Do hospitals with electronic medical records (EMRs) provide higher quality care?: an examination of three clinical conditions

Reconsidering hospital EHR adoption at the dawn of HITECH: implications of the reported 9% adoption of a "basic" EHR

Objective

In 2009, a prominent national report stated that 9% of US hospitals had adopted a “basic” electronic health record (EHR) system. This statistic was widely cited and became a memetic anchor point for EHR adoption at the dawn of HITECH. However, its calculation relies on specific treatment of the data; alternative approaches may have led to a different sense of US hospitals’ EHR adoption and different subsequent public policy.

Materials and Methods

We reanalyzed the 2008 American Heart Association Information Technology supplement and complementary sources to produce a range of estimates of EHR adoption. Estimates included the mean and median number of EHR functionalities adopted, figures derived from an item response theory-based approach, and alternative estimates from the published literature. We then plotted an alternative definition of national progress toward hospital EHR adoption from 2008 to 2018.

Results

By 2008, 73% of hospitals had begun the transition to an EHR, and the majority of hospitals had adopted at least 6 of the 10 functionalities of a basic system. In the aggregate, national progress toward basic EHR adoption was 58% complete, and, when accounting for measurement error, we estimate that 30% of hospitals may have adopted a basic EHR.

Discussion

The approach used to develop the 9% figure resulted in an estimate at the extreme lower bound of what could be derived from the available data and likely did not reflect hospitals’ overall progress in EHR adoption.

Conclusion

The memetic 9% figure shaped nationwide thinking and policy making about EHR adoption; alternative representations of the data may have led to different policy.

Electronic health records systems and hospital clinical performance: a study of nationwide hospital data

OBJECTIVE

Electronic health records (EHRs) were expected to yield numerous benefits. However, early studies found mixed evidence of this. We sought to determine whether widespread adoption of modern EHRs in the US has improved clinical care.

METHODS

We studied hospitals reporting performance measures from 2008-2015 in the Centers for Medicare and Medicaid Services Hospital Compare database that also reported having an EHR in the American Hospital Association 2015 IT supplement. Using interrupted time-series analysis, we examined the association of EHR implementation, EHR vendor, and Meaningful Use status with 11 process measures and 30-day hospital readmission and mortality rates for heart failure, pneumonia, and acute myocardial infarction.

RESULTS

A total of 1246 hospitals contributed 8222 hospital-years. Compared to hospitals without EHRs, hospitals with EHRs had significant improvements over time on 5 of 11 process measures. There were no substantial differences in readmission or mortality rates. Hospitals with CPSI EHR systems performed worse on several process and outcome measures. Otherwise, we found no substantial improvements in process measures or condition-specific outcomes by duration of EHR use, EHR vendor, or a hospital's Meaningful Use Stage 1 or Stage 2 status.

CONCLUSION

In this national study of hospitals with modern EHRs, EHR use was associated with better process of care measure performance but did not improve condition-specific readmission or mortality rates regardless of duration of EHR use, vendor choice, or Meaningful Use status. Further research is required to understand why EHRs have yet to improve standard outcome measures and how to better realize the potential benefits of EHR systems.

Comparing the Hospital-Acquired Condition Reduction Program and the Accreditation of Cancer Program: A Cross-sectional Study

Under the Hospital-Acquired Condition Reduction Program (HACRP), introduced by the Affordable Care Act, the Centers for Medicare and Medicaid must reduce reimbursement by 1% for hospitals that rank among the lowest performing quartile in regard to hospital-acquired conditions (HACs). This study seeks to determine whether Accredited Cancer Program (ACP) hospitals (as defined by the American College of Surgeons) score differently on the HACRP metrics than nonaccredited cancer program hospitals. This study uses data from the 2014 American Hospital Association Annual Survey database, the 2014 Area Health Resource File, the 2014 Medicare Final Rule Standardizing File, and the FY2017 HACRP database (Medicare Hospital Compare Database). The association between ACPs, HACs, and market characteristics is assessed through multinomial logistic regression analysis. Odds ratios and 95% confidence intervals are reported. Accredited cancer hospitals have a greater risk of scoring in the Worse outcome category of HAC scores, vs Middle or Better outcomes, compared with nonaccredited cancer hospitals. Despite this, they do not have greater odds of incurring a payment reduction under the HACRP measurement system. While ACP hospitals can likely improve scores, questions concerning the consistency of the message between ACP hospital quality and HACRP quality need further evaluation to determine potential gaps or issues in the structure or measurement. ACP hospitals should seek to improve scores on domain 2 measures. Although ACP hospitals do likely see more complex patients, additional efforts to reduce surgical site infections and related HACs should be evaluated and incorporated into required quality improvement efforts. From a policy perspective, policy makers should carefully evaluate the measures utilized in the HACPR.

Does participation in health information exchange improve hospital efficiency?

The federal government allocated nearly $30 billion to spur the development of information technology infrastructure capable of supporting the exchange of interoperable clinical data, leading to growth in hospital participation in health information exchange (HIE) networks. HIEs have the potential to improve care coordination across healthcare providers, leading ultimately to increased productivity of health services for hospitals. However, the impact of HIE participation on hospital efficiency remains unclear. This dynamic prompts the question asked by this study: does HIE participation improve hospital efficiency. This study estimates the effect of HIE participation on efficiency using a national sample of 1017 hospitals from 2009 to 2012. Using a two-stage analytic design, efficiency indices were determined using the Malmquist algorithm and then regressed on a set of hospital characteristics. Results suggest that any participation in HIE can improve both technical efficiency change and total factor productivity (TFP). A second model examining total years of HIE participation shows a benefit of one and three years of participation on TFP. These results suggest that hospital investment in HIE participation may be a useful strategy to improve hospital operational performance, and that policy should continue to support increased participation and use of HIE. More research is needed to identify the exact mechanisms through which HIE participation can improve hospital efficiency.

Assessing the relationship between patient safety culture and EHR strategy

Purpose

– The purpose of this paper is to explore the relationship between hospitals’ electronic health record (EHR) adoption characteristics and their patient safety cultures. The “Meaningful Use” (MU) program is designed to increase hospitals’ adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated.

Design/methodology/approach

– Providers’ perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality’s surveys on patient safety culture (level 1) and the American Hospital Association’s survey and healthcare information technology supplement (level 2).

Findings

– The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers’ perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research.

Originality/value

– Relating EHR MU and providers’ care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.

Texas hospitals with higher health information technology expenditures have higher revenue: A longitudinal data analysis using a generalized estimating equation model

BACKGROUND

The benefits of health information technology (IT) adoption have been reported in the literature, but whether health IT investment increases revenue generation remains an important research question.

METHODS

Texas hospital data obtained from the American Hospital Association (AHA) for 2007-2010 were used to investigate the association of health IT expenses and hospital revenue. The generalized estimation equation (GEE) with an independent error component was used to model the data controlling for cluster error within hospitals.

RESULTS

We found that health IT expenses were significantly and positively associated with hospital revenue. Our model predicted that a 100% increase in health IT expenditure would result in an 8% increase in total revenue. The effect of health IT was more associated with gross outpatient revenue than gross inpatient revenue.

CONCLUSION

Increased health IT expenses were associated with greater hospital revenue. Future research needs to confirm our findings with a national sample of hospitals.

Impact of CPOE usage on medication management process costs and quality outcomes

We assess the impact of computerized physician order entry (CPOE) systems usage on cost and process quality in the medication management process. Data are compiled from 1,014 U.S. acute-care hospitals that have already implemented CPOE. Data sources include the American Hospital Association, HIMSS Analytics, and the Centers for Medicare and Medicaid Services. We examine the association of CPOE usage with nursing and pharmacy salary costs, and evidence-based medication process compliance. Empirical findings controlling for endogeneity in usage show that benefits accrue even when 100 percent usage is not achieved. We demonstrate that the relationship of CPOE usage with cost and compliance is non-linear.

The influence of institutional pressures on hospital electronic health record presence

Electronic health records (EHR) are a promising form of health information technology that could help US hospitals improve on their quality of care and costs. During the study period explored (2005-2009), high expectations for EHR diffused across institutional stakeholders in the healthcare environment, which may have pressured hospitals to have EHR capabilities even in the presence of weak technical rationale for the technology. Using an extensive set of organizational theory-specific predictors, this study explored whether five factors - cause, constituents, content, context, and control - that reflect the nature of institutional pressures for EHR capabilities motivated hospitals to comply with these pressures. Using information from several national data bases, an ordered probit regression model was estimated. The resulting predicted probabilities of EHR capabilities from the empirical model's estimates were used to test the study's five hypotheses, of which three were supported. When the underlying cause, dependence on constituents, or influence of control were high and potential countervailing forces were low, hospitals were more likely to employ strategic responses that were compliant with the institutional pressures for EHR capabilities. In light of these pressures, hospitals may have acquiesced, by having comprehensive EHR capabilities, or compromised, by having intermediate EHR capabilities, in order to maintain legitimacy in their environment. The study underscores the importance of our assessment for theory and policy development, and provides suggestions for future research.

Hospital characteristics associated with achievement of meaningful use

The objective of this study was to identify factors associated with hospitals that achieved the Medicare meaningful use incentive thresholds for payment under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. We employed a cross-sectional design using data from the 2011 American Hospital Association Annual Survey, including the Information Technology Supplement; the Centers for Medicare & Medicaid Services report of hospitals receiving meaningful use payments; and the Health Resources and Services Administration's Area Resource File. We used a lagged value from 2010 to determine electronic health record (EHR) adoption. Our methods were a descriptive analysis and logistic regression to examine how various hospital characteristics are associated with the achievement of Medicare meaningful use incentives. Overall, 1,769 (38%) of 4,683 potentially eligible hospitals achieved meaningful use incentive thresholds by the end of 2012. Characteristics associated with organizations that received incentive payments were having an EHR in place in 2010, having a larger bed size, having a single health information technology vendor, obtaining Joint Commission accreditation, operating under for-profit status, having Medicare share of inpatient days in the middle two quartiles, being eligible for Medicaid incentives, and being located in the Middle Atlantic or South Atlantic census region. Characteristics associated with not receiving incentive payments were being a member of a hospital system and being located in the Mountain or Pacific census region. Thus far, little evidence suggests that the HITECH incentive program has enticed hospitals without an EHR system to adopt meaningful use criteria. Policy makers should consider modifying the incentive program to accelerate the adoption of and meaningful use in hospitals without EHRs.

Impact of electronic health records on the patient experience in a hospital setting

BACKGROUND

The impact of electronic health records (EHRs) and their effects on optimizing the patient experience has been debated nationally. Currently, there is a paucity of data in this area, and existing research offers conflicting results. Since 2006, the Assessing Residents' CI-CARE (ARC) program has evaluated the physician-patient interaction of resident physicians at University of California, Los Angeles (UCLA) Health utilizing a 20-item questionnaire administered through facilitator-patient interviews.

OBJECTIVE

To evaluate the impact of EHR implementation on the patient experience.

DESIGN

Retrospective cohort study.

SETTING

Two academic medical campuses: Ronald Reagan UCLA Medical Center and UCLA Medical Center, Santa Monica.

METHODS

A total of 3417 surveys, spanning December 1, 2012 to May 30, 2013, were assessed. This included patient representation from 9 departments within UCLA Health. Surveys were analyzed to assess physician-patient communication. Statistical comparisons were made using χ analysis.

RESULTS

All 16 questions assessing physician-patient communication received better responses in the 3 months following EHR implementation, compared to the 3 months prior to implementation. Of these, 9 questions illustrated statistically significant improvement, whereas the improvement in the remaining 7 questions was not statistically significant.

DISCUSSION

These results suggest that EHRs may improve physician-patient communication. The ARC infrastructure allowed for observation of this trend; however, future research should aim to further validate and understand the etiologies of this improvement.

The long-term financial impact of electronic health record implementation

OBJECTIVE

To examine the financial impact of electronic health record (EHR) implementation on ambulatory practices.

METHODS

We tracked the practice productivity (ie, number of patient visits) and reimbursement of 30 ambulatory practices for 2 years after EHR implementation and compared each practice to their pre-EHR implementation baseline.

RESULTS

Reimbursements significantly increased after EHR implementation even though practice productivity (ie, the number of patient visits) decreased over the 2-year observation period. We saw no evidence of upcoding or increased reimbursement rates to explain the increased revenues. Instead, they were associated with an increase in ancillary office procedures (eg, drawing blood, immunizations, wound care, ultrasounds).

DISCUSSION

The bottom line result-that EHR implementation is associated with increased revenues-is reassuring and offers a basis for further EHR investment. While the productivity losses are consistent with field reports, they also reflect a type of efficiency-the practices are receiving more reimbursement for fewer seeing patients. For the practices still seeing fewer patients after 2 years, the solution likely involves advancing their EHR functionality to include analytics. Although they may still see fewer patients, with EHR analytics, they can focus on seeing the right patients.

CONCLUSIONS

Practice reimbursements increased after EHR implementation, but there was a long-term decrease in the number of patient visits seen in this ambulatory practice context.

The effect of health information technology implementation in Veterans Health Administration hospitals on patient outcomes

BACKGROUND

The impact of health information technology (HIT) in hospitals is dependent in large part on how it is used by nurses. This study examines the impact of HIT on the quality of care in hospitals in the Veterans Health Administration (VA), focusing on nurse-sensitive outcomes from 1995 to 2005.

METHODS

Data were obtained from VA databases and original data collection. Fixed-effects Poisson regression was used, with the dependent variables measured using the Agency for Healthcare Research and Quality Inpatient Quality Indicators and Patient Safety Indicators software. Dummy variables indicated when each facility began and completed implementation of each type of HIT. Other explanatory variables included hospital volume, patient characteristics, nurse characteristics, and a quadratic time trend.

RESULTS

The start of computerized patient record implementation was associated with significantly lower mortality for two diagnoses but significantly higher pressure ulcer rates, and full implementation was associated with significantly more hospital-acquired infections. The start of bar-code medication administration implementation was linked to significantly lower mortality for one diagnosis, but full implementation was not linked to any change in patient outcomes.

CONCLUSIONS

The commencement of HIT implementation had mixed effects on patient outcomes, and the completion of implementation had little or no effect on outcomes.

IMPLICATIONS

This longitudinal study provides little support for the perception of VA staff and leaders that HIT has improved mortality rates or nurse-sensitive patient outcomes. Future research should examine patient outcomes associated with specific care processes affected by HIT.

Institutionalizing HIPAA compliance: organizations and competing logics in U.S. health care

Health care in the United States is highly regulated, yet compliance with regulations is variable. For example, compliance with two rules for securing electronic health information in the 1996 Health Insurance Portability and Accountability Act took longer than expected and was highly uneven across U.S. hospitals. We analyzed 3,321 medium and large hospitals using data from the 2003 Health Information and Management Systems Society Analytics Database. We find that organizational strategies and institutional environments influence hospital compliance, and further that institutional logics moderate the effect of some strategies, indicating the interplay of regulation, institutions, and organizations that contribute to the extensive variation that characterizes the U.S. health care system. Understanding whether and how health care organizations like hospitals respond to new regulation has important implications both for creating desired health care reform and for medical sociologists interested in the changing organizational structure of health care.

Predicting unplanned readmission after myocardial infarction from routinely collected administrative hospital data

Objective Readmission rates are high following acute myocardial infarction (AMI), but risk stratification has proved difficult because known risk factors are only weakly predictive. In the present study, we applied hospital data to identify the risk of unplanned admission following AMI hospitalisations. Methods The study included 1660 consecutive AMI admissions. Predictive models were derived from 1107 randomly selected records and tested on the remaining 553 records. The electronic medical record (EMR) model was compared with a seven-factor predictive score known as the HOSPITAL score and a model derived from Elixhauser comorbidities. All models were evaluated for the ability to identify patients at high risk of 30-day ischaemic heart disease readmission and those at risk of all-cause readmission within 12 months following the initial AMI hospitalisation. Results The EMR model has higher discrimination than other models in predicting ischaemic heart disease readmissions (area under the curve (AUC) 0.78; 95% confidence interval (CI) 0.71–0.85 for 30-day readmission). The positive predictive value was significantly higher with the EMR model, which identifies cohorts that were up to threefold more likely to be readmitted. Factors associated with readmission included emergency department attendances, cardiac diagnoses and procedures, renal impairment and electrolyte disturbances. The EMR model also performed better than other models (AUC 0.72; 95% CI 0.66–0.78), and with greater positive predictive value, in identifying 12-month risk of all-cause readmission. Conclusions Routine hospital data can help identify patients at high risk of readmission following AMI. This could lead to decreased readmission rates by identifying patients suitable for targeted clinical interventions. What is known about the topic? Many clinical and demographic risk factors are known for hospital readmissions following acute myocardial infarction, including multivessel disease, high baseline heart rate, hypertension, diabetes, obesity, chronic obstructive pulmonary disease and psychiatric morbidity. However, combining these risk factors into indices for predicting readmission had limited success. A recent study reported a C-statistic of 0.73 for predicting 30-day readmissions. In a recent American study, a simple seven-factor score was shown to predict hospital readmissions among medical patients. What does this paper add? This paper presents a way to predict readmissions following myocardial infarction using routinely collected administrative data. The model performed better than the recently described HOSPITAL score and a model derived from Elixhauser comorbidities. Moreover, the model uses only data generally available in most hospitals. What are the implications for practitioners? Routine hospital data available at discharges can be used to tailor preventative care for AMI patients, to improve institutional performance and to decrease the cost burden associated with AMI.

Medical home interventions and quality outcomes for older adults: a systematic review

PURPOSE

Medical home care has been identified as a model for improving primary care delivery and population-specific quality and safety outcomes. Questions remain how this model affects older adult quality. This systematic review addresses 2 important questions: Are quality and safety outcomes associated with medical home and patient-centered interventions, and how is quality studied in older adult primary care research?

METHODS

The authors searched MEDLINE for articles that examined interventions that were associated with medical home principles. Each article was evaluated using a standardized data abstraction form. Studies were categorized according to how interventions influenced specific quality and safety outcomes-improved clinical and treatment measures and care delivery processes-for older adults.

RESULTS

Thirteen research studies were identified by the authors. A great deal of variety exists in both research design and how quality and safety outcomes for older adults are operationalized in primary care. In general, studies indicate potentially beneficial relationships between 3 types of medical home interventions targeting health care utilization, disease management, and patient-provider communication to improved quality outcomes.

CONCLUSION

It would be advantageous for practices looking to align with patient-centered medical home quality and safety goals to consider the needs of older adults when redesigning care delivery.

Meaningful use of electronic health record systems and process quality of care: evidence from a panel data analysis of U.S. acute-care hospitals

OBJECTIVE

To estimate the incremental effects of transitions in electronic health record (EHR) system capabilities on hospital process quality.

DATA SOURCE

Hospital Compare (process quality), Health Information and Management Systems Society Analytics (EHR use), and Inpatient Prospective Payment System (hospital characteristics) for 2006-2010.

STUDY SETTING

Hospital EHR systems were categorized into five levels (Level_0 to Level_4) based on use of eight clinical applications. Level_3 systems can meet 2011 EHR "meaningful use" objectives. 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.

PRINCIPAL FINDINGS

Among all hospitals, implementing Level_3 systems yielded an incremental 0.35-0.49 percentage point increase in quality (over Level_2) across three conditions. Hospitals in bottom quartile of baseline quality increased 1.16-1.61 percentage points across three conditions for reaching Level_3. However, transitioning to Level_4 yielded an incremental decrease of 0.90-1.0 points for three conditions among all hospitals and 0.65-1.78 for bottom quartile hospitals.

CONCLUSIONS

Hospitals transitioning to EHR systems capable of meeting 2011 meaningful use objectives improved process quality, and lower quality hospitals experienced even higher gains. However, hospitals that transitioned to more advanced systems saw quality declines.

A randomized controlled trial of health information exchange between human immunodeficiency virus institutions

CONTEXT

In order for patients to benefit from a multidisciplinary treatment approach, diverse providers must communicate on patient care.

OBJECTIVE

We sought to examine the effect of information exchange across multidisciplinary human immunodeficiency virus (HIV) care providers on patient health outcomes.

DESIGN

Randomized controlled trial, randomized at the patient level.

SETTING

Six infectious disease clinics paired with 9 ancillary care settings (eg, HIV case management).

PARTICIPANTS

Two hundred fifty-four patients with HIV receiving care at the infectious disease clinics.

INTERVENTION

Health information was exchanged for 2 years per patient between medical and ancillary care providers using electronic health records and printouts inserted into charts. Medical care providers gave ancillary care providers HIV viral loads, CD4 values, current medications, and appointment attendance. Ancillary care providers gave medical providers the information on medication adherence and major changes (eg, loss of housing).

MAIN OUTCOME MEASURES

We abstracted from medical records HIV viral loads, CD4 counts, and antiretroviral medication prescriptions before and during the intervention. From 0-, 12-, and 24-month patient surveys, we assessed hospitalizations, emergency department use, and health-related quality of life measured by the Medical Outcomes Study Short Form-36 (SF-36).

RESULTS

No statistically significant differences between cases and controls were found across time for the following: proportion with suppressed viral load, changes in viral load or CD4 values, patients being prescribed antiretroviral medication, hospitalizations, emergency department visits, or any scale of the SF-36. Trends were mixed but leaned toward better health for control participants.

CONCLUSIONS

The exchange of this specific set of information between HIV medical and ancillary care providers was neutral on a variety of patient health outcomes.

Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico

The findings of a case study assessing the design and implementation of an electronic health record (EHR) in the public health system of Colima, Mexico, its perceived benefits and limitations, and recommendations for improving the implementation process are presented. In-depth interviews and focus group discussions were used to examine the experience of the actors and stakeholders participating in the design and implementation of EHRs. Results indicate that the main driving force behind the use of EHRs was to improve reporting to the two of the main government health and social development programs. Significant challenges to the success of the EHR include resistance by physicians to use the ICD-10 to code diagnoses, insufficient attention to recurrent resources needed to maintain the system, and pressure from federal programs to establish parallel information systems. Operating funds and more importantly political commitment are required to ensure sustainability of the EHRs in Colimaima.

A review of hospital characteristics associated with improved performance

PURPOSE

The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance.

DATA SOURCES

The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles.

STUDY SELECTION

and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume.

CONCLUSION

There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.

Is electronic health record use associated with patient satisfaction in hospitals?

PURPOSE

The aim of this study was to examine the relationship between hospital electronic health record (EHR) use and patient satisfaction.

DATA SOURCES/STUDY SETTING

We used EHR and other data from the American Hospital Association and Area Resource File as well as all 10 measures of patient satisfaction from the Hospital Compare data from 2008.

METHODOLOGY/APPROACH

We used a retrospective cross-sectional approach and control for potential selection bias with propensity score matching. Ten regression models were used to measure the relationship between EHR use and patient satisfaction. Of these, 3 of the 10 patient satisfaction items were hypothesized to be amenable by EHR automation; the remaining 7 measures served as counterfactuals.

FINDINGS

Electronic health record use was positively and significantly associated with the 3 hypothesized measures and none of the counterfactual measures of patient satisfaction. The three measures associated with EHR use included (a) whether the staff gave the patient information on what to do for recovery at home, (b) whether the patient would rate the hospital as a 9 or a 10, and (c) whether the patient would recommend the hospital. The significant relationships persisted with propensity score adjustments.

PRACTICE IMPLICATIONS

Electronic health record use is positively associated with 3 of 10 measures of patient satisfaction. Policy and decision makers interested in EHR adoption should also consider the potential impact that such adoption can have on patient satisfaction.

The association between health information exchange and measures of patient satisfaction

OBJECTIVE

Health information exchange (HIE) is the interorganizational sharing of patient information and is one of many health information technology initiatives expected to transform the U.S. healthcare system. Two outcomes expected to be improved by HIE are patient-provider communication and patient satisfaction . This analysis examined the relationship between the level of HIE engagement and these two factors in a sample of U.S. hospitals.

METHODS

Independent variables came from existing secondary sources and the dependent measures were from the Hospital Consumer Assessment of Healthcare Providers and Systems. The analysis included 3,278 hospitals. Using ordinary least squares regression, implemented HIE was positively associated with the percentage of patients reporting nurses communicated well and higher satisfaction. Due to the potential for selection bias, results were further explored using a propensity score analysis.

RESULTS

Hospitals that had adopted HIE, but not yet implemented saw no benefits. Hospitals' level of HIE was not associated with the percentage of patients reporting doctors communicated well. According to propensity score corrected estimates, implemented HIE was associated with the percentage of patients who reported nurses always communicated well and who would definitely recommend the hospital.

CONCLUSION

Few studies have examined the impact of HIE at the organizational level. This examination provides some evidence that hospitals engaging in HIE are associated with higher patient satisfaction.

Medication administration quality and health information technology: a national study of US hospitals

OBJECTIVE

To determine whether the use of computerized physician order entry (CPOE) and electronic medication administration records (eMAR) is associated with better quality of medication administration at medium-to-large acute-care hospitals. DATA/STUDY SETTING: A retrospective cross-sectional analysis of data from three sources: CPOE/eMAR usage from HIMSS Analytics (2010), medication quality scores from CMS Hospital Compare (2010), and hospital characteristics from CMS Acute Inpatient Prospective Payment System (2009). The analysis focused on 11 quality indicators (January-December 2009) at 2603 medium-to-large (≥ 100 beds), non-federal acute-care hospitals measuring proportion of eligible patients given (or prescribed) recommended medications for conditions, including acute myocardial infarction, heart failure, and pneumonia, and surgical care improvement. Using technology adoption by 2008 as reference, hospitals were coded: (1) eMAR-only adopters (n=986); (2) CPOE-only adopters (n=115); and (3) adopters of both technologies (n=804); with non-adopters of both technologies as reference group (n=698). Hospitals were also coded for duration of use in 2-year increments since technology adoption. Hospital characteristics, historical measure-specific patient volume, and propensity scores for technology adoption were used to control for confounding factors. The analysis was performed using a generalized linear model (logit link and binomial family).

PRINCIPAL FINDINGS

Relative to non-adopters of both eMAR and CPOE, the odds of adherence to all measures (except one) were higher by 14-29% for eMAR-only hospitals and by 13-38% for hospitals with both technologies, translating to a marginal increase of 0.4-2.0 percentage points. Further, each additional 2 years of technology use was associated with 6-15% higher odds of compliance on all medication measures for eMAR-only hospitals and users of both technologies.

CONCLUSIONS

Implementation and duration of use of health information technologies are associated with improved adherence to medication guidelines at US hospitals. The benefits are evident for adoption of eMAR systems alone and in combination with CPOE.

Effects of electronic health information technology implementation on nursing home resident outcomes

OBJECTIVE

To examine the effects of electronic health information technology (HIT) on nursing home residents.

METHODS

The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.

RESULTS

No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.

DISCUSSION

The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.

Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence From the National Database of Nursing Quality Indicators

Electronic medical records (EMR) have the potential to improve nursing care in the hospital setting. This study estimated the association of EMR implementation with nurse staffing levels, skill mix, contract/agency percent, and nurse-sensitive patient outcomes in U.S. hospitals. Data on nurse staffing and patient outcomes came from the 2004-2008 National Database of Nursing Quality Indicators. Data on EMR implementation came from the 2004-2008 HIMSS Analytics Database. The authors conducted a longitudinal analysis of an unbalanced panel of 3,048 medical/surgical units in 509 short-term, general acute care hospitals. EMR implementation was associated with lower total nurse hours per patient day, higher Registered Nurse percent and contract/agency percent, and higher adverse patient events in the short term. EMR may create a skill bias toward higher-skilled nurses. As more advanced EMR systems diffuse into practice, managers and policy makers should consider potential negative associations of EMR implementation with patient safety.

Electronic Health Records

Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. This study investigates how EHR use, as implemented and utilized, impacts patient safety and quality performance. Data in this paper include nonfederal acute care hospitals in the state of Texas, and the data sources include the American Hospital Association, the Dallas Fort Worth Hospital Council, and the American Hospital Directory. The authors use partial least squares modeling to assess the relationship between hospital EHR use, patient safety, and quality of care. Patient safety is measured using 11 indicators as identified by the Agency for Healthcare Research and Quality (AHRQ) and quality performance is measured by 11 mortality indicators as related to 2 constructs, that is, conditions and surgical procedures. Results identify positive significant relationships between EHR use, patient safety, and quality of care with respect to procedures. The authors conclude that there is sufficient evidence of the relationship between hospital EHR use and patient safety, and that sufficient evidence exists for the support of EHR use with hospital surgical procedures.

Social networks and physician adoption of electronic health records: insights from an empirical study

OBJECTIVE

To study how social interactions influence physician adoption of an electronic health records (EHR) system.

DESIGN

A social network survey was used to delineate the structure of social interactions among 40 residents and 15 attending physicians in an ambulatory primary care practice. Social network analysis was then applied to relate the interaction structures to individual physicians' utilization rates of an EHR system.

MEASUREMENTS

The social network survey assessed three distinct types of interaction structures: professional network based on consultation on patient care-related matters; friendship network based on personal intimacy; and perceived influence network based on a person's perception of how other people have affected her intention to adopt the EHR system. EHR utilization rates were measured as the proportion of patient visits in which sentinel use events consisting of patient data documentation or retrieval activities were recorded. The usage data were collected over a time period of 14 months from computer-recorded audit trail logs.

RESULTS

Neither the professional nor the perceived influence network is correlated with EHR usage. The structure of the friendship network significantly influenced individual physicians' adoption of the EHR system. Residents who occupied similar social positions in the friendship network shared similar EHR utilization rates (p<0.05). In other words, residents who had personal friends in common tended to develop comparable levels of EHR adoption. This effect is particularly prominent when the mutual personal friends of these 'socially similar' residents were attending physicians (p<0.001).

CONCLUSIONS

Social influence affecting physician adoption of EHR seems to be predominantly conveyed through interactions with personal friends rather than interactions in professional settings.

Robust replication of genotype-phenotype associations across multiple diseases in an electronic medical record

Large-scale DNA databanks linked to electronic medical record (EMR) systems have been proposed as an approach for rapidly generating large, diverse cohorts for discovery and replication of genotype-phenotype associations. However, the extent to which such resources are capable of delivering on this promise is unknown. We studied whether an EMR-linked DNA biorepository can be used to detect known genotype-phenotype associations for five diseases. Twenty-one SNPs previously implicated as common variants predisposing to atrial fibrillation, Crohn disease, multiple sclerosis, rheumatoid arthritis, or type 2 diabetes were successfully genotyped in 9483 samples accrued over 4 mo into BioVU, the Vanderbilt University Medical Center DNA biobank. Previously reported odds ratios (OR(PR)) ranged from 1.14 to 2.36. For each phenotype, natural language processing techniques and billing-code queries were used to identify cases (n = 70-698) and controls (n = 808-3818) from deidentified health records. Each of the 21 tests of association yielded point estimates in the expected direction. Previous genotype-phenotype associations were replicated (p < 0.05) in 8/14 cases when the OR(PR) was > 1.25, and in 0/7 with lower OR(PR). Statistically significant associations were detected in all analyses that were adequately powered. In each of the five diseases studied, at least one previously reported association was replicated. These data demonstrate that phenotypes representing clinical diagnoses can be extracted from EMR systems, and they support the use of DNA resources coupled to EMR systems as tools for rapid generation of large data sets required for replication of associations found in research cohorts and for discovery in genome science.

Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non-government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Enhanced identification of eligibility for depression research using an electronic medical record search engine

PURPOSE

Electronic medical records (EMRs) have become part of daily practice for many physicians. Attempts have been made to apply electronic search engine technology to speed EMR review. This was a prospective, observational study to compare the speed and clinical accuracy of a medical record search engine vs. manual review of the EMR.

METHODS

Three raters reviewed 49 cases in the EMR to screen for eligibility in a depression study using the electronic medical record search engine (EMERSE). One week later raters received a scrambled set of the same patients including 9 distractor cases, and used manual EMR review to determine eligibility. For both methods, accuracy was assessed for the original 49 cases by comparison with a gold standard rater.

RESULTS

Use of EMERSE resulted in considerable time savings; chart reviews using EMERSE were significantly faster than traditional manual review (p=0.03). The percent agreement of raters with the gold standard (e.g. concurrent validity) using either EMERSE or manual review was not significantly different.

CONCLUSIONS

Using a search engine optimized for finding clinical information in the free-text sections of the EMR can provide significant time savings while preserving clinical accuracy. The major power of this search engine is not from a more advanced and sophisticated search algorithm, but rather from a user interface designed explicitly to help users search the entire medical record in a way that protects health information.