Electronic Health Records: A Prescription for Quality Care?

The use of electronic health records (EHRs), known interchangeably as electronic medical records or electronic patient records, has been thought of as a way to streamline patient data, thereby reducing costs and providing a higher quality of care to patients. When coupled with incentive payments or pay-for-performance (P4P), the use of EHRs is believed to achieve even greater improvement in the quality of care. However, much of the research in support of this assertion has focused on large, high capacity patient care facilities. By contrast, roughly 82 percent of American physicians provide care at small practices, which, due to their lack of size and resources relative to larger organizations, traditionally produce relatively worse health outcomes.

Last month, Naomi Bardach, MD of the University of California, San Francisco authored “Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial,” published in JAMA. The intent was to examine the effects of EHRs and quality improvement incentive payments on the improvement of care in practices with fewer than 10 physicians in order to gain insight into how EHRs and P4P would affect quality of care in small clinical settings. Dr. Bardach and her research team found that EHRs improved the quality of care in all of the participating clinics, though the improvements were greater in clinics receiving incentives based on their performance results.

The data used in the study were collected between April 2009 and March 2010 using a sampling of small clinics that were also participating in the New York City Department of Health and Mental Hygiene’s Primary Care Information Project (PCIP). When PCIP launched in 2005, each participating clinic was outfitted with identical EHR software to be used as a data collection tool for the program. In order to be included in the Bardach study, each clinic was required to have more than 200 regular patients, 10 percent of whom were insured by Medicaid or not insured at all. Once chosen, the clinics were split into two groups: one that received P4P incentives and quarterly benchmarking reports and another group that only received the quarterly reports.

The study showed that the quality of patients’ cardiovascular care in the incentivized clinics improved more during the study period than in the clinics not receiving incentives. Such care included the appropriate application of aspirin therapy, blood-pressure control, cholesterol management, and smoking cessation therapy. The quality of care also improved for patients enrolled in Medicaid or those without any kind of health insurance coverage. However, the results were not statistically significant. When compared to studies that investigated the use of EHRs and P4P in large medical practices, the improvements in performance among small practices were largely similar.

Dr. Bardach’s findings are key in the argument for health reform. When coupled with performance-based incentive payments, EHRs allow clinicians to track medical orders, medications, changes over time in blood levels, and biometric statistics. They are viewed as a way to reduce the wastefulness of unnecessary tests, misdiagnoses, overmedication, and, ultimately, avoidable repeat visits. Proponents of reform are hoping for a reduction of costs passed on to patients and their insurers. For patients covered by Medicare and Medicaid, a reduction in government spending on healthcare would follow. The anticipated consequences are cost savings and a net health benefit across the board in the United States, which, not inconsequentially, are why EHRs and P4P are cornerstones of the Affordable Care Act.

Feature Photo: cc/(Christine)