Effect of electronic health records in ambulatory care: retrospective,
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《英国医生杂志》
1 Clinical Systems Planning and Consulting, Kaiser Permanente, 2101 Webster Street, Oakland, CA 94612, USA
Correspondence to: T Garrido terhilda.garrido@kp.org
The quality of health care in the United States warrants concern.1 The problems have been categorised as underuse, overuse, or misuse of healthcare services,2 and uncertainty in clinical decision making about individual patients plays a part in inappropriate use.3
Uncertainty in clinical decision making can arise from unavailable or poor quality data on the patient. Medical records are still predominantly paper based despite well documented shortcomings in terms of accuracy, completeness, availability, and legibility.4-8 Indeed, although widescale development of electronic health record systems has been repeatedly recommended in the United States,4 7 9 only about 5% of US primary care providers use an electronic health record.10 Incomplete, illegible, or unavailable patient information may necessitate conservative management strategies and result in redundant or marginally productive visits, diagnostic and screening tests, and interventions. Preventive care and patient education may also be overlooked if consultations have to focus on rebuilding clinical data.
Electronic health records reduce uncertainty by providing greater accessibility, accuracy, and completeness of clinical information than their paper counterparts.9 Two Kaiser Permanente regions separately implemented comprehensive electronic health record systems. We examined their effect on selected measures of use and quality of ambulatory care.
Methods
At the time of assessment, the Colorado and Northwest regions had two and four years' experience, respectively, with electronic health records. Changes in definitions of measures in the Colorado region precluded meaningful comparisons over a longer time.
Use of ambulatory care
Both regions had significant decreases in use of services. The age adjusted number of total office visits per member in year 2 decreased by 9% compared with year I1 (P < 0.0001, in both regions), and age adjusted primary care visits decreased by 11%. Age adjusted specialty care visits decreased by 5% in Colorado and 6% in the Northwest (both P < 0.0001). In year 4, the total office visit rate in the Northwest region was 8% lower than before electronic records became available (fig 1). Partial implementation had minimal effect during year I1.
The frequency pattern of ambulatory primary care visits suggested a general decrease in use across all patients, with larger reductions among patients making three or more visits (fig 2). The percentage of members making three or more visits a year decreased by 10% in the Colorado region and 11% in the Northwest region between year I1 and year 2. In year 4, the rate in the Northwest region had decreased by an additional 2%. Moreover, the percentage of members with 2 visits a year increased. This finding is particularly striking in light of the ageing Colorado membership (a disproportionate number of people aged over 65 were enrolled during the study period) and is consistent with the effects of electronic health records described by clinical and operational leaders.
Fig 2 Distribution of number of primary care visits per member in Colorado and Northwest regions before and after introduction of electronic health records. (Records were introduced in years I1 and I2)
We reviewed data relating to other factors that could potentially explain decreased use of ambulatory care. Rates of visits to emergency departments (internal and external to Kaiser Permanente) did not rise over the study. To rule out inadvertent reductions in access to services or shifting of care to other providers, we reviewed the ratio of all primary care providers (physicians, nurse practitioners, and physician assistants) to members and the ratio of referrals to outside providers in both regions throughout the study. Both ratios remained stable.
To rule out other global influences, we compared the changes in the Colorado and Northwest regions with trends in Kaiser Permanente regions without electronic health records and with national trends. Inconsistent definitions of office visits precluded direct comparisons between regions. We examined the rate of change in office visits, as independently defined by three other Kaiser Permanente regions, for which trend data were available for the same period. The data did not show comparable decreases. The rate of ambulatory care visits by people aged 45 or older increased by 14% across the United States between 1992 and 2002, which encompasses our study period.13
Telephone contact
The electronic health record enabled more effective telephone contacts. In the Northwest region, telephone encounters scheduled at the discretion of physicians increased from a baseline of 1.26 per member per year to 2.09 after two years. In the Colorado region, staffing of call centres briefly shifted from primarily nursing staff to include doctors with access to electronic health records. Appointments needed by patients after telephone contact decreased by 7% when contact was with a doctor with access to electronic health records. Doctors reported being able to resolve health issues by phone more readily with the electronic health record. Rates of appointments after telephone contact rose when staffing reverted to nurses. Comparable data on telephone contact from other Kaiser Permanente regions were not available.
The effect of telephone contact on use of ambulatory care is shown through a contemporaneous operational evaluation of the telephone treatment of uncomplicated urinary tract infections. In the Colorado region, a previously available nursing protocol was built into an electronic health record template in year I1, increasing ease of access for nursing staff. Between year I1 and year 2, the age adjusted visit rate for urinary tract infection among women fell by 31%. The records of women treated with antibiotics for a urinary tract infection during three months in year I1 were randomly audited. Of 262 women whose records were audited, 73 were prescribed antibiotics by a nurse; 67 of these did not require a return visit within eight weeks of treatment, indicating appropriate resolution.
Radiology and clinical laboratory services
Age adjusted rates of use of radiology services decreased by 14% in the first two years after introduction of electronic health records in the Northwest region. Despite more recent increases in general use of imaging inside and outside Kaiser Permanente, the age adjusted rate remained 4% lower than before implementation. The chief of radiology in the Colorado region believed strongly that availability of electronic records to all carers improved interpretation of films.
Laboratory usage in the Northwest region had decreased by 18% four years after electronic health record were introduced; rates subsequently increased 5-7% annually. Rates of laboratory usage in the Colorado region remained generally stable, rising 14% before electronic health records were introduced and falling 2.9% in the two subsequent years.
Quality of care process measures
Intermediate measures of quality of health care remained unchanged or slightly improved after electronic health record were introduced (table 2). This allays any fleeting concerns that decreased usage compromised quality of care.
Table 2 Percentage of eligible members receiving intervention in Colorado and Northwest regions before and after implementation of electronic health records (years I1 and I2). Data from Health Plan Employer and Data Information Set quality of care indicators
Discussion
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.
Chassin, MR, Galvin, RW. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280: 1000-5.
McNeil BJ, Hidden barriers to improvement in the quality of care. N Engl J Med 2001;345: 1612-20.
Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in US primary care. J Am Med Inform Assoc 2003;10: 1-10.
Hersh WK. Medical informatics: improving health care through information. JAMA 2002;288: 1955-8.
Carroll AE, Tarczy-Hornoch P, O'Reilly E, Christakis DA. Resident documentation discrepancies in a neonatal intensive care unit. Pediatrics 2003;111: 976-80.
Committee on Improving the Patient Record. The computer-based patient record: an essential technology for health care. Washington, DC: National Academy Press, 1997.
Burnum JF. The misinformation era: the fall of the medical record. Ann Intern Med 1989;110: 482-4.
General Accounting Office. Medical ADP systems: automated medical record systems hold promise to improve patient care. Washington, DC: GAO, 1991.
Anderson, JD. Increasing the acceptance of clinical information systems. MD Comput 1999;16(1): 62-5.
Kaiser Permanente. About Kaiser Permanente: who we are. http://newsmedia.kaiserpermanente.org/kpweb/toc.do?theme=learnaboutkp_newsmedia (accessed 18 Jul 2003).
Duffy SQ, Farley DE. Patterns of decline among inpatient procedures. Public Health Rep 1995;110: 674-81.
Woodwell DA, Cherry DK. National ambulatory medical care survey: 2002 summary. Adv Data 2004 Aug 26;(346): 1-44.
Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr C, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000;160; 2741-7.
Van Wijk MAM, van der Lei J, Mosseveld M, Bohnen AM, van Bemmel JH. Assessment of decision support for blood test ordering in primary care—a randomized trial. Ann Intern Med 2001;134: 274-81.
Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA 1993;269: 379-83.
Penrod LE, Gadd CS. Assessing physician attitudes regarding use of an outpatient EMR: a longitudinal, multi-practice study. Proc AMIA Symp 2001: 528-32.
Krall MA. Acceptance and performance by clinicians using an ambulatory electronic record in an HMO. Annu Symp Comput Appl Med Care 1995: 708-11.
Keshavjee K, Troyan S, Holbrook AM, VanderMolen D. Measuring the success of electronic medical record implementation using electronic and survey data. Proc AMIA Symp 2001: 309.
Bates DW, Studer J, Reilly, CA, Cureton, EA, Spurr, CD, Kuperman GJ. Evaluating the impact of a computerized ambulatory record. Proc AMIA Symp 2000: 964.
Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in US primary care. J Am Med Inform Assoc 2003;10: 1-10.
National Committee for Quality Assurance. Health plan report card. http://hprc.ncqa.org (accessed 3 Jun 2004).
National Committee for Quality Assurance. The state of health care quality: 2003. Washington, DC: NCQA, 2003.(Terhilda Garrido, senior director1, Laur)
Correspondence to: T Garrido terhilda.garrido@kp.org
The quality of health care in the United States warrants concern.1 The problems have been categorised as underuse, overuse, or misuse of healthcare services,2 and uncertainty in clinical decision making about individual patients plays a part in inappropriate use.3
Uncertainty in clinical decision making can arise from unavailable or poor quality data on the patient. Medical records are still predominantly paper based despite well documented shortcomings in terms of accuracy, completeness, availability, and legibility.4-8 Indeed, although widescale development of electronic health record systems has been repeatedly recommended in the United States,4 7 9 only about 5% of US primary care providers use an electronic health record.10 Incomplete, illegible, or unavailable patient information may necessitate conservative management strategies and result in redundant or marginally productive visits, diagnostic and screening tests, and interventions. Preventive care and patient education may also be overlooked if consultations have to focus on rebuilding clinical data.
Electronic health records reduce uncertainty by providing greater accessibility, accuracy, and completeness of clinical information than their paper counterparts.9 Two Kaiser Permanente regions separately implemented comprehensive electronic health record systems. We examined their effect on selected measures of use and quality of ambulatory care.
Methods
At the time of assessment, the Colorado and Northwest regions had two and four years' experience, respectively, with electronic health records. Changes in definitions of measures in the Colorado region precluded meaningful comparisons over a longer time.
Use of ambulatory care
Both regions had significant decreases in use of services. The age adjusted number of total office visits per member in year 2 decreased by 9% compared with year I1 (P < 0.0001, in both regions), and age adjusted primary care visits decreased by 11%. Age adjusted specialty care visits decreased by 5% in Colorado and 6% in the Northwest (both P < 0.0001). In year 4, the total office visit rate in the Northwest region was 8% lower than before electronic records became available (fig 1). Partial implementation had minimal effect during year I1.
The frequency pattern of ambulatory primary care visits suggested a general decrease in use across all patients, with larger reductions among patients making three or more visits (fig 2). The percentage of members making three or more visits a year decreased by 10% in the Colorado region and 11% in the Northwest region between year I1 and year 2. In year 4, the rate in the Northwest region had decreased by an additional 2%. Moreover, the percentage of members with 2 visits a year increased. This finding is particularly striking in light of the ageing Colorado membership (a disproportionate number of people aged over 65 were enrolled during the study period) and is consistent with the effects of electronic health records described by clinical and operational leaders.
Fig 2 Distribution of number of primary care visits per member in Colorado and Northwest regions before and after introduction of electronic health records. (Records were introduced in years I1 and I2)
We reviewed data relating to other factors that could potentially explain decreased use of ambulatory care. Rates of visits to emergency departments (internal and external to Kaiser Permanente) did not rise over the study. To rule out inadvertent reductions in access to services or shifting of care to other providers, we reviewed the ratio of all primary care providers (physicians, nurse practitioners, and physician assistants) to members and the ratio of referrals to outside providers in both regions throughout the study. Both ratios remained stable.
To rule out other global influences, we compared the changes in the Colorado and Northwest regions with trends in Kaiser Permanente regions without electronic health records and with national trends. Inconsistent definitions of office visits precluded direct comparisons between regions. We examined the rate of change in office visits, as independently defined by three other Kaiser Permanente regions, for which trend data were available for the same period. The data did not show comparable decreases. The rate of ambulatory care visits by people aged 45 or older increased by 14% across the United States between 1992 and 2002, which encompasses our study period.13
Telephone contact
The electronic health record enabled more effective telephone contacts. In the Northwest region, telephone encounters scheduled at the discretion of physicians increased from a baseline of 1.26 per member per year to 2.09 after two years. In the Colorado region, staffing of call centres briefly shifted from primarily nursing staff to include doctors with access to electronic health records. Appointments needed by patients after telephone contact decreased by 7% when contact was with a doctor with access to electronic health records. Doctors reported being able to resolve health issues by phone more readily with the electronic health record. Rates of appointments after telephone contact rose when staffing reverted to nurses. Comparable data on telephone contact from other Kaiser Permanente regions were not available.
The effect of telephone contact on use of ambulatory care is shown through a contemporaneous operational evaluation of the telephone treatment of uncomplicated urinary tract infections. In the Colorado region, a previously available nursing protocol was built into an electronic health record template in year I1, increasing ease of access for nursing staff. Between year I1 and year 2, the age adjusted visit rate for urinary tract infection among women fell by 31%. The records of women treated with antibiotics for a urinary tract infection during three months in year I1 were randomly audited. Of 262 women whose records were audited, 73 were prescribed antibiotics by a nurse; 67 of these did not require a return visit within eight weeks of treatment, indicating appropriate resolution.
Radiology and clinical laboratory services
Age adjusted rates of use of radiology services decreased by 14% in the first two years after introduction of electronic health records in the Northwest region. Despite more recent increases in general use of imaging inside and outside Kaiser Permanente, the age adjusted rate remained 4% lower than before implementation. The chief of radiology in the Colorado region believed strongly that availability of electronic records to all carers improved interpretation of films.
Laboratory usage in the Northwest region had decreased by 18% four years after electronic health record were introduced; rates subsequently increased 5-7% annually. Rates of laboratory usage in the Colorado region remained generally stable, rising 14% before electronic health records were introduced and falling 2.9% in the two subsequent years.
Quality of care process measures
Intermediate measures of quality of health care remained unchanged or slightly improved after electronic health record were introduced (table 2). This allays any fleeting concerns that decreased usage compromised quality of care.
Table 2 Percentage of eligible members receiving intervention in Colorado and Northwest regions before and after implementation of electronic health records (years I1 and I2). Data from Health Plan Employer and Data Information Set quality of care indicators
Discussion
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.
Chassin, MR, Galvin, RW. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280: 1000-5.
McNeil BJ, Hidden barriers to improvement in the quality of care. N Engl J Med 2001;345: 1612-20.
Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in US primary care. J Am Med Inform Assoc 2003;10: 1-10.
Hersh WK. Medical informatics: improving health care through information. JAMA 2002;288: 1955-8.
Carroll AE, Tarczy-Hornoch P, O'Reilly E, Christakis DA. Resident documentation discrepancies in a neonatal intensive care unit. Pediatrics 2003;111: 976-80.
Committee on Improving the Patient Record. The computer-based patient record: an essential technology for health care. Washington, DC: National Academy Press, 1997.
Burnum JF. The misinformation era: the fall of the medical record. Ann Intern Med 1989;110: 482-4.
General Accounting Office. Medical ADP systems: automated medical record systems hold promise to improve patient care. Washington, DC: GAO, 1991.
Anderson, JD. Increasing the acceptance of clinical information systems. MD Comput 1999;16(1): 62-5.
Kaiser Permanente. About Kaiser Permanente: who we are. http://newsmedia.kaiserpermanente.org/kpweb/toc.do?theme=learnaboutkp_newsmedia (accessed 18 Jul 2003).
Duffy SQ, Farley DE. Patterns of decline among inpatient procedures. Public Health Rep 1995;110: 674-81.
Woodwell DA, Cherry DK. National ambulatory medical care survey: 2002 summary. Adv Data 2004 Aug 26;(346): 1-44.
Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr C, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000;160; 2741-7.
Van Wijk MAM, van der Lei J, Mosseveld M, Bohnen AM, van Bemmel JH. Assessment of decision support for blood test ordering in primary care—a randomized trial. Ann Intern Med 2001;134: 274-81.
Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA 1993;269: 379-83.
Penrod LE, Gadd CS. Assessing physician attitudes regarding use of an outpatient EMR: a longitudinal, multi-practice study. Proc AMIA Symp 2001: 528-32.
Krall MA. Acceptance and performance by clinicians using an ambulatory electronic record in an HMO. Annu Symp Comput Appl Med Care 1995: 708-11.
Keshavjee K, Troyan S, Holbrook AM, VanderMolen D. Measuring the success of electronic medical record implementation using electronic and survey data. Proc AMIA Symp 2001: 309.
Bates DW, Studer J, Reilly, CA, Cureton, EA, Spurr, CD, Kuperman GJ. Evaluating the impact of a computerized ambulatory record. Proc AMIA Symp 2000: 964.
Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in US primary care. J Am Med Inform Assoc 2003;10: 1-10.
National Committee for Quality Assurance. Health plan report card. http://hprc.ncqa.org (accessed 3 Jun 2004).
National Committee for Quality Assurance. The state of health care quality: 2003. Washington, DC: NCQA, 2003.(Terhilda Garrido, senior director1, Laur)