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Electronic health records didn't improve quality of outpatient care, Stanford researcher finds

Randall Stafford

BY SUSAN IPAKTCHIAN

Electronic health records have been hailed as a key element in making U.S. medical care more effective and efficient, but a new study led by a researcher at the School of Medicine shows that electronic records were not associated with improved quality of outpatient health care in 2003 and 2004.

Of 17 quality indicators assessed by the study, electronic health records made no difference in 14 measures. In two areas, better quality was associated with electronic records, while worse quality was found in one area.

Senior author Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center, said that given the overall mediocre performance of physicians in the 17 quality indicators, he and his colleagues had expected better results for doctors using electronic records.

Stafford said the study doesn't discount the value of electronic health records, but points out that the entire health-care system needs to embrace the concept of improving the quality of care delivered in clinic and office visits.

"We need to be cautious about the assumption that electronic health records are going to solve problems around health-care quality by themselves," Stafford said. "It's not sufficient to have an electronic health record system that provides readily available patient data and decision-making guidance. Physicians have to be receptive to that input and willing to act on that input."

The study, produced by a team of researchers from the Stanford and Harvard medical schools, was published in the July 9 Archives of Internal Medicine.

The 14 quality indicators for which electronic records made no significant difference included prescribing recommended antibiotics; diet and exercise counseling for high-risk adults; screening tests; and avoiding potentially inappropriate prescriptions for elderly patients.

In two quality areas—not prescribing benzodiazepine tranquilizers for patients with depression, and avoiding routine urinalysis during general exams—doctors using electronic record systems fared better. But when prescribing statins for patients with high cholesterol, physicians using electronic systems did worse.

Electronic health record systems have become a centerpiece in a quest to improve the quality of health care. Storing a patient's medical history in electronic form can eliminate errors from bad handwriting, make it easier to follow patients over time and simplify sharing patients' records.

The more sophisticated systems can flag potential problems, such as mixing medications that can trigger a bad reaction, and provide advice on which tests to order or medications to prescribe.

Past studies have assessed the use of electronic health records in hospitals, where patients are acutely ill and quality can have life-threatening consequences. But few have examined the impact of electronic health records in outpatient settings, Stafford said, even though much of today's health care is delivered during visits to clinics or doctors' offices.

For the study, Stafford and his colleagues drew data from the National Ambulatory Medical Care Survey, conducted by the National Center of Health Statistics, which provides information on patient visits to doctor's offices.

The researchers found that electronic health records were used in 18 percent of an estimated 1.8 billion physician visits in 2003 and 2004. Using a set of 17 quality indicators for ambulatory care, the researchers checked the database to see whether an electronic health record system enhanced the quality of care.

"In essence, we found little difference in the quality of care being provided by physicians with electronic health record systems, compared to those without these systems," he said.

Stafford had a couple of theories as to why. First, in 2003 and 2004, doctors may have been using older systems that did little more than transfer information from paper to electronic form. Many systems today, however, can recommend medications or tests best-suited to a patient's condition.

Which brings up the second theory: No matter how sophisticated the system, it can't dictate a course of action to a doctor, Stafford said. In many cases, doctors don't see any incentive to heed an electronic system.

"We're still on a learning curve in terms of how physicians relate to electronic media," Stafford said. "Recent graduates of medical school are clearly more comfortable with these technologies, and it's only gradually diffusing into the whole of the medical practitioner population."

With more U.S. patients seeking medical help in managing chronic diseases, such as diabetes and asthma, Stafford said an electronic health record system can be a valuable tool for physicians. "But there has to be recognition within the entire health-care system that chronic disease prevention and management deserves emphasis," he said.

The lead author of the study is Jeffrey Linder, MD, MPH, an instructor at Harvard Medical School and expert in electronic health record design and implementation. Stafford's Stanford colleague on the paper is Jun Ma, MD, PhD, associate scientist at the Palo Alto Medical Foundation Research Institute.

The study was funded by the U.S. Agency for Healthcare Research and Quality.