Association of Hospital Public Quality Reporting With Electronic Health Record Medication Safety Performance

A Jay Holmgren,David W Bates

doi:10.1001/jamanetworkopen.2021.25173

Abstract

Despite billions spent in public investment, electronic health records (EHRs) have not delivered on the promise of large quality and safety improvement. Simultaneously, there is debate on whether public quality reporting is a useful tool to incentivize quality improvement. To evaluate whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related clinical decision support (CDS) safety performance. This nonrandomized controlled trial included US hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool in the Leapfrog Hospital Survey, a national quality reporting program that evaluates safety performance of hospital CDS using simulated orders and patients, in 2017 to 2018. A sharp regression discontinuity design was used to identify the association of receiving negative feedback with hospital performance improvement in the subsequent year. Data were analyzed from January through September 2020. Publicly reported quality feedback. The main outcome was improvement from 2017 to 2018 on the Leapfrog CPOE Evaluation Tool, using regression discontinuity model estimates of the association of receiving negative publicly reported feedback with quality improvement. A total of 1183 hospitals were included, with a mean (SD) CPOE score of 59.3% (16.3%) at baseline. Hospitals receiving negative feedback improved 8.44 (95% CI, 0.09 to 16.80) percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation. This change was driven by differences in improvement in basic CDS capabilities (β = 8.71 [95%CI, 1.67 to 18.73]) rather than advanced CDS (β = 6.15 [95% CI, -9.11 to 26.83]). In this nonrandomized controlled trial, publicly reported feedback was associated with quality improvement, suggesting targeted measurement and reporting of process quality may be an effective policy lever to encourage improvement in specific areas. Clinical decision support represents an important tool in ensuring patient safety and decreasing adverse drug events, especially for complex patients and those with multiple chronic conditions who often receive several different drugs during an episode of care.

Highlights

The US federal government has spent more $30 billion to digitize the health care system by adopting electronic health records (EHRs).[1,2] Despite this investment, the promise of EHRs to dramatically improve quality has remained elusive.[3]
Hospitals receiving negative feedback improved 8.44 percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation
This change was driven by differences in improvement in basic clinical decision support (CDS) capabilities (β = 8.71 [95%CI, 1.67 to 18.73]) rather than advanced CDS (β = 6.15 [95% CI, −9.11 to 26.83])

Summary

Introduction

The US federal government has spent more $30 billion to digitize the health care system by adopting electronic health records (EHRs).[1,2] Despite this investment, the promise of EHRs to dramatically improve quality has remained elusive.[3]. Computerization of drug ordering in particular is associated with reduced rates of adverse drug events, which remain a significant source of patient harm.[4,5,6]. CDS linked with CPOE uses EHR data about the patient as well as medication reference databases to supplement clinician decision-making and prevent potential adverse drug events, such as ordering a drug that the patient has a documented allergy to or is likely to have a negative interaction with another drug the patient is using.[7] CDS tools intervene at the point of care and alert clinicians to potential adverse drug events before they happen. Performance outcomes have been mixed, and a significant amount of customization happens at the organization level, resulting in heterogeneity even within hospitals using the same technology.[6,7,8,9] As a result, while medication-related safety performance has improved, there is major progress to be made, with hospitals correctly alerting clinicians to fewer than two-thirds of potential adverse drug events.[8]

Results

Discussion

Conclusion