Health Information Management Systems Society survey data, which includes 90% of U.S. hospitals and includes clinical IT application implementation status, excluding hospitals that didn't disclose their software vendor. Hospital process measures were taken from Medicare's Hospital Compare.
The authors segmented hospitals by their level of EHR adaptation:
Basic EHR indicates the full complement of an operational clinical data repository, electronic patient record, and clinical decision support systems.
Advanced EHR indicates all the components of a basic EHR plus operational computerized provider order entry.
The authors acknowledge six significant limitations in their study. First, they could not quantify the impacts EHR might have on conditions other than these three. Second, they could not measure how extensively hospital teams used their systems nor could it account for significant variation in the different types of systems used.
Third, the hospitals for which they had data may not be transferrable to all hospitals n the country. And fourth, they suggest that for some conditions such as AMI and pneumonia, there may be points over which improvement is difficult to achieve.
"These ceiling effects may explain why we observed a significant decrease in the rate of quality improvement for AMI and no significant change in the rate of quality improvement for pneumonia in hospitals that adopted the new EHR capabilities," they write.
Fifth, they suggested the possibility that improvement resources may have been redirected toward EHR implementation rather than quality improvement efforts. "The literature suggests that both tasks (quality improvement and EHR implementation) are resource-intensive, and it is feasible that both processes might suffer if conducted simultaneously and forced to compete for resources."
Sixth, the study "may not have been long enough to fully estimate the relationship between EHR adoption and quality improvement" and said that hospitals that have been using and refining their EHR systems over decades do report improvement in clinician adherence to recommended practices.
And, the authors say that numerous resources to handle some of these challenges are called for in the HITECH legislation and at the Office of National Coordinator for Health Information Technology.
"We believe that these programs are well conceived and anticipate that they will lead to more effective use of EHRs, which will in turn lead to improved quality in U.S. hospitals," they concluded. "However, we are concerned that the standard methods for measuring hospital quality will not be appropriate for measuring the clinical effects of EHR adoption.
"The generally high levels of performance on the Hospital Compare database are to be celebrated, but in going forward, these high levels of performance will make it difficult to detect the effect of EHR adoption on hospital quality."