The Relationship between Electronic Health Record Use and Quality of Care over Time, Zhou et al. Daniel Beemsigne HAD5726 October 5, 2009

Why do a CATCH-IT report? Multidisciplinary field No standard way of reporting findings Create a standard Promote research and foster debate

Multidisciplinary field

No standard way of reporting findings

Create a standard

Promote research and foster debate

What is an EHR? An electronic health record (EHR) (also electronic patient record or computerised patient record ) is an evolving concept defined as a longitudinal collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared within across different health care settings, by being embedded in network-connected enterprise-wide information system. (Wikipedia, 2009)

An electronic health record (EHR) (also electronic patient record or computerised patient record ) is an evolving concept defined as a longitudinal collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared within across different health care settings, by being embedded in network-connected enterprise-wide information system.

(Wikipedia, 2009)

Background Increase quality of care by: providing timely access to patients’ health information; tracking patients over time to ensure that they receive guideline-recommended care; and offering decision-support mechanisms to reduce medical errors. Randomized controlled trials demonstrate clearly that quality improvement occurs when specific decision support is in place Benefits of EHR adoption and use may be time-dependent

Increase quality of care by:

providing timely access to patients’ health information;

tracking patients over time to ensure that they receive guideline-recommended care;

and offering decision-support mechanisms to reduce medical errors.

Randomized controlled trials demonstrate clearly that quality improvement occurs when specific decision support is in place

Benefits of EHR adoption and use may be time-dependent

Research Question How does the quality of care delivered in ambulatory care practices vary according to duration of EHR adoption and usage?

How does the quality of care delivered in ambulatory care practices vary according to duration of EHR adoption and usage?

Methods Study design involved two data sources: (1) a statewide survey of physicians’ adoption and use of EHR and; (2) statewide (Massachusetts) data on physicians’ quality of care as indicated by their performance on widely used quality measures. These two sets of data were integrated and linked for each included physician.

Study design involved two data sources:

(1) a statewide survey of physicians’ adoption and use of EHR and;

(2) statewide (Massachusetts) data on physicians’ quality of care as indicated by their performance on widely used quality measures.

These two sets of data were integrated and linked for each included physician.

Methods Stratified random sample i.e., Hospital based, large and rural practices in MA, by specialty, etc. Sample size calculated to provide 80% power to detect differences of 10% or greater Eight page questionnaire Surveys mailed with a $20 honorarium to a doctor in each practice Sample weights were used to adjust for overall representation Simon SR, Kaushal R, Cleary PD, et al. Correlates of electronic health record adoption in office practices: A statewide survey. J Am Med Inform Assoc 2007 Jan–Febr;14(1):110 –7.

Stratified random sample

i.e., Hospital based, large and rural practices in MA, by specialty, etc.

Sample size calculated to provide 80% power to detect differences of 10% or greater

Eight page questionnaire

Surveys mailed with a $20 honorarium to a doctor in each practice

Sample weights were used to adjust for overall representation

Simon SR, Kaushal R, Cleary PD, et al. Correlates of electronic health record adoption in office practices: A statewide survey. J Am Med Inform Assoc 2007 Jan–Febr;14(1):110 –7.

Methods Analysis Examined the cross-sectional relationship between having an EHR and concurrent indicators of quality of care Carried out a longitudinal analysis to study the trend of EHR adoption and usage as well as to examine the association between the duration of EHR usage and quality of care Compared the HEDIS® quality measures of respondents to the length of time using an EHR

Analysis

Examined the cross-sectional relationship between having an EHR and concurrent indicators of quality of care

Carried out a longitudinal analysis to study the trend of EHR adoption and usage as well as to examine the association between the duration of EHR usage and quality of care

Compared the HEDIS® quality measures of respondents to the length of time using an EHR

Blog: Finally, a positive comment! “ Wouldn't it be cool if they compared quality of care versus use of a specific feature in EHR?"

“ Wouldn't it be cool if they compared quality of care versus use of a specific feature in EHR?"

Methods

Methods

Results: Recall the Research Question How does the quality of care delivered in ambulatory care practices vary according to duration of EHR adoption and usage?

How does the quality of care delivered in ambulatory care practices vary according to duration of EHR adoption and usage?

Results EHR adoption – increase over time Availability and Use of EHR core functions Difference b/w EHR users and non-users? No statistical difference Having an EHR was not related to physicians’ reported financial incentives for patient satisfaction or clinical quality. Page 462 How does the quality of care delivered in ambulatory care practices vary according to duration of EHR adoption and usage?

EHR adoption – increase over time

Availability and Use of EHR core functions

Difference b/w EHR users and non-users?

No statistical difference

Having an EHR was not related to physicians’ reported financial incentives for patient satisfaction or clinical quality.

Page 462

Limitations HEDIS data: Exclusion criteria made respondents younger, more recently graduated, smaller practices, more patient visits, female, non-hospital based Survey did not record the length of time using specific EHR features Prevented analysis of the associations between the duration of using a specific EHR feature and quality of care. The sample sizes for long-time users were relatively small, only 9 MD’s – hard to detect ∆’s

HEDIS data:

Exclusion criteria made respondents younger, more recently graduated, smaller practices, more patient visits, female, non-hospital based

Survey did not record the length of time using specific EHR features

Prevented analysis of the associations between the duration of using a specific EHR feature and quality of care.

The sample sizes for long-time users were relatively small, only 9 MD’s – hard to detect ∆’s

Blog: What is adoption? EHR availability vs. adoption vs. use Feature availability vs. use

EHR availability vs. adoption vs. use

Feature availability vs. use

Assumptions EHR adoption and availability and use of EHR core functions by year were estimated based on these assumptions: If a physician indicated in the 2005 survey that a feature was available in his or her EHR system, we assumed that the feature had been available since the time when the practice first began using an EHR. The same assumption was also applied to the extent of usage of the EHR feature.

EHR adoption and availability and use of EHR core functions by year were estimated based on these assumptions:

If a physician indicated in the 2005 survey that a feature was available in his or her EHR system, we assumed that the feature had been available since the time when the practice first began using an EHR.

The same assumption was also applied to the extent of usage of the EHR feature.

Implications Only two references cited for relationship of EHR use and quality of care (growing body of literature) We found no evidence that quality of care improved with increasing duration of EHR usage Paying more for higher quality care and ensuring that physicians are using EHRs to their full capacity through education and workflow transformation

Only two references cited for relationship of EHR use and quality of care (growing body of literature)

We found no evidence that quality of care improved with increasing duration of EHR usage

Paying more for higher quality care and ensuring that physicians are using EHRs to their full capacity through education and workflow transformation

Implications Study showed that the usage of decision support among EHR users was low: only 23.5% in 2005, compared to its availability, which was 65.0% among EHR adopters The 2005 EHR adoption rate will need to triple in less than a decade (for MA), which represents a challenge for health care policy Stronger incentives or more extensive programs to support physician office transformation may be needed

Study showed that the usage of decision support among EHR users was low: only 23.5% in 2005, compared to its availability, which was 65.0% among EHR adopters

The 2005 EHR adoption rate will need to triple in less than a decade (for MA), which represents a challenge for health care policy

Stronger incentives or more extensive programs to support physician office transformation may be needed

Validity Unmeasured confounding factors may have obscured true associations Models included “all” available covariates HEDIS rates used Derived from claims data Self-reported Similar results to nationwide survey Follow-up surveys indicated usage rate stability and increased usage of features External: State of MA, may not be generalizable to the USA

Unmeasured confounding factors may have obscured true associations

Models included “all” available covariates

HEDIS rates used

Derived from claims data

Self-reported

Similar results to nationwide survey

Follow-up surveys indicated usage rate stability and increased usage of features

External: State of MA, may not be generalizable to the USA

Conclusions No association between duration of using an EHR and quality of ambulatory care In general, EHR use was not associated with improved quality of care The old standby: more research needed

No association between duration of using an EHR and quality of ambulatory care

In general, EHR use was not associated with improved quality of care

The old standby: more research needed

Discussion

Reductionism or study complex systems? Often complex socio-technical systems with multiple components are evaluated: difficult to determine relative contribution / importance of their different components (communication –community – content) Do we need to evaluate “comprehensive systems” (with p2p as one of many components), or should we break them down to different components and evaluate these separately? Are the components “additive” in their effect, or is the sum bigger than its parts?

Often complex socio-technical systems with multiple components are evaluated: difficult to determine relative contribution / importance of their different components (communication –community – content)

Do we need to evaluate “comprehensive systems” (with p2p as one of many components), or should we break them down to different components and evaluate these separately?

Are the components “additive” in their effect, or is the sum bigger than its parts?

Which is the chicken? Egg? In the UK, with the combination of near-universal EHR implementation, decision support, and substantial pay-for-performance, very high levels of quality performance have been achieved,

In the UK, with the combination of near-universal EHR implementation, decision support, and substantial pay-for-performance, very high levels of quality performance have been achieved,

HEDIS Questions answered Was there any relationship with HEDIS scores and physician payment with the insurers? Open question Where HEDIS scores determined by all of the physicians' patients? HEDIS scores are determined with claims data How do HEDIS scores determine quality? Do they determine quality?

Was there any relationship with HEDIS scores and physician payment with the insurers?

Open question

Where HEDIS scores determined by all of the physicians' patients?

HEDIS scores are determined with claims data

How do HEDIS scores determine quality?

Do they determine quality?

HEDIS vs. other databases Would any of the following have been a better choice? If so, why? If not, why not?

Would any of the following have been a better choice? If so, why? If not, why not?

Massachusetts Health Care Quality and Cost Council

Agency for Healthcare Research and Quality

Ontario Health Quality Council

CIHI

HEDIS vs. other databases Would any of the following have been a better choice? If so, why? If not, why not?

Would any of the following have been a better choice? If so, why? If not, why not?

Discussion The authors conducted a longitudinal analysis for EHR adoption duration (years) vs. HEDIS measures, but wouldn't it be worthwhile to perform a stratified analysis which separated physicians based on their actual usage of EHR or EHR features (most, some, none) vs. HEDIS scores?

The authors conducted a longitudinal analysis for EHR adoption duration (years) vs. HEDIS measures, but wouldn't it be worthwhile to perform a stratified analysis which separated physicians based on their actual usage of EHR or EHR features (most, some, none) vs. HEDIS scores?

Adjustment for patient characteristics Would this be considered a valid risk adjustment measure? How would the investigator collect data on patient characteristics? What are the legal implications of such data collection?

Would this be considered a valid risk adjustment measure?

How would the investigator collect data on patient characteristics?

What are the legal implications of such data collection?

Standards? In eHealth? HA! Develop an EHR usage measure that would perform a standardized method for reporting on usage for EHRs.

Develop an EHR usage measure that would perform a standardized method for reporting on usage for EHRs.

Alternative Measures? Discuss in class some measures that may have been more appropriate assessing the impact of EHR use on quality of patient care

Discuss in class some measures that may have been more appropriate assessing the impact of EHR use on quality of patient care

Thanks Questions/comments/concerns

Questions/comments/concerns

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