Does the Use of Electronic Medical Records Improve Surrogate Patient Outcomes in Outpatient Settings?
Two other COSTAR studies involved the use of a concurrent control group of providers that did not receive computer-generated reminders.17-18 In the first study, 12-month rates of follow-up blood pressure measurement in response to an index diastolic blood pressure measurement of higher than 100 mm Hg in previously non-hypertensive patients were determined.17 Forty-nine percent of patients with providers in the reminder group had a follow-up blood pressure measurement within 12 months, while only 31% of patients with providers in the control group had a follow-up measurement.
Finally, in the most recent COSTAR study, rates of completion for 8 preventive health care maneuvers were determined for 2 groups.18 One group of internal medicine house staff in the University of Nebraska program received patient-specific printed reminders at the time of patient encounters, and a second group did not. Assignment was not random; residents who had clinic on alternating weeks were arbitrarily assigned to study or control groups. Computerized reminders were found to improve overall rates of tetanus, influenza, and pneumococcal vaccination and flexible sigmoidoscopy completion but had no significant impact on rates of fecal occult blood testing, mammography, Papanicolaou tests, or serum thyroxine screening in the elderly. Using factorial analysis, strong interaction was noted among group assignment, the supervising attending, and resident level of training, such that compliance scores doubled among first-year residents supervised by 2 particular attending physicians but did not substantially improve in other subgroups. Overall rates of compliance with health care maintenance maneuvers were quite low even for the intervention group (eg, 7.1% for flexible sigmoidoscopy).
Other Complete Systems. A controlled trial using the Medical University of South Carolina’s EMR evaluated 1-year rates of family medicine house staff and faculty compliance with 5 preventive health maneuvers.19 Providers and their patients were randomly assigned to 1 of 4 groups: physician and patient reminders from the EMR; patient reminders only; physician reminders only; or no reminders (control group). Patient letters were generated by the computer system, and printed patient-specific physician reminders were available at the time of encounters. Adherence to 4 of the 5 preventive services (cholesterol measurement, fecal occult blood testing, mammography, and tetanus immunization) increased significantly for all intervention groups compared with the control group, but the largest gains were seen for the group that received both physician and patient reminders. Consistent with the findings for COSTAR,18 no clinically or statistically significant impact of any reminder approach could be demonstrated for Papanicolaou test rates.
A final study involving the use of the Beth Israel Hospital’s Center for Clinical Computing system was reflective of current trends, because it involved direct provider entry of clinical encounter data into the EMR and on-screen (rather than printed) reminder prompts.20 The primary outcome in this controlled trial was general internists’ median response time to EMR-generated on-screen alerts and reminders regarding care for patients with human immunodeficiency virus (HIV) infection; secondary outcomes included primary care, specialty clinic, and emergency department visit rates and hospitalizations. Providers at 5 practice sites were nonrandomly divided into a study group (on-screen prompts) and control group (no prompts of any kind). Alerts included items such as consideration of Pneumocystis carinii prophylaxis when the CD4 cell count dropped below 200 cells per cubic millimeter, and reminders included items such as the need for purified protein derivative skin testing. The median response times to 303 alerts in the intervention group and 388 in the control group were 11 and 52 days, respectively, and the median response times to 432 reminders in the intervention group and 360 reminders in the control group were 114 days and more than 500 days, respectively (both P <0001 by log-rank test). There was no effect of the intervention on health system use outcomes except for a significant increase in the rate of ophthalmologic screening examinations for the intervention group.
Studies Involving Hybrid EMRs
The Regenstrief System. The largest number of reports involving a hybrid EMR have come from the Regenstrief Institute for Health Care at Indiana University.21-24 Most studies were randomized controlled trials monitoring rates of house staff or faculty compliance with preventive health care, prophylactic treatment (eg, b-blockers for patients who have had a myocardial infarction), and active problem treatment reminders. The reminders were generated by the EMR and supplied in printed form, either at the time of encounters or via delayed feedback messages.21-23 Studies have built upon one another sequentially, beginning with a 1984 trial that examined the impact of encounter-based printed reminders. For 61 internal medicine residents who received computer-generated printed reminders, a 49% response rate was reported, and 54 residents who received no reminder reported a 29% response rate (P <0001 by analysis of variance). Subsequently, a 1986 trial comparing the impact of encounter-based reminders with delayed feedback messages found that the impact of the encounter reminder was approximately double that of delayed feedback, and that combining the 2 reminders had no additive effect.21 Finally, in 1989 a third study used encounter-based reminders for the providers in the control group and compared action rates for this group with those in which an accompanying form required providers to circle which (if any) action was taken on each reminder.23 Compliance for faculty in the response form group was not further improved, while compliance for house staff in the response form group was significantly improved for fecal occult blood testing (63% vs 46%, P <0001) and mammography (55% vs 45%, P = .013), but not Papanicolaou tests.
