Electronic health records are expected to play a key role in improving the quality of U.S. healthcare. For this reason, the Obama administration's $27 billion HITECH ACT is urging the implementation of EHR systems through an incentive-based program for organizations that demonstrate the meaningful use of certified EHR technology. If hospitals don't demonstrate meaningful use of EHR systems, they face reductions in Medicare reimbursements starting in 2015. On the other hand, hospitals that adopt new systems and demonstrate meaningful use are able to receive up to $2 million in incentives.
Many believe this focus on the meaningful use — breadth of use, extent of use and quality of improvement — of health information technology is essential, especially to improve the U.S. healthcare delivery system. However, there is very little empirical evidence on the benefits of HIT. Is the focus and push for HIT and meaningful use really effective?
According to "Meaningful Use of Electronic Health Record Systems and Process Quality of Care: Evidence from a Panel Data Analysis of U.S. Acute-Care Hospitals," recently published in Health Services Research, meaningful use of EHRs does improve hospital quality. Hospitals with primitive or limited IT that upgraded to an EHR system satisfying stage 1 meaningful use objectives saw a significant improvement in healthcare delivery, according to the study.
"Finding that EHR systems, especially those following meaningful use requirements, provide value in healthcare delivery is assuring. Many of the hospitals that showed improvements were the ones struggling with quality to begin with. This is a great finding in light of the government incentives to drive adoption of EHRs," says Eric Johnson, PhD, director of the center for digital strategies at the Tuck School of Business at Dartmouth University and principal investigator of the study.
Study
The aim of the study was to determine if implementing and upgrading EHR systems to meet meaningful use improves hospital process quality. The study focused on quality measures for heart attack, heart failure, pneumonia and surgical care infection prevention.
Dr. Johnson and fellow researchers at Dartmouth University analyzed an extensive dataset of 3,921 hospitals over a five-year time period from 2006 to 2010. They conducted 16,650 hospital observations and analyzed data on EHR systems, which came from 2005 to 2009 HIMSS Analytics Databases. The data included hospital characteristics and the operational status of clinical health IT applications.
Dr. Johnson developed a classification system for the study that designates each hospital's EHR system capability into five levels.
• Level 0 — This level was used as a reference group and included hospitals with very primitive EHR capabilities. Most would consider them less than rudimentary because they have no or very little clinical systems.
• Level 1 — Level one included hospitals with three ancillary IT systems: laboratory, pharmacy and radiology.
• Level 2 — Level two hospitals had the capabilities of level one with clinical data repository and clinical decision support EHR function as well.
• Level 3 — Level three further added nursing documentation and electronic medication administration records to the preceding levels.
• Level 4 — This level included computerized physician order entry and all the EHR functions in the preceding levels.
According to the study, process quality was measured as composite scores on a 100-point scale for heart attack, heart failure, pneumonia and surgical care infection prevention. Statistical analyses were conducted using fixed effects linear panel regression model for all hospitals, hospitals stratified on condition-specific baseline quality, and for large hospitals.
Some hospitals were deemed "low quality" hospitals, meaning their historical quality levels were below a majority of other hospitals. "We based controls in the study on what a hospital's historic CMS measures were. Low quality meant the hospitals had historically performed at the bottom half of those measures," says Dr. Johnson.
Findings
Hospitals transitioning to EHR systems to meet the meaningful use stage 1 requirements saw statistically significant improvements in the outcomes for conditions of heart attack, heart failure and pneumonia. The improvements varied depending on hospital baseline quality performance, with low-quality hospitals seeing the largest improvements in quality.
• Among all hospitals, those upgrading from Level 2 EHR systems to Level 3 yielded an incremental 0.35 to 0.49 percentage point increase in quality for the three conditions.
• Hospitals in the bottom quartile of baseline quality increased 1.16 to 1.61 percentage points across three conditions for reaching Level 3. This was the highest improvement percentage out of all 3,921 hospitals studied.
• The hospitals transitioning to Level 4 systems yielded an incremental decrease of 0.90 to 1.0 points for the three conditions among all hospitals.
• There was no significant improvement in quality for surgical care infections.
"The biggest improvements were for hospitals that were not performing well — the hospitals in the bottom quartile [of CMS quality measures]. When they upgraded, they moved a full percentage point or a point and a half increase," says Dr. Johnson.
An interesting finding of the study was that advanced hospitals with superior healthcare delivery — hospitals transitioning from Level 3 to Level 4 EHR systems — actually saw their quality compliance go down. "This could be attributable to how hard it is to improve an already high quality level, and that there can be a backlash from healthcare professionals in using complicated software systems," says Dr. Johnson.
Implications
While research on HIT outcomes has been done before, those studies were on a much smaller scale. They never found statistically significant improvement. "These findings are the first step in investigating the outcomes of HIT on healthcare delivery because the study was so extensive," says Dr. Johnson.
As to why the advanced hospitals may have decreased in quality, Dr. Johnson believes it shows the limitations of technology. Sometimes technology can be more disruptive than helpful. "More technology isn't necessarily better. While it is important to have certain EHR capabilities, hospitals need to go back and improve the care processes along with technology," says Dr. Johnson.
Risk Assessments – What's the Big Deal? Your Responsibilities If You Adopt Electronic Health Records
According to "Meaningful Use of Electronic Health Record Systems and Process Quality of Care: Evidence from a Panel Data Analysis of U.S. Acute-Care Hospitals," recently published in Health Services Research, meaningful use of EHRs does improve hospital quality. Hospitals with primitive or limited IT that upgraded to an EHR system satisfying stage 1 meaningful use objectives saw a significant improvement in healthcare delivery, according to the study.
"Finding that EHR systems, especially those following meaningful use requirements, provide value in healthcare delivery is assuring. Many of the hospitals that showed improvements were the ones struggling with quality to begin with. This is a great finding in light of the government incentives to drive adoption of EHRs," says Eric Johnson, PhD, director of the center for digital strategies at the Tuck School of Business at Dartmouth University and principal investigator of the study.
Study
The aim of the study was to determine if implementing and upgrading EHR systems to meet meaningful use improves hospital process quality. The study focused on quality measures for heart attack, heart failure, pneumonia and surgical care infection prevention.
Dr. Johnson and fellow researchers at Dartmouth University analyzed an extensive dataset of 3,921 hospitals over a five-year time period from 2006 to 2010. They conducted 16,650 hospital observations and analyzed data on EHR systems, which came from 2005 to 2009 HIMSS Analytics Databases. The data included hospital characteristics and the operational status of clinical health IT applications.
Dr. Johnson developed a classification system for the study that designates each hospital's EHR system capability into five levels.
• Level 0 — This level was used as a reference group and included hospitals with very primitive EHR capabilities. Most would consider them less than rudimentary because they have no or very little clinical systems.
• Level 1 — Level one included hospitals with three ancillary IT systems: laboratory, pharmacy and radiology.
• Level 2 — Level two hospitals had the capabilities of level one with clinical data repository and clinical decision support EHR function as well.
• Level 3 — Level three further added nursing documentation and electronic medication administration records to the preceding levels.
• Level 4 — This level included computerized physician order entry and all the EHR functions in the preceding levels.
According to the study, process quality was measured as composite scores on a 100-point scale for heart attack, heart failure, pneumonia and surgical care infection prevention. Statistical analyses were conducted using fixed effects linear panel regression model for all hospitals, hospitals stratified on condition-specific baseline quality, and for large hospitals.
Some hospitals were deemed "low quality" hospitals, meaning their historical quality levels were below a majority of other hospitals. "We based controls in the study on what a hospital's historic CMS measures were. Low quality meant the hospitals had historically performed at the bottom half of those measures," says Dr. Johnson.
Findings
Hospitals transitioning to EHR systems to meet the meaningful use stage 1 requirements saw statistically significant improvements in the outcomes for conditions of heart attack, heart failure and pneumonia. The improvements varied depending on hospital baseline quality performance, with low-quality hospitals seeing the largest improvements in quality.
• Among all hospitals, those upgrading from Level 2 EHR systems to Level 3 yielded an incremental 0.35 to 0.49 percentage point increase in quality for the three conditions.
• Hospitals in the bottom quartile of baseline quality increased 1.16 to 1.61 percentage points across three conditions for reaching Level 3. This was the highest improvement percentage out of all 3,921 hospitals studied.
• The hospitals transitioning to Level 4 systems yielded an incremental decrease of 0.90 to 1.0 points for the three conditions among all hospitals.
• There was no significant improvement in quality for surgical care infections.
"The biggest improvements were for hospitals that were not performing well — the hospitals in the bottom quartile [of CMS quality measures]. When they upgraded, they moved a full percentage point or a point and a half increase," says Dr. Johnson.
An interesting finding of the study was that advanced hospitals with superior healthcare delivery — hospitals transitioning from Level 3 to Level 4 EHR systems — actually saw their quality compliance go down. "This could be attributable to how hard it is to improve an already high quality level, and that there can be a backlash from healthcare professionals in using complicated software systems," says Dr. Johnson.
Implications
While research on HIT outcomes has been done before, those studies were on a much smaller scale. They never found statistically significant improvement. "These findings are the first step in investigating the outcomes of HIT on healthcare delivery because the study was so extensive," says Dr. Johnson.
As to why the advanced hospitals may have decreased in quality, Dr. Johnson believes it shows the limitations of technology. Sometimes technology can be more disruptive than helpful. "More technology isn't necessarily better. While it is important to have certain EHR capabilities, hospitals need to go back and improve the care processes along with technology," says Dr. Johnson.
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