Does the Use of Electronic Medical Records Improve Surrogate Patient Outcomes in Outpatient Settings?
One additional Regenstrief study outside this line of inquiry evaluated the impact of general internists’ remote access to EMRs on emergency department visits and hospitalization rates.24 Patients receiving care in a general internal medicine clinic were randomly allocated to 1 of 3 groups: after-hours access to a study internist by phone; after-hours access to a study internist by phone who also had remote access to the EMR; or no after-hours access except via the emergency department (control). This is the only study meeting our criteria that reported no benefit of EMR use on the primary outcomes. Provider use of the remote EMR was low, accessed for only 55.8% of all calls in this intervention group. Common reasons for not using the resource were that the access device was not with the provider at the time of the call and that it did not function properly.
Ottawa System. Another series of reports came from the Family Medicine Center at Ottawa Civic Hospital.24-28 All data appear to have been collected concurrently as part of a single randomized controlled trial and published over a 6-year period. Patients in 4 practices were randomly assigned to the control group or an intervention group. Those allocated to an intervention were then sub-randomized to 1 of 3 approaches to improving preventive health maintenance, all based on EMR-generated reminder prompts: (1) physician-provided reminder during an encounter in response to an EMR prompt; (2) computer-generated letter to the patient; or (3) telephone call from a nurse in response to an EMR prompt. Using these methods, rates of influenza,25 tetanus vaccination,28 Papanicolaou tests, and blood pressure screening27 were substantially higher in all intervention groups than in the control group. For tetanus vaccination, the highest rate was achieved in the patient letter group (27.4%), followed by the telephone call group (20.8%), physician reminder group (19.6%), and control group (3.2%). The patient letter group also achieved the highest rate of Papanicolaou test and blood pressure screening. The telephone call group, however, had the highest rate of influenza vaccination, possibly because of the more time-sensitive, seasonal nature of this vaccination.
Other Hybrid Systems. A more recent trial involved the use of The Medical Record (TMR), developed at Duke University.29 In a randomized controlled trial, rates of house staff and faculty adherence to diabetes mellitus care standards were compared in 2 groups: an intervention group, which received patient-specific, computer-generated, printed reminders at the time of patient encounters; and a control group, which received no reminders. The reminder system resulted in a 32% median compliance rate for the study group compared with a 15.6% rate in the control group (P = .01). While mean patient encounter lengths for the study group were not significantly increased, the subgroup of encounters that addressed at least some aspect of diabetes care were 10 minutes longer than those that did not involve diabetes care. Study group physicians cited encounter time constraints as the primary reason for ignoring recommendations.
Discussion
It is not possible to draw firm conclusions from the results of these trials because they were of varying quality, conducted in dissimilar centers, and employed a variety of EMRs. However, it is apparent that EMR systems offer great potential for improving rates of patient completion of health maintenance and screening maneuvers. One could argue that an EMR is not required to generate reminders, since other studies have shown similar results with non-EMR–based reminder initiatives.9,10 However, for most medium to large practice settings, EMRs are likely to be a far superior use of time and resources than any manual or stand-alone computer system in facilitating this task.
While all the EMR-based reminder methods in these studies were superior to no method at all, EMR-generated patient reminder letters and EMR-prompted nurse reminder phone calls have been associated with screening rates superior to those resulting from EMR-prompted physician reminders to patients during clinical encounters. When physicians are relied on to make reminders to patients, success appears more likely if they are supplied with patient-specific, printed or on-screen point-of-encounter prompts rather than delayed feedback letters that are not linked to an encounter. It also appears that the ability of EMR-based reminder systems to increase the rates of screening maneuvers is greater for those interventions that can be quickly completed (eg, serum cholesterol level) than for those that require a second appointment and more inconvenience (eg, Papanicolaou test).
Limitations
A number of factors limit the strength of our conclusions. While most EMR research has been conducted in a few centers, studies of TMR30 and COSTAR18 conducted outside their originating centers reveal the difficulty in moving these systems into the community setting. In addition, the reviewed studies generally lacked rigor, using sequential designs or nonrandom assignment to study groups and implementing potentially confounding interventions, such as provider health maintenance education seminars, that make it difficult to determine the incremental benefit of the EMR system. Furthermore, studies have examined surrogate end points, such as the completion of screening interventions, rather than changes in morbidity and mortality, which are of much greater importance to primary care clinicians.11 Finally, many of the studies were poorly reported, with incomplete definitions of the EMR and practice setting and only partial coverage of outcomes data.Future studies must set a more rigorous standard for EMR research.9,31
