JAMIA: EMR benefits are unclear for outpatient clinical outcomes
EMRs and EHRs appear to have structural and process benefits for primary care outpatient practices, but the impact on clinical outcomes is less clear, according to a review published online first on March 9 in the Journal of the American Medical Informatics Association.
Jayna M. Holroyd-Leduc, MD, of the departments of medicine and community health sciences at the University of Calgary in Calgary, Alberta, and colleagues sought to systematically review recent literature around the impact of the EMR and EHR within primary-care outpatient practices. “We chose to focus on studies examining the effectiveness or benefits of the EMR/EHR broadly, and consider the impact on healthcare structure, process and outcomes,” the authors wrote.
The researchers reviewed Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ABI Inform and Cochrane Library to identify articles that involved primary-care outpatient practices and EHRs or EMRs and were published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. Thirty studies met inclusion criteria, according to the study.
The search strategies included terms such as “electronic or computer or internet, CPOE or EHR or EPR, ambulatory care or outpatient or primary care or family doctor and decision support system,” Holroyd-Leduc and colleagues wrote. The review excluded articles not published in English, as well as those that did not focus primarily on family doctors or primary-care outpatient practices, did not focus on evaluating the effectiveness or benefits of the EMR/EHR, or focused on only one component of the EMR.
Among the articles that were included were four studies that compared the EMR to paper records; three of which were case-control studies and one which was a cross-sectional survey. These studies involved primary-care practices in the U.K. and the U.S. The fifth study was a chart review from Finland that focused solely on the EMR/EHR. The impact of the EMR/EHR on clinical processes was assessed in 17 articles (in 14 different datasets). These studies involved surveys, focus groups, chart and database reviews and/or interviews.
Only one study included clinical outcomes. It was a cross-sectional analysis of 11,889 visits across the U.S. that examined the impact of the EMR on clinical outcomes (blood pressure control) and processes (receipt of appropriate pharmacological therapies for chronic conditions).
“There is modest evidence that CPOE decreases prescribing errors,” but it appears that mostly minor errors are decreased, and CPOE may actually increase duplicate orders and result in failures to discontinue medications, Holroyd-LeDuc et al wrote. In addition, a review of electronic reminder systems found only a small improvement in adherence to processes of care, with a trend toward larger improvements when clinicians were required to enter a response.
In addition, a review of electronic strategies to improve dosage selection when prescribing found some improved clinical outcomes, such as a decrease in rates of toxic drug levels and a decrease in hospital length of stay, according to the study.
The researchers noted several limitations to their study. The search was limited to English-language articles published since 1998. In addition, “we accepted the EMR/EHR definitions adopted by studies included in this review. These studies could have defined EMR/EHR differently, and it is possible that these definitions were similar to those used in studies excluded from this review,” they wrote.
“The EMR/EHR appears to have both positive and negative impacts on primary-care outpatient practices. The EMR/EHR has structural and process benefits, but the impact on clinical outcomes is less clear,” Holroyd-LeDuc and colleagues concluded. “When implementing an EMR/EHR, appropriate resources need to be allocated.”
Jayna M. Holroyd-Leduc, MD, of the departments of medicine and community health sciences at the University of Calgary in Calgary, Alberta, and colleagues sought to systematically review recent literature around the impact of the EMR and EHR within primary-care outpatient practices. “We chose to focus on studies examining the effectiveness or benefits of the EMR/EHR broadly, and consider the impact on healthcare structure, process and outcomes,” the authors wrote.
The researchers reviewed Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ABI Inform and Cochrane Library to identify articles that involved primary-care outpatient practices and EHRs or EMRs and were published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. Thirty studies met inclusion criteria, according to the study.
The search strategies included terms such as “electronic or computer or internet, CPOE or EHR or EPR, ambulatory care or outpatient or primary care or family doctor and decision support system,” Holroyd-Leduc and colleagues wrote. The review excluded articles not published in English, as well as those that did not focus primarily on family doctors or primary-care outpatient practices, did not focus on evaluating the effectiveness or benefits of the EMR/EHR, or focused on only one component of the EMR.
Among the articles that were included were four studies that compared the EMR to paper records; three of which were case-control studies and one which was a cross-sectional survey. These studies involved primary-care practices in the U.K. and the U.S. The fifth study was a chart review from Finland that focused solely on the EMR/EHR. The impact of the EMR/EHR on clinical processes was assessed in 17 articles (in 14 different datasets). These studies involved surveys, focus groups, chart and database reviews and/or interviews.
Only one study included clinical outcomes. It was a cross-sectional analysis of 11,889 visits across the U.S. that examined the impact of the EMR on clinical outcomes (blood pressure control) and processes (receipt of appropriate pharmacological therapies for chronic conditions).
“There is modest evidence that CPOE decreases prescribing errors,” but it appears that mostly minor errors are decreased, and CPOE may actually increase duplicate orders and result in failures to discontinue medications, Holroyd-LeDuc et al wrote. In addition, a review of electronic reminder systems found only a small improvement in adherence to processes of care, with a trend toward larger improvements when clinicians were required to enter a response.
In addition, a review of electronic strategies to improve dosage selection when prescribing found some improved clinical outcomes, such as a decrease in rates of toxic drug levels and a decrease in hospital length of stay, according to the study.
The researchers noted several limitations to their study. The search was limited to English-language articles published since 1998. In addition, “we accepted the EMR/EHR definitions adopted by studies included in this review. These studies could have defined EMR/EHR differently, and it is possible that these definitions were similar to those used in studies excluded from this review,” they wrote.
“The EMR/EHR appears to have both positive and negative impacts on primary-care outpatient practices. The EMR/EHR has structural and process benefits, but the impact on clinical outcomes is less clear,” Holroyd-LeDuc and colleagues concluded. “When implementing an EMR/EHR, appropriate resources need to be allocated.”