The relationship between a physician practice's adoption of electronic health records (EHR) and quality improvements in patient care remains unclear. However, a new study published in the January issue of Health Affairs by Weill Cornell Medical College and the Primary Care Information Project (PCIP) of the New York City Health Department shows evidence that EHR implementation can improve patient care in small physician practices in New York City when combined with sustained high-intensity technical assistance.
To evaluate the effects EHRs have on patient care within small physician practices, the research team used an independent data source using multi-payer medical claims in New York state (New York Quality Alliance), linking the data to small practices enrolled in the Primary Care Information Project. This New York City Health Department initiative provided subsidized EHR software with clinical decision support and onsite technical assistance to 3,300 physicians at 600 primary care practices in underserved neighborhoods serving disadvantaged populations to improve quality of care. This is the United States' largest community-based EHR implementation program, and the PCIP continues to provide technical assistance and education to more than 7,200 providers through its regional extension center, NYC REACH.
The research study found EHR implementation alone was not enough to improve patient care overall or known "EHR sensitive" quality improvement measures, such as cancer screenings and diabetes care. In fact, the researchers reported it took physician practices a minimum of nine months of EHR exposure, combined with eight or more technical assistance visits, to demonstrate any significant statistical improvements in certain key quality measures, including breast cancer screening, retinal exam and urine testing for diabetes patients, chlamydia screening for women and colorectal cancer screening. Physician offices with minimal or no technical support did not show any significant improvements, even when these practices had been using EHRs for up to two years.
"EHRs were once thought to be a cure-all for helping improve patient care, but there are implementation issues and the technology has a steep learning curve," says lead author Dr. Andrew M. Ryan, assistant professor of public health at Weill Cornell Medical College. "Our study shows EHRs can in fact be a tool for quality improvement, but not in isolation. Technical assistance must be at the heart of the EHR implementation process. Under resourced, small physician practices, especially those taking care of underserved populations; need help to effectively use EHR technology to improve patient quality of care."
"These study findings are consistent with observations from our field staff that small physician practices serving the disadvantaged areas of New York City need considerably more technical support to use EHRs to improve quality," says Sarah Shih, executive director of Health Care Quality Information and Program Evaluation at PCIP. "High-intensity technical support has helped improve the quality of care provided by small physician practices in some key quality measures after nine months. In addition, PCIP has made major strides in using EHRs to improve population health among other key quality indicators not measured by claims data. We have also observed improved quality trends for smoking cessation counseling, blood pressure control, cholesterol screening and treatment."
Researchers say it will be important to continue to evaluate the effectiveness of various levels of technical support provided by regional extension centers in improving health outcomes. EHRs supply physicians with clinical decision support, tools to reduce medical errors, e-prescribing, test result displays, patient health registry information, population data management and improved communication with patients and other providers. The rate of EHR adoption for outpatient care is rising. Physician use of basic EHR systems has increased from 22 percent in 2009 to 35 percent in 2011.
But small practices, which constitute the majority of practices in the U.S., have the lowest rate of EHR adoption. Some evidence suggests small practices, especially those in underserved communities like New York City, are less likely to use EHRs. "EHRs hold a lot of hope and promise and the technology is taking health care a step in the right direction. Our study supports proof of concept that EHRs can improve outcomes, but widespread implementation of the technology and strong technical assistance is needed," says Dr. Ryan.
"Our hope is the extension of EHRs with proper technical support will have a direct impact on population health." The study findings are consistent with other research showing that EHRs alone do not consistently improve quality of care. This is one of the few studies to have evaluated the effect of EHRs implementation on the quality of care in a community outpatient setting focusing on physicians in small practices who serve primarily disadvantaged patients. "Our study results stand in contrast to widespread perceptions that EHRs automatically improve quality of care. It shows that regional extension centers like NYC REACH have an important role to play in facilitating the use of EHRs to improve the quality of care patients receive — which is always our ultimate goal," says the study's senior author Dr. Lawrence P. Casalino, the Livingston Farrand Associate Professor of Public Health and chief of the Division of Outcomes and Effectiveness Research at Weill Cornell.
In addition, Dr. Tara F. Bishop, assistant professor of public health and medicine at Weill Cornell, is a co-author of the study. This research was funded by the Robert Wood Johnson Foundation and performed in close collaboration with the New York City Department of Health and Mental Hygiene, who shared data from its Primary Care Information Project.
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