More Studies Assessing Quality Improvement Using Electronic Health Records

Earlier this year, the informatics world was abuzz with a study published in Archives of Internal Medicine by Romano and Stafford that found a lack of improvement in healthcare quality measures for patients whose physicians had adopted electronic health records (EHRs) [1]. As I detailed in a posting to this blog, as well as in a co-authored letter to the editor that was published in Archives [2], this study had a number of flaws. My main complaint with the study was that the quality measures assessed were independent of the EHR intervention, hence any association, positive or negative, was indirect at best.

The furor about the paper died down, and most people got back to working on implementing meaningful use. No one disagreed that we need more research on whether EHR systems do improve healthcare quality, including studies with better methodology.

Last month, another study came along. Published in the New England Journal of Medicine (NEJM) by Cebul et al., this study used a somewhat similar methodology to assess 46 practices in the Cleveland area, 33 of which had adopted EHRs [3]. The study assessed the outcomes of 27,207 patients with diabetes mellitus who were followed by a total of 569 providers. The study looked at four process measures and five outcome measures in those diabetic patients, comparing them for providers who had and had not adopted EHRs. Overall composite quality measures were developed for the process and outcome measures, and found to be 35.1% higher in the former and 15.2% higher in the latter. The difference was found to persist across all insurance types and, even more gratifying, for "safety net" clinics that historically see more complicated patients of lower socioeconomic status.

This study did use a roughly similar methodology to the Romano and Stafford study, and as such must be viewed as having a weaker form of evidence than a direct randomized controlled trial (RCT). Of course, in reality, such an RCT would be near impossible to do, i.e., randomizing patients to receive their care from a provider having an EHR or not. We also know that there can be confounders between practices utilizing and not utilizing EHRs.

Nonetheless, this study did have advantages over similar studies done before it, including the Romano and Stafford study. One clear advantage was that the study had complete data on all patients (unlike the Romano and Stafford study that only relied on a data set from the CDC National Center for Health Statistics (NCHS). The researchers also had precise data on the providers, the EHR implementation, and how the quality measures were integrated into the provision of care.

While this new study received a great deal of press, another study that received less press, which was published shortly after the publication of the Romano and Stafford study, should have received more [4]. Although still not an RCT design,  this study did use a before-and-after methodology to examine change in compliance with 16 quality measures before and after implementation of a commercial EHR in a large academic internal medicine practice. The results showed improvement after the EHR was implemented.

In an editorial accompanying the Cebul et al. study, Classen and Bates noted that the new NEJM study showed the "meaning in meaningful use" [5]. They correctly point out that implementing EHRs is not what HITECH should be about, but rather showing that the technology can be used to make meaningful improvement in the health of patients whose providers use it. As in most areas of medicine, we cannot wait for the perfect study or studies to answer all questions unequivocally, but the evidence base is growing for the value of informatics, especially when systems are implemented properly.

References
1. Romano, M. and Stafford, R. (2011). Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Archives of Internal Medicine, 171: 897-903.
2. Mohan, V. and Hersh, W. (2011). EHRs and health care quality: correlation with out-of-date, differently purposed data does not equate with causality. Archives of Internal Medicine, 171: 952-953.
3. Cebul, R., Love, T., et al. (2011). Electronic health records and quality of diabetes care. New England Journal of Medicine, 365: 825-833.
4. Persell, S., Kaiser, D., et al. (2011). Changes in performance after implementation of a multifaceted electronic-health-record-based quality improvement system. Medical Care, 49: 117-125.
5. Classen, D. and Bates, D. (2011). Finding the meaning in meaningful use. New England Journal of Medicine, 365: 855-858.

Will There Be a Need for Informaticians After EHR Implementation? Yes!

A question I am asked from time to time is whether there will be a need for informaticians once we are "done" implementing electronic health records (EHRs). My reply is that implementing EHRs is only a beginning, and actually not the most interesting part. Much more important is what we do with those EHRs and other information systems after they are implemented.

Once EHRs are implemented, there will still be all sorts of "meaningful" things that need to be done with them, and I am not just talking about the meaningful use guidelines, though those will keep us busy well past the middle of this decade. (Even the Office of the National Coordinator for Health IT [ONC] believes it unlikely that most eligible professionals and hospitals will achieve Stage 3 meaningful use before 2018-2019.)

But I only see healthcare becoming more data-driven in the future, with increasing emphasis on managing information to provide safe and less costly care. Activities such as quality measurement and improvement, improving efficiency, dealing with new types of information, and continued advances in information technology (IT) are likely to keep us busy for a long time to come.

One insight to these future needs comes from a new article by Bill Stead and colleagues (Academic Medicine, 2010, Epub ahead of print). It is unfortunate that this article is published in a journal that requires an individual or institutional subscription to access it, because it presents a clear picture that the complexity of information required to practice medicine is increasing and that clinicians - and the educators who train them - must learn how to function in the increasingly "information-rich" healthcare environment.

This article also lists a number of key competencies in informatics for physicians, organizing them within the framework Accreditation Council for Graduate Medical Education (ACGME) core competencies for physicians. The article also recommends that informatics become a foundational science for healthcare, advocating development of academic units involved in academic and operational activities, using the IT infrastructure of academic health centers as testing laboratories, and retraining faculty to lead the transformation of healthcare through the use of informatics.

There are many other reasons why informatics will not cease to be important once there are EHRs on every desk in healthcare. As us baby boomers age and develop more health problems, we will likely want to manage our healthcare the way we manage many other things in life (e.g., banking, air travel, buying certain things such as books, etc.), which is on-line. We also know that there is still plenty of room for improvement with existing EHRs. Data entry is too time-consuming, poor interfaces can hide critical data, and we still need much smoother interoperability, especially of data. The ONC SHARP program acknowledges the need for continued research in the four areas it is funding: architecture, privacy and security, secondary use of data, and cognitive-centered computing.

In essence, the implementation of EHRs enables a whole host of other activities that will allow improvement of health, healthcare, public health, and biomedical research. As such, there will only be increased demand for informaticians to perform and lead these activities.

Academia = Education AND Research

The American Medical Informatics Association (AMIA) Annual Symposium is clearly the best informatics meeting of the year. It is rigorously academic, so the quality is top-notch, but not too much, so you can glean plenty of practical information as well.

The AMIA symposium is also an opportunity for us because we can showcase our department. As always, our faculty and students will pepper the program with great papers, panels, and posters. In addition, the annual OHSU banquet is a gratifying display of the energy and passion of our program, not to mention quite fun. I look forward to this year's meeting in San Francisco later this month.

This meeting always give me a chance to reflect on the importance of a comprehensive academic program that values both education and research. A vibrant graduate-level program cannot thrive without both. Being at the cutting edge of research allows faculty to be the knowledge and thought leaders in their respective areas.

This was borne out a couple years ago when we hosted a focus group that assembled a number of what we call "local distance" students, which are students who live in the Portland area but prefer to enroll in our on-line program. We wanted to know why they preferred that instead of coming "up the hill" to the OHSU campus. The answers were obvious in retrospect: they appreciate the convenience of being able to carry out their studies at their preferred hours (usually evenings and weekends) and they did not want to deal with the hassle of driving to and parking on our campus (which everyone knows can be a pain, at least during regular working hours).

There was, however, another interesting finding that came from the focus group. These students told us they were drawn to our program not only because of its local connection, but also because they valued the faculty and their leadership roles in the field, especially their research. Even though they were unlikely to become researchers themselves, or for some to even do research, they believed it was important to obtain their education in a department that was known for being a leader in research as well.

As always, I look forward to catching up with students, alumni, and old friends at the AMIA meeting.