The Relationship between the Use of Electronic
Health Records and Quality of Care in U.S.
Hospitals
Catherine M. DesRoches DrPH
Academy Health
June 28, 2009
Introduction
• Funding: Office of the National Coordinator
for Health Information Technology, the
Robert Wood Johnson Foundation
• Study Team: Institute for Health Policy,
MGH; George Washington University;
Harvard School of Public Health; American
Hospital Association
Research Question
• Is the adoption of an EHR system or the
key clinical functionalities that comprise an
EHR associated with higher quality care?
– Nearly 400 studies examining the effect of
specific electronic functionalities on quality.
– Most of these studies come from a small set
of pioneering hospitals.
– Little evidence beyond these institutions.
Methods
Data Sources
• 2008 HIT Survey of Acute Care Hospitals in the
US
• 2005 AHA Annual Survey
• 2008 Hospital Quality Alliance Database
• 2006 Medicare Provider Analysis and Review
Database
2008 HIT Survey of Acute Care Hospitals
in the United States
• Survey of all 4,840 acute-care general medical/surgical
hospitals in the US.
• Field period: March – September 2008
• Response rate: 63.1% (3,054 hospitals)
• EHR definition: created with an expert consensus panel
– Comprehensive EHR: 24 clinical functionalities
implemented across all major clinical units
– Basic EHR: 10 clinical functionalities implemented in
at least one major clinical unit
• Analytic sample: 2,952 non-federal acute care general
hospitals.
Other Data Sources
2005 American Hospital Association Annual Survey
2007 Hospital Quality Alliance database
• Performance scores for 4,470 acute care hospitals based
on patients seen during the 2007 calendar year.
– Created summary scores for AMI, CHF, Pneumonia,
Surgical Infection Protection.
• 30-day Risk Standardized Mortality for AMI, CHF,
Pneumonia, Surgical Infection Protection.
2006 Medicare Provider Analysis and Review database
(MEDPAR)
• 30-day risk adjusted readmission rates for AMI, CHF,
Pneumonia, Surgical Infection Protection.
EHR Adoption Among Hospitals in the US
Percent of US hospitals with a comprehensive or basic EHR
50%
Comprehensive System: 1.5%
40%
Basic System: 7.8%
30%
18.5%
20%
21.1%
9.8%
10%
8.0%
6.1%
10.5%
7.4%
0%
Small
Medium
Hospital Size
Large
Teaching
Nonteaching
Teaching Status
Yes
No
Member of
a System
HQA Summary Scores and EHR Availability
Comprehensive or basic
100%
95.9% 95.0%*
86.9% 85.9%
91.2% 90.5%
No EHR
87.5% 85.4%*
90.9% 89.4%*
75%
50%
25%
0%
AMI
CHF
Pneumonia
Surgical Infection
prevention
SUMMARY SCORES
*Difference is significant at p < 0.01
Summary scores adjusted by hospital size, region, teaching, urban, CICU, and percent Medicaid.
Overall
HQA Summary Scores and Clinical
Decision Support - Guidelines
Comprehensive or basic
100%
95.7% 94.8% *
87.5% 85.3%*
91.1% 90.4%*
No EHR
86.2% 85.4%
90.1% 89.9%*
75%
50%
25%
0%
AMI
CHF
Pneumonia
Surgical Infection
prevention
Overall
SUMMARY SCORES
*Difference is significant at p < 0.01
Summary scores adjusted by hospital size, region, teaching, urban, CICU, and percent Medicaid.
HQA Summary Scores and Clinical
Decision Support – Clinical Reminders
Comprehensive or basic
100%
95.5% 94.8% *
86.9% 85.4% *
91.0% 90.4% *
No EHR
85.9% 85.5%
89.9% 89.3% **
75%
50%
25%
0%
AMI
*Difference is significant at p < 0.01.
**Difference is significant at p < 0.05.
CHF
Pneumonia
Surgical Infection
prevention
Overall
SUMMARY SCORES
Summary scores adjusted by hospital size, region, teaching, urban, CICU, and percent Medicaid.
Risk Adjusted 30-day Mortality and EHR
Availability
Comprehensive or basic
No EHR
25
20
16.1
16.1
15
11.1
11.1
11.4
11.4
10
5
0
AMI
CHF
Pneumonia
Mortality rates are risk adjusted and adjusted for hospital size, region, teaching, urban, CICU, and percent Medicaid patients.
Risk Adjusted 30-day Mortality and
Computerized Order Entry for Medications
Comprehensive or basic
No EHR
25
20
16.1
16.0
15
11.1
11.1
11.3
11.5 *
10
5
0
AMI
CHF
Pneumonia
*Difference is significant at p =0.02.
Mortality rates are risk adjusted and adjusted for hospital size, region, teaching, urban, CICU, and percent Medicaid patients.
30-Day Readmissions Rates and EHR
Availability
Comprehensive or basic
No EHR
40
30
25.8
24.9
25.1
24.4
19.0
20
20.2
10
0
AMI
CHF
Pneumonia
Readmission rates are risk adjusted and adjusted for hospital size, region, teaching, urban, CICU, and percent Medicaid patients.
30-Day Readmissions Rates and
Electronic Discharge Summaries
Comprehensive or basic
No EHR
40
29.6 *
30
25.0
26.2 **
24.4
19.6
20
20.9 **
10
0
AMI
CHF
Pneumonia
*Difference is significant at p =.0.02.
**Difference is significant at p < 0.01.
Readmission rates are risk adjusted and adjusted for hospital size, region, teaching, urban, CICU, and percent Medicaid patients.
Limitations
• Response rate: Non-responders were
different from responders.
• We could not measure use of HIT, only
availability.
• Limited detail on where the systems were
implemented.
• Cross-sectional data
• Limited set of quality metrics
Conclusions
• Modest but generally consistent relationships between EHR
adoption and performance on standard quality process measures
and readmission rates.
• This study moves us beyond the “efficacy” argument for EHRs by
assessing effectiveness.
• Study suggests that even beyond pioneering institutions,
functionalities such as clinical decision support seem to be
associated with better performance on process measures.
• Overall, findings are sobering: HIT adoption is likely to be an
important part of improving the efficiency and efficacy of our
health care system BUT just implementing systems will not have
a dramatic effect on care.