EHRs: Small Practices Need Sustained Technical Help

Only those physicians who received extensive, sustained, technical assistance with electronic health records (EHRs) had significant improvements in quality of care, according to a study published in the January issue of Health Affairs. This study of small physician practices in New York City also showed that quality improved only for a limited group of measures.

"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," lead author Andrew M. Ryan, PhD, assistant professor of public health at Weill Cornell Medical College, New York City, said in a Cornell news release. "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."

Potential benefits of EHRs include clinical decision support, tools to minimize medical errors, e-prescribing, displays of test findings, patient health registry data, population data management, and enhanced communication with patients and with other providers. The 2009 American Recovery and Reinvestment Act offered financial incentives for providers to implement EHRs through Medicare and Medicaid and funds for regional extension centers supporting practices with ongoing technical assistance. Accordingly, overall physician use of basic EHR systems increased from 22% in 2009 to 35% in 2011. However, the rate of EHR adoption is lowest in small practices, particularly those in underserved communities.

Notably, the association between use of EHRs and quality of care is still unclear. To analyze this relationship, the investigators assessed quality outcomes in small primary care practices enrolled in the Primary Care Information Project (PCIP), a New York City Health Department initiative and the largest community-based EHR implementation program in the United States.

To improve quality of care in underserved neighborhoods, PCIP subsidized EHR software and offered clinical decision support and onsite technical assistance to more than 3300 physicians at more than 600 primary care practices. Through NYC REACH, its regional extension center, the PCIP provides ongoing education and technical assistance to more than 7200 providers, according to the news release.

The New York Quality Alliance, an independent data source using multipayer medical claims in New York State, allowed linkage to data from the PCIP practices participating in this study. Quality of care did not improve in those practices merely exposed to or participating in the PCIP. Before improvement occurred in measures of care most responsive to EHR use, such as cancer screenings and diabetes care, these practices needed sustained exposure to the PCIP, as well as ongoing technical assistance.

No Tech Support, No Quality Improvements

PCIP participation for at least 9 months was linked to significantly improved quality, but only among physicians receiving at least 8 technical assistance visits. In these practices, significant statistical improvements occurred only in those quality measures most likely to be affected by EHR use, including breast cancer screening, retinal examination and urinalysis in patients with diabetes, chlamydia screening for women, and colorectal cancer screening.

In contrast, practices with minimal or no technical support had no significant improvements in these key quality measures, even after nearly 2 years of EHR use.

"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," Sarah Shih, MPH, PCIP executive director of Health Care Quality Information and Program Evaluation, noted in the news release. "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."

Other outcome measures showing trends toward improvement, according to Shih, include smoking-cessation counseling, blood pressure control, cholesterol screening, and treatment of hypercholesterolemia.

"Our study results stand in contrast to widespread perceptions that EHRs automatically improve quality of care," senior author Lawrence P. Casalino, MD, PhD, the Livingston Farrand Associate Professor of Public Health and chief of the Division of Outcomes and Effectiveness Research at Weill Cornell, said in the news release. "It shows that regional extension centers like NYC REACH have an important role to play in facilitating the use of EHRs to improve the quality of care patients receive — which is always our ultimate goal."

Consistent Results

Results of this study echo those of previous research showing that EHR implementation alone is not consistently associated with better quality of care. However, this study is one of the few to have examined the relationship between EHR use and quality of care in a small practice, underserved community outpatient setting. The investigators recommend continued assessment of the efficacy of various levels of technical support given by regional extension centers in improving health outcomes.

Limitations of this study include a lack of generalizability to other populations and settings, a relatively small sample size limiting statistical power, and a lack of data on physicians' payer mix. In addition, quality measures were limited to those collected by the New York Quality Alliance.

"EHRs hold a lot of hope and promise and the technology is taking health care a step in the right direction," Dr. Ryan said in the news release. "Our study supports proof of concept that EHRs can improve outcomes, but widespread implementation of the technology and strong technical assistance is needed. Our hope is the extension of EHRs with proper technical support will have a direct impact on population health."

The Robert Wood Johnson Foundation funded this project. The authors have disclosed no relevant financial relationships.

Health Aff. 2013;32:53-62. Abstract