EHRs and the quality conundrum

A quick peek at the past few days in the literature on whether electronic health records are capable of improving quality care shows EHRs taking it on the chin a few times. Despite the efforts and expense of installing EHRs in practices, EHRs are not improving overall quality as much as might be expected, several researchers said. But taking a closer look, it's important to ask ourselves: Are we all on the same page when it comes to defining quality?

After covering the issue of healthcare quality for the past two decades, it's become apparent to me that there's no one single definition of quality. It can mean many things, such as improving the overall well-being of a patient, or creating a better standard of living for a group of individuals or a population.

What we all can agree on, though, is that achieving quality care is an important goal. But exactly how do we monitor and measure it--and can EHRs provide the means to do it?

In a study appearing online in the Jan. 24 issue of the Archives of Internal Medicine, Stanford University researchers Max Romano and Randall Stafford, MD, PhD, reviewed guideline adherence for 250,000 outpatient visits using data from the National Ambulatory Medical Care Survey and from the National Hospital Ambulatory Medical Care Survey from 2005 to 2007.

Overall, what they found was that among 20 indexes of care quality, only diet counseling for high-risk adults showed "significantly better performance" in visits where EHRs were used when compared with visits using other types of record-keeping systems. "There were no other significant quality differences" regarding the clinical benefits of EHRs and clinical decision support, they said.

However, in a commentary appearing in the same journal, two National Library of Medicine (NLM) researchers--Clement McDonald, MD, and Swapna Abhyankar, MD--said that they suspected that the EHR and clinical decision support systems in use at the time of Stanford study were "immature," failed to cover many of the guidelines that the study targeted, and had incomplete patient data.

They also said that EHRs without clinical decision support do not affect guideline adherence because without that support, "most EHRs function primarily as data repositories that gather, organize, and display patient data--not as prods to action."

Most of the guidelines in the Stanford study concerned medication use, but none dealt with such areas as immunizations or screening tests. "In our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization," they wrote.

In another study appearing online Jan. 18 in the Public Library of Science (PLoS), British researchers--looking at the use of eHealth technologies including EHRs--said that little empirical evidence was found to substantiate their claims of quality and safety.

However, they noted that the absence of evidence does not necessarily mean the absence of quality. More concrete studies are needed to move forward--"before substantial sums of money are committed to large-scale national deployments under the auspices of improving healthcare quality and/or safety," they said.

The answers on how to link quality and EHRs are not going to be easy. This was indicated a few weeks ago in a RAND study on hospitals possibly not seeing the quality improvement they had anticipated with EHRs.

According to a statement from the study's lead author, Spencer Jones, an information scientist at RAND: "The lurking question has been whether we are examining the right measures to truly test the effectiveness of health information technology. Our existing tools are probably not the ones we need going forward to adequately track the nation's investment in health information technology."

So on the question of whether EHRs improve quality, it's going to depend on not only how we define quality--but when. - Jan