Study: EHRs and CDS don't improve care

By Mike Miliard
10:43 AM

A new study by a Stanford University Research team, published in the Archives of Internal Medicine, has found that current usage of EHR and clinical decision support technology may improve administrative efficiency but does "not appear to translate into better outpatient quality of care."

The three-year study, titled Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality, was coauthored by Randall S. Stafford, MD, PhD, and Max J. Romano, who examined data from more than 250,000 ambulatory visits between 2005 and 2007.

EHRs were in use for roughly 30 percent of those visits, with clinical decision support used for about 17 percent of them.

The pair's findings could be seen as a splash of cold water for the healthcare IT industry – and the federal government intent on spurring widespread EHR adoption with billions in financial incentives.

Even supplemented with clinical decision support (CDS), the study finds, EHRs were not associated with any significant gains in care improvement.

While certain past studies "within specific institutions have demonstrated better quality as a result of EHR implementation," they write, other research, taking a more general  view has "found no quality difference between ambulatory care provided with and without EHRs. Several recent studies have also failed to observe an association between EHR use and improved quality of care."

The question, then, was whether the addition of CDS might help lead to better results.

"Clinical decision support is an often-cited EHR mechanism of quality improvement, yet this study failed to detect significant improvements in healthcare quality among all U.S. practices using CDS systems," write Stafford and Romano. "While our findings do not rule out the possibility that the use of CDS may improve quality in some settings, they cast doubt on the argument that the use of EHRs is a "magic bullet" for healthcare quality improvement, as some advocates imply."

Indeed, they wrote, "several anecdotal articles describe how CDS can disrupt care and decrease care quality; however, further empirical research is needed."

It's important to note that the time period for the study preceded the 2009 passage of the 2009 HITECH act, which provided billions of dollars to help drive adoption.

[For a closer look at those numbers, see: HITECH Act 'lit a fire' under health systems.]

Stafford and Romano do note that the adoption of healthcare IT in this country is still in its infancy – a fact that may have contributed to their findings. And it's possible, they indicate, that ARRA stimulus and its subsequent meaningful use standards, could lead to different results in any similar studies in coming years.
"In the absence of governmental impetus and standards, current adoption patterns may have fostered incomplete implementation and use of less effective technologies," they write. "Systematic federal intervention through HITECH may be needed to realize the potential of these technological advances."

In the short term, however, they caution that "our findings may suggest a need for greater attention to quality control and coordinated implementation to realize the potential of EHRs and CDS to improve healthcare" and that "in the absence of broad evidence supporting existing CDS systems, planned investment should be monitored carefully and its impact and cost evaluated rigorously."

[Even so, CDS is poised for huge gains in adoption in the coming years. See: New report forecasts large gains for decision support.]

Meanwhile, Stafford and Romano found glimpses of hope in the various self-contained success stories they came across in their research – and suggested that the goal should be to build on those successes to see improved care nationwide.

"Future research should investigate why the CDS benefits in randomized controlled trials have not translated into national quality improvement," they write. "Research also is needed to elucidate the factors influencing HIT adoption."

Such studies "will be vital to federal decisions about HIT implementation in the coming years," they added. "As in this assessment, further research should continue to evaluate the role of EHRs and CDS outside of academic medical centers in the smaller-scale settings in which most Americans receive outpatient health services."

Read the entire report at the Archives of Internal Medicine.