Does the Use of Electronic Medical Records Improve Surrogate Patient Outcomes in Outpatient Settings?

Revised Research Question. After conducting the literature search and reviewing the retrieved citations, it was apparent that there were no published studies examining the impact of EMRs on patient morbidity and mortality. We felt that pursuing a systematic review of papers evaluating the impact of EMR systems on surrogate outcomes that have been clearly linked with changes in morbidity and mortality¹¹ would still be of value to primary care physicians. An example of a paper involving such an outcome would be one examining the impact of an EMR system on the rate of screening mammography in women age 50-69.¹²

All retrieved citations, including abstracts when available, were reviewed independently by each author. For papers in which a difference of opinion or uncertainty on the part of either reviewer existed, final consensus was reached by joint review and discussion. Relevant citations from the reference lists of reviewed papers that were not retrieved in the MEDLINE searches were also requested and reviewed.

Quality Assessment. We assessed the quality of included reports using the scale outlined in Table 1. However, given the preliminary nature of research regarding the clinical impact of EMRs, we used only the absence of a control group as a criterion for article exclusion. Of the 3 elements of our scale that were based on the instrument developed by Jadad et al¹³ (randomization, blinding, and treatment of withdrawals), 2 were modified so as to be more applicable to EMR intervention studies. Double blinding, which would require blinding of study physicians to EMR interventions, would not be feasible. However, single blinding of outcome assessment would be desirable and was included as a scoring element. In regard to withdrawals and dropouts, both physicians and their patients were considered subjects in several EMR studies (eg, both provider compliance rates with screening recommendations and patient follow-up rates following provider recommendations were outcomes). In these cases, the number and reasons for withdrawal of subjects (providers and, when applicable, patients) had to be stated or no points could be assigned. Finally, in addition to adding a control group element to Jadad’s original scale, we also added an element concerning measures taken to minimize simultaneous and potentially confounding interventions. We felt this was important, since initiatives such as clinic educational seminars could confound the results of an EMR intervention trial even in the presence of randomized, controlled clinic group assignment.

Results

Our search strategy retrieved a total of 406 citations. Three-hundred eight citations were not relevant to our study subject and were rejected without further review, leaving 98 articles requiring retrieval and detailed review (a full listing of these articles is available upon request). After independent review of each, followed by joint discussion for several articles that were initially in dispute, a total of 16 articles containing data that was not duplicated in any other reports met our inclusion criteria. Following are the EMR systems that studied in those 16 papers included in our final systematic review. (Table 2 presents the full list and details of the complete EMRs, and Table 3 presents the hybrid EMRs included in our study.)

Studies of Complete EMRs

Computer-Stored Ambulatory Record. The Computer-Stored Ambulatory Record (COSTAR) was developed in the early 1970s at Massachusetts General Hospital.⁶ In COSTAR, all clinical data collected by any provider is recorded on a paper encounter form and later entered into the computer system by support personnel. For each study, the clinical information of interest was retrieved from the EMR using a system-specific query language. Subsequently, COSTAR was used to generate printed reminder sheets for providers, prompting them to either complete problem-specific tasks noted as incomplete in the EMR query or to indicate why they had not been accomplished (eg, patient refusal). In earlier studies,^14-17 the printed reminder was not linked to a patient encounter, while in the most recent study¹⁸ the printed reminder was provided at the time of the next encounter with the patient.

Several studies employed a sequential design, with subjects serving as their own historical controls.^14-16 All general internists’ compliance with tasks was measured at baseline, then during a period when printed reminders were provided, and then again after the intervention was discontinued. Using this approach, they achieved an improved rate of antibiotic treatment in response to Group A b-hemolytic Streptococcus-positive throat culture.¹⁶ While the authors did not report exact rates, approximately 10% of patients with positive throat cultures had no documentation of antibiotic treatment in their computerized records at baseline. This rate declined to approximately 5% during the reminder intervention, and then rapidly returned to the baseline rate when the intervention was discontinued. In 2 similarly designed studies, general internists’ rates of compliance with institutionally determined lithium carbonate prescribing standards¹⁵ and syphilis quality-of-care standards¹⁴ showed significant improvement during the reminder period. In the syphilis study, providers’ mean global syphilis care scores (maximum score = 100) improved from 72.7 at baseline to 90.5 (P < 0.05 by Mann-Whitney test) during the reminder period but had dropped to 86.2 3 months after the end of the reminder period.