Study finds better outcomes as hospitals achieve Stage 1 Meaningful Use, but gains recede in the rush to move beyond those standards.
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Meeting Stage 1 standards for Meaningful Use of electronic health records (EHRs) can help hospitals achieve measurable gains in quality of care, but higher levels of functionality might actually lead to worse clinical outcomes, a new study from Dartmouth College suggests.
Research published in the journal Health Services Research found a small but measurable increase of quality in treatment of inpatients with acute myocardial infarction, heart failure, and pneumonia at hospitals transitioning to EHRs in line with Stage 1 Meaningful Use requirements. But facilities saw a decrease of 0.9 to 1 percentage point for those conditions when moving beyond the 2011 requirements for Stage 1. The changes are more noticeable at hospitals with baseline quality scores in the lowest quartile.
"Our findings also have significant implications for practice ... [H]ospital leadership should be cautious in building expectations from organization-wide EHR implementations, and more important, that technology implementation alone is likely not sufficient to produce quality improvements," the study said.
"I think everybody realizes that there are some usability issues that have to be overcome," said Johnson, who has been studying EHR usability for several years. EHRs need to demonstrate just functionality, not usability, to meet federal certification criteria. The 2009 American Recovery and Reinvestment Act, which authorized the $27 billion Meaningful Use incentive program, requires healthcare providers to adopt "certified" EHR technology in order to earn their share of the money.
In this study, which was designed to measure incremental effects of upgrading EHRs on hospital processes and clinical outcomes, Johnson and two colleagues examined data from 2006 through 2010 on 3,921 acute care hospitals in the U.S.
The Dartmouth team determined each hospital's EHR capabilities by drawing on the extensive Healthcare Information and Management Systems Society (HIMSS) Analytics database. Data on inpatient process quality came from the Hospital Compare website run by the Centers for Medicare and Medicaid Services (CMS).
The researchers classified EHRs into five levels, 0 to 4, with level 3 corresponding to Meaningful Use Stage 1, including clinical data repositories, clinical decision support, nursing documentation, and an electronic medication administration record. Level 4 adds computerized physician order entry (CPOE) on a greater scale than what the first stage of Meaningful Use calls for.
To measure quality for acute MI, heart failure, pneumonia, and surgical care infection, they used a complex formula that took into account factors such as whether the hospital was a teaching facility, whether it was part of an integrated delivery network, the presence of a cardiac intensive care unit, and level of competition in the local market.
"Transitioning to a level 3 EHR system capable of meeting the 2011 MU objectives was associated with statistically significant, but clinically modest, incremental gains in process quality for AMI, heart failure, and pneumonia care by about 0.35-0.49 percentage points, but not for prevention of surgical infection," the journal article said. Not surprisingly, those starting at a lower level of quality posted the biggest improvements, due to the law of diminishing returns, or what Johnson dubbed a "ceiling effect."
But the move to level 4 technology actually wiped out gains made in previous upgrades, leading Johnson to surmise that hospitals often overlook necessary process redesign when rushing to install new systems and capabilities. The short timeline to get from Stage 1 to Stage 2 Meaningful Use, even after a year's delay, followed by the expected beginning of Stage 3 in 2016, could exacerbate the problem.
"My guess is we're going to watch dips in quality all over the place in the next couple of years," Johnson said.
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