Will electronic health records improve healthcare quality? Challenges and future prospects

Keywords::

• electronic health records
• health information technology
• healthcare costs
• healthcare quality
• patient-centeredness
• patient safety

Health information technology has been widely touted as a key component to improving healthcare delivery along the six components of quality identified by the Institute of Medicine: effectiveness, efficiency, safety, timeliness, patient-centeredness and equity [1,2]. Owing to health information technology’s potential, many national governments have policies designed to promote the adoption of electronic health records (EHRs). In the USA alone, the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act allocated billions of dollars to promote widespread adoption and use of certified EHRs among individual clinicians and hospitals. Despite these efforts, there are many documented barriers to widespread EHR use [3,4], including the absence of robust evidence guaranteeing that the benefits of EHRs will be realized systemwide.

In this article, we categorize and critically appraise the existing literature on the benefits of EHRs (or their subcomponents) vis a vis each of the Institute of Medicine quality components named above. Our brief discussion is not meant to be comprehensive per se but instead it is intended to bring readers unfamiliar with this area of research ‘up to speed’ regarding prior studies. In doing so, we also define a research agenda for new studies to focus on so that gaps in the literature can be filled.

EHRs & patient safety

Patient safety refers to care delivered free of medical errors. EHRs can affect patient safety by checking for errors in medication orders and administration, by requiring higher-quality documentation and by suggesting clinical practices consistent with established guidelines. Several studies, including multiple randomized controlled trials, have found fewer medication errors or adverse drug events when orders are made electronically and/or decision support systems are used to provide feedback to clinicians [5,6]. Although the overall body of evidence suggests that EHRs and related technologies improve medication safety [7], some notable studies have produced null or negative findings, and have suggested mechanisms through which EHR subcomponents may actually facilitate new types of errors in care delivery [8]. Moreover, the strength of evidence for reductions in adverse drug events tends to be weaker than the evidence for the ability of EHRs to reduce medication errors [9]. Studies on medication issues notwithstanding, far fewer studies have been conducted on other patient safety concerns. Nevertheless, existing studies have found at least some positive effects of EHRs on infection control [10] and infant mortality [11].

EHRs & efficiency

Efficient healthcare delivery is about providing care without wasteful use of financial, human or other resources. EHRs have the potential to reduce redundant test orders and can reduce provider time and effort spent on documentation or other nonpatient care-related tasks [2]. Several rigorous studies examining the impact of EHRs on efficiency have been conducted in leading academic and federal institutions. Many such studies showed reductions in the number of tests ordered, and savings of either provider time and/or costs [12,13]. Studies outside of academic institutions that have examined commercially available EHRs have also found positive results, but have typically utilized less robust study designs that are not able to unequivocally establish causality [6].

However, several studies of the impact of EHRs on efficiency have reported null, negative or conflicting findings. For example, a recent study that examined whether the electronic availability of previous test results through health information exchange (a key feature of EHRs as promoted in the HITECH Act) found that physicians with access to previous laboratory and imaging studies unexpectedly ordered tests at higher rates [14]. Conflicting this study, the sharing of laboratory results between two academic medical centers has been shown to reduce test volumes [15]. Comprehensive, rigorous and generalizable studies on the impact of EHRs on efficiency have been elusive due to the wide range of ‘efficiency’ outcomes, not all of which are easy to track with readily available data.

EHRs & effectiveness

The effective delivery of healthcare is done in accordance with scientific knowledge. EHRs are expected to improve effectiveness by making evidence-based clinical guidelines and other best practice information easily available at the point of care. Numerous experimental and observational studies have examined whether computerization increases physician adherence to guideline-based care. These studies show examples of not only improvements [13] but also cases where clinician responsiveness to EHR reminders decreases over time [16] or where computerization has limited or no benefits [17]. Overall, EHRs are expected to positively affect the effectiveness of care, but it is not clear that all benefits expected by some policy makers and researchers will ultimately be realized.

EHRs & patient-centeredness

Patient-centeredness refers to care that is delivered in a way that addresses patient preferences and values, and not necessarily those of the provider. Despite the importance of patient-centered care in the context of quality, the empirical literature examining the ability of EHRs to improve patient-centered care is relatively small. Whereas the typical EHR is a clinician-centric technology that allows medical experts to document and share information among themselves, patient-centered care relies on less frequently used technologies such as patient-accessible personal health records (PHRs), or disease management tools that allow patients and providers to share information outside of traditional clinical encounters. Nevertheless, some studies have found that patients expect and benefit from the use of EHRs by their providers [18]. Patients also desire technologies that allow them to access information and communicate with providers outside of traditional delivery settings [19]. To our knowledge, only one study has addressed the relationship between EHR use and patient satisfaction on a broader scale, and found a positive relationship between EHR use and several hospital-level patient satisfaction measures [20].

EHRs & equity

Equitable healthcare involves services that are delivered equally, regardless of patient characteristics. EHRs and related technologies can enhance equity by increasing access to quality healthcare, by improving patient access to information and by facilitating better care for underserved populations. However, these improvements are dependent on the meaningful use of EHRs and other technologies by providers who disproportionately care for the underserved. As such, much research has simply focused on describing technology adoption and use by vulnerable patients and/or their providers. For example, EHR adoption was found to be lower among providers in rural areas [21] and among providers who serve the poor, minorities and the uninsured [22]. Similarly, PHR adoption rates were lower among African–American and less-educated patients [23]. More research is needed to examine whether EHR use will improve equitable delivery of care or whether existing quality disparities will be exacerbated if ­disparities in ­technology adoption persist.

EHRs & timeliness

Timely healthcare is achieved by eliminating lengthy wait times or delays associated with accessing care, or at the point of service. EHRs and web technologies can potentially influence timeliness through quicker access to patient information or through technologies such as telemedicine, which can connect geographically distant patients and providers. The evidence for timeliness gains associated with EHRs is mixed. On the one hand, studies have shown that EHRs with computerized order entry can improve medication and procedure turnaround times [24]. On the other hand, studies also suggest that EHRs may increase the time needed for clinician documentation [25]. This may occur because of cumbersome computer interfaces or because EHRs facilitate more thorough (and therefore more time-consuming) care.

The literature on telemedicine suggests that providers and patients can be successfully linked from afar and that adequate care can be provided via such technology [19]. Nevertheless, to date, telemedicine has only been consistently used in selected niche markets, such as healthcare for incarcerated inmates, and/or certain subspecialties such as radiology. Moreover, quality gains from telemedicine will be tied to the widespread adoption of this technology, which will not occur without updated payment models that adequately reimburse providers for these virtual encounters.

Expert commentary

This article provides an overview and synthesis of a broad and growing literature on the benefits of EHRs. Ultimately, EHRs are expected to improve healthcare quality, but it is not clear whether the level of benefits anticipated by some policy makers and experts will be realized. The USA, like other nations, has embarked on an ambitious journey of transforming the healthcare system by heavily incentivizing the use of EHRs. This unprecedented investment in healthcare computerization creates an opportunity to study the impact of EHRs in settings and with research methods not previously used.

Although there is strong evidence that EHRs can improve patient safety, effectiveness and to a lesser degree efficiency, more research in diverse settings would round out the literature. In addition, research in any setting that is designed to detect the impact of EHRs on patient-centeredness, equity and timeliness is warranted. To the extent possible, future studies should assess commercially available EHR systems in community settings, such as physician practices, mental health clinics, federally qualified health centers, public health clinics and other sources of care where a large percentage of the population seek medical attention. In addition, given that experimental studies may not always be feasible, especially when wanting to study a large number of facilities, researchers should utilize other rigorous methodologies, such as econometric techniques suited for causal inference. Such approaches can include taking advantage of natural experiments, examining organizational performance changes after EHR adoption (relative to a control group) [10], or identifying and utilizing instrumental variables [11], which can aid in determining the causal impact of EHRs in the context of observational studies.

Ultimately, EHRs are multifaceted technologies being implemented in complex healthcare organizations making it challenging to comprehensively characterize their impact on quality. We believe there is sufficient evidence, particularly when compared with other major policy decisions, to justify national investment in EHRs associated with the HITECH Act. Nevertheless, the evidence is not yet sufficient to provide a clear path toward ­realizing the maximum possible benefits.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.