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EHRs Fare Well in Battle of QI Strategies

Ever since the practice of medicine began evolving from a simple bedside exercise to the complex care system it has become, people have been proposing ways to improve the quality and efficiency with which care is delivered.

Proposals have ranged from rewarding superior clinician performance to the application of TQM principles to, recently, the widespread dissemination of EHRs.

EHRs Fare Well in Battle of QI StrategiesIs there any way to determine which of these quality improving proposals is the most effective?
That’s what Mark Friedberg and colleagues from Brigham and Women’s Hospital and Blue Cross/Blue Shield of Massachusetts set out to do, and lo and behold, they found that EHRs acquitted themselves rather nicely.

The scientists performed a cross-sectional analysis of 412 primary care practices in the Bay state, in which they collected data about utilization of various quality improvement techniques and linked these results to performance on 13 process quality measures derived from the HEDIS data bases.

Four hot quality topics were examined: screening, diabetes, depression and the overuse of clinical services.

The scientists looked at these QI techniques, among others: providing feedback to physicians regarding their performance, distributing reminders to patients and physicians about needed services, making interpreter services available, extending office hours to weekends and evenings and and using multifunctional EHRs.

Multifunctional EHRs were defined as those which included alerts and reminder systems, as well as decision support at the point of care.

The scientists found that practices which routinely used multifunctional EHRs scored significantly higher on 5 HEDIS measures, including screening for breast cancer, colorectal cancer and Chlamydia, and 2 in diabetes care. The improved performance ranged from 3.1% to 7.6%.

Frequent clinical meetings to discuss quality were were associated with improved performance on 3 measures of diabetes care, with the increments ranging from 2.3% to 3.1%. In addition, practices that reported high physician awareness of patient experience ratings showed improved performance on breast and cervical cancer screening by 1.9% and 2.2% respectively.

None of the remaining QI techniques were found to be associated with improved performance for more than 1 measure, and none improved performance when it came to the management of depression and the overuse of services.

“Overall, we were surprised by how few strategies to improve the quality of care were linked to measurably better performance,” Friedberg told BurrillReport. “The strategy that showed the most impact was use of advanced electronic health records. Increasing their adoption may help improve the quality of care in important areas of preventive care and chronic disease management.”

Friedberg and colleagues claim their study is among the first to show a link between EHR utilization in primary care settings and improved quality of care.

That may be, but the magnitude of the improvements they found were modest, and the limited number of associations between the QI techniques studied and the resulting quality of care give us pause. It may be that their sample size was too small, or the measurement tool too insensitive to detect significant differences. It’s also possible that baseline levels of quality in the study group were quite high to begin with.

Regardless, no one should conclude from this pioneering study that EHRs are a cure-all for the quality-related issues that plague modern, complex health care delivery systems, or that the Obama Administration is a lock to recover substantial returns on its enormous bet on EHRs. That said, EHRs, it appears from this study, certainly merit a place at the table.

The write-up appears in Annals of Internal Medicine.

Glenn Laffel, MD, PhD
Sr. Vice President Clinical Affairs, Practice Fusion

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