Electronic Health Records Didn't Improve Quality Of Outpatient Care

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 indicator areas, he and his colleagues had expected better quality from 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, will be published in the July 9 issue of the Archives of Internal Medicine.

The 14 quality indicators for which electronic records made no significant difference included such factors as 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 medical exams - doctors using electronic record systems fared better than those who didn't. But when it came to prescribing statins for patients with high cholesterol, physicians using electronic systems did worse.

Electronic health record systems have become a centerpiece in the quest to improve the quality of health care. By storing a patient's medical history in electronic form, such systems can eliminate errors due to bad handwriting, make it easier to follow patient information over time and enable physicians to easily share patients' records. Additionally, the more sophisticated systems can flag potential problems, such as mixing medications that might trigger a bad reaction, and provide advice about which tests to order or which medications to prescribe.

Past studies have assessed the use of electronic health records in hospitals, where patients are acutely ill and quality issues can have life-threatening consequences. But relatively little research has examined the performance of electronic health records in outpatient settings, Stafford said. However, much of today's health care is delivered during visits to clinics or doctors' offices, so it's important to know whether the electronic systems are producing better outcomes, he added.

For the study, Stafford and his colleagues drew their data from the National Ambulatory Medical Care Survey, a survey conducted by the National Center of Health Statistics that provides information on patient visits to office-based physician practices.

The researchers found that electronic health records were used in 18 percent of the estimated 1.8 billion physician visits that occurred in 2003 and 2004. Using a previously defined set of 17 quality indicators for ambulatory care developed by the Stanford investigators, the researchers checked the database to determine 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," Stafford said.

Stafford had a couple of theories as to why electronic health record systems didn't boost the quality of medical care that was delivered. First, in 2003 and 2004 doctors may have been using older systems that did little more than transfer information from the paper record into electronic form. Many of the more sophisticated systems available today, however, can recommend the types of medications or tests that might be 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 physician, Stafford said. And in many cases, he added, physicians don't see any incentive for heeding the input of 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 who is an expert in electronic health records design and implementation. Stafford's Stanford colleague on the paper is Jun Ma, MD, PhD, who is now an associate scientist at the Palo Alto Medical Foundation Research Institute.

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