HIT and Clinical Outcomes
A number of recent studies seek to illuminate the relationship of HIT use to clinical outcomes. Several of these studies are described and commented on here.
• Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality. Romano, M.J. & R.S. Stafford. Archives of Internal Medicine. Published online January 24. 2011.
The study analyzed data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Surveys (225,402 visits ). Electronic Health Records (EHRs) were used in 30% of visits and of these 57%, or 17% of all visits, had some form of electronic clinical decision support (CDSs) available as well . The study found higher quality in only one (of 20) clinical indicators, diet counseling for at-risk adults, For E H R visits as compared with non-HER visits. Additionally, only one of 20 clinical quality measures, routine electrocardiograph ordering in low-risk patients, was significantly higher in visits with clinical decision support visits than as compared with those that did not include CDS. The increases were under 3% in both cases. There were no other significant differences in quality measures.
There are a number of possible explanations for this study’s results. The first, and perhaps the most important one, is that the data are from the 2005-2007 NAMCS and NHAMCS. The study points out that standards of practice using EHRs and CDS systems may have improved since 2007 and the use of these applications may be more effective now. This is especially true of clinical decision support systems as their use, even now, is episodic and inconsistent. The authors further note that HIT adoption and use is also governed by cultural, technical and non-technical issues, and that these may also affect the results of studies of HIT effectiveness.
Finally, one of the authors opines out that effective use of EHRs and CDS may be a training issue and that few providers are well trained in the use of complex HIT systems. Several NIH researchers were asked to comment on this study. They noted that EHRs were simply ‘data repositories” and their use without the associated use of clinical decision support systems could not be expected to improve many quality measures as medication adherence.
• A Patient-Centric, Provider-Assisted Diabetes Telehealth, Self-Management Intervention for Urban Minorities. E.L. Carter, G. Nunlee-Brand & C. Callender. Perspectives in health Information Management (Winter 2011). 1-9.
This study describes implementation and outcomes of an on-line intervention for African-American patients with Type 2 Diabetes cared for in primary care practice in Washington, D.C. Study participants were randomly assigned to a treatment or control group. During an introductory home visist, the treatment group (26) was provided with laptop computers, and peripherals including wireless scales, blood pressure cuff and glucometer, instructions on the use of equipment, and a care plan that included access to a telehelath nurse. An online portal, consisting of three modules, was also offered to the treatment group: a self-management module that included the care action plan and health records and could also serve as a communication link to the provider, who updated the action plan based on ongoing measurements, a health education module offering culturally appropriate materials and links, and a social networking module that facilitated interaction among participants. This group also participated in a biweekly video call with a telehealth nurse during which their progress was discussed and questions answered. The control group ( 21) received the normal standard of care from their provider, and did not have access to the portal or telehealth applications and nursing support..
Outcomes in the treatment group were significantly improved for all clinical measures (mean weight, mean BMI, mean blood pressure and mean HbA1c) and social and educational measures as compared with those of the control group. Patients also reported additional benefits beyond the health outcomes, including the both the direct and intangible benefits associated with the relationship with the telehealth nurse. There were some limitations to the study: an eighth grade reading level was required for participation, work needed to be done to develop and maintain the online portals, a telehealth nurse needed to be provided, and equipment including laptops and measurement devices were required for home use. Finally, additional time had to be provided for both the telehealth nurse and providers to interact with the study group patients. This was a small study with a high cost, but one which is very interesting in terms of future directions in population health management. The study shows that it is possible to design and deliver effective telehealth interventions for underserved inner city populations.
• Use of Health Information technology Among Racial and Ethnic Underserved Communities. M.C.Gibbons. Perspectives in Health Information Management (Winter 2011). 1-13.
This Perspectives article surveys the use of HIT among healthcare organizations and providers serving minority and underserved populations, and the use of Personal Health Records (PHRs) and consumer health informatics (CHI) among members of those populations. A number of other studies have found that while somewhat higher in CHCs than in small practices, adoption of EHRs in this segment is low overall. It has also been found that minority patients are less likely to have and use PHIs or CHI than non-minority populations. The opportunity exists, however, to change both of these statistics. Federal incentives for EHR adoption for Medicaid providers are changing the rate of adoption for H I T, while improved capability for clinical information sharing and communications links for coordination of care among PCMH and integrated care teams will improve the rate of adoption even further.
While acknowledging that there remain important HIT adoption barriers, the author notes that almost 90% of people in the U.S. minority population own mobile phones, and over 60% use wireless internet primarily for social networking. This presents an opportunity for PHR and CHI use on mobile phones, especially as healthcare plans and pharmacy groups start using these applications for both treatment and commercial transactions. It is also possible that EHRs, and HIT in general, may be used to provide more culturally, linguistically and cognitively appropriate healthcare education which would greatly improve the use of HIT by both providers and patients. The author suggests that HIT devices and application should to be designed to address the diversity of cultural, linguistic and social experience to improve adoption and use for and by minority populations and increase the potential for broader access and better care.