The relationship between a physician practice's adoption of electronic health records (EHRs) and quality improvements in patient care remains unclear. However, a new study published in the January issue of Health Affairs by Weill Cornell Medical College and the Primary Care Information Project (PCIP) of the New York City Health Department shows evidence that EHR implementation can improve patient care in small physician practices in New York City when combined with sustained high-intensity technical assistance.
To evaluate the effects EHRs have on patient care within small physician practices, the research team used an independent data source using multi-payer medical claims in New York state (New York Quality Alliance), linking the data to small practices enrolled in the Primary Care Information Project. This New York City Health Department initiative provided subsidized EHR software with clinical decision support and onsite technical assistance to 3,300 physicians at 600 primary care practices in underserved neighborhoods serving disadvantaged populations to improve quality of care. (This is the United States' largest community-based EHR implementation program, and the PCIP continues to provide technical assistance and education to more than 7,200 providers through its regional extension center, NYC REACH.)
The research study found EHR implementation alone was not enough to improve patient care overall or known "EHR sensitive" quality improvement measures, such as cancer screenings and diabetes care. In fact, the researchers reported it took physician practices a minimum of nine months of EHR exposure, combined with eight or more technical assistance visits, to demonstrate any significant statistical improvements in certain key quality measures, including breast cancer screening, retinal exam and urine testing for diabetes patients, chlamydia screening for women and colorectal cancer screening. Physician offices with minimal or no technical support did not show any significant improvements, even when these practices had been using EHRs for up to two years.
“EHRs were once thought to be a cure-all for helping improve patient care, but there are implementation issues and the technology has a steep learning curve,” says lead author Dr. Andrew M. Ryan, assistant professor of public health at Weill Cornell Medical College. “Our study shows EHRs can in fact be a tool for quality improvement, but not in isolation. Technical assistance must be at the heart of the EHR implementation process. Under resourced, small physician practices, especially those taking care of underserved populations; need help to effectively use EHR technology to improve patient quality of care.”
"These study findings are consistent with observations from our field staff that small physician practices serving the disadvantaged areas of New York City need considerably more technical support to use EHRs to improve quality," says Sarah Shih, executive director of Health Care Quality Information and Program Evaluation at PCIP. "High-intensity technical support has helped improve the quality of care provided by small physician practices in some key quality measures after nine months. In addition, PCIP has made major strides in using EHRs to improve population health among other key quality indicators not measured by claims data. We have also observed improved quality trends for smoking cessation counseling, blood pressure control, cholesterol screening and treatment."
Researchers say it will be important to continue to evaluate the effectiveness of various levels of technical support provided by regional extension centers in improving health outcomes.
The rate of EHR adoption for outpatient care is rising, according to Weill Cornell. Physician use of basic EHR systems has increased from 22 percent in 2009 to 35 percent in 2011. But small practices, which constitute the majority of practices in the U.S., have the lowest rate of EHR adoption. Some evidence suggests small practices, especially those in underserved communities like New York City, are less likely to use EHRs.
