Comprehensive Electronic Health Record Research Articles

Implementing electronic health records (EHRs): health care provider perceptions before and after transition from a local basic EHR to a commercial comprehensive EHR.

We assessed changes in the percentage of providers with positive perceptions of electronic health record (EHR) benefit before and after transition from a local basic to a commercial comprehensive EHR. Changes in the percentage of providers with positive perceptions of EHR benefit were captured via a survey of academic health care providers before (baseline) and at 6-12 months (short term) and 12-24 months (long term) after the transition. We analyzed 32 items for the overall group and by practice setting, provider age, and specialty using separate multivariable-adjusted random effects logistic regression models. A total of 223 providers completed all 3 surveys (30% response rate): 85.6% had outpatient practices, 56.5% were >45 years old, and 23.8% were primary care providers. The percentage of providers with positive perceptions significantly increased from baseline to long-term follow-up for patient communication, hospital transitions - access to clinical information, preventive care delivery, preventive care prompt, preventive lab prompt, satisfaction with system reliability, and sharing medical information (P < .05 for each). The percentage of providers with positive perceptions significantly decreased over time for overall satisfaction, productivity, better patient care, clinical decision quality, easy access to patient information, monitoring patients, more time for patients, coordination of care, computer access, adequate resources, and satisfaction with ease of use (P < 0.05 for each). Results varied by subgroup. After a transition to a commercial comprehensive EHR, items with significant increases and significant decreases in the percentage of providers with positive perceptions of EHR benefit were identified, overall and by subgroup.

Care Coordination and Comprehensive Electronic Health Records are Associated With Increased Transition Planning Activities

ObjectiveYouth with special health care needs (YSHCN) require assistance from their pediatricians to transition to adult care. There are few data on what transition resources pediatricians have. In this article we discuss whether care coordination and/or comprehensive electronic health record (CEHR) implementation are associated with improved transition processes. MethodsUsing the American Academy of Pediatrics Periodic Survey #79, we report whether practices generated written transition plans, assisted in finding adult providers, and discussed confidentiality issues. Descriptive statistics and a logistic regression model were done to evaluate whether CEHR, care coordination, or practice and physician characteristics were associated with improved transition planning. ResultsTransition planning support in practices is low. Pediatricians with any care coordinator report more written transition plans for YSHCN (23% vs 6%; P < .001), assistance identifying adult providers (59% vs 39%; P < .001), and discussing confidentiality issues (50% vs 33%; P < .001). Pediatricians with a CEHR compared with those without are more likely to report written transition plans for YSHCN (24% vs 12%; P < .05) and discussing confidentiality issues (51% vs 39%; P < .05). In the logistic regression model, having care coordination (adjusted odds ratio, 11.1; 95% confidence interval, 5.9–21.3) and CEHR (adjusted odds ratio, 2.6; 95% confidence interval, 1.5–5.0) were independently associated with higher odds of having a written transition plan. ConclusionsOnly 1 in 5 pediatricians have a transition coordinator in their practice and just 15% have a CEHR, even as these resources are associated with improved transition processes for YSHCN. Policy decisions should be made to help practices with supports, such as care coordination and electronic health record implementation, to improve transitions to adulthood.

Abstract 028: Electronic Health Record Meaningful Use Did Not Improve Pay-for-Performance Outcomes

Objective: With the goal of improving healthcare quality, Medicare has implemented a series of pay-for-performance initiatives and allocated substantial financial resources to promote meaningful use of electronic health records (EHRs). The purpose of this study was to examine whether hospitals achieving EHR meaningful use improved hospital 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates used in Medicare pay-for-performance (P4P) initiatives. Methods: We used publically available data on Medicare EHR Incentive Program achievement (2014 to 2015) to categorize hospitals as achieving two years, one year, or no years of stage 2 meaningful use (i.e. comprehensive EHR) from 2014-2015. Using generalized linear models, we compared the change in publically reported 30-day RSMRs and RSRRs for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PN) from 2012 to 2016 by years of stage 2 meaningful use. Models were adjusted for hospital teaching status, system affiliation, ownership status, urban/rural location, bed size, and safety-net status obtained from the American Hospital Association Annual Survey and Medicare Impact File (both 2009-2011). Results: From the 4,755 hospitals participating in the Medicare EHR program, 19.8% and 46.0% had two years and one year of stage 2 meaningful use, while 34.2% never achieved stage 2 meaningful use. The Figure shows that from 2012 to 2016 thirty-day mortality for AMI decreased (-1.2% to -1.4%), increased modestly for CHF (+0.5), and increased for PN (+4.1 to +4.6%). All thirty-day readmission rates decreased during this time, with decreases greater in AMI and CHF (both -2.7% to -2.8%) than in PN (-1.3% to -1.4%). We found that there were no significant differences in risk-standardized mortality or readmission rate changes by years of stage 2 meaningful use, even after adjusting for hospital characteristics (all comparisons p&gt;0.05). Conclusions: While RSMRs and RSRRs have changed substantially from 2012 to 2016 for most conditions, changes were similar for hospitals with two years, one year, or no years of stage 2 EHR meaningful use. Our findings suggest that adoption of more comprehensive EHRs did not improve hospital P4P outcomes. Figure. Change in RSMRs and RSRRs rates by years of stage 2 meaningful use.

Rate of electronic health record adoption in South Korea: A nation-wide survey

ObjectiveThe adoption rate of electronic health record (EHR) systems in South Korea has continuously increased. However, in contrast to the situation in the United States (US), where there has been a national effort to improve and standardize EHR interoperability, no consensus has been established in South Korea. The goal of this study was to determine the current status of EHR adoption in South Korean hospitals compared to that in the US. MethodsAll general and tertiary teaching hospitals in South Korea were surveyed regarding their EHR status in 2015 with the same questionnaire as used previously. The survey form estimated the level of adoption of EHR systems according to 24 core functions in four categories (clinical documentation, result view, computerized provider order entry, and decision supports). The adoption level was classified into comprehensive and basic EHR systems according to their functionalities. ResultsEHRs and computerized physician order entry systems were used in 58.1% and 86.0% of South Korean hospitals, respectively. Decision support systems and problem list documentation were the functions most frequently missing from comprehensive and basic EHR systems. The main barriers cited to adoption of EHR systems were the cost of purchasing (48%) and the ongoing cost of maintenance (11%). DiscussionThe EHR adoption rate in Korean hospitals (37.2%) was higher than that in US hospitals in 2010 (15.1%), but this trend was reversed in 2015 (58.1% vs. 75.2%). The evidence suggests that these trends were influenced by the level of financial and political support provided to US hospitals after the HITECH Act was passed in 2009. ConclusionsThe EHR adoption rate in Korea has increased, albeit more slowly than in the US. It is logical to suggest that increased funding and support tied to the HITECH Act in the US partly explains the difference in the adoption rates of EHRs in both countries.

A Comprehensive Electronic Health Record Based Patient Navigation Module Including Technology Driven Colorectal Cancer Outreach and Education.

The purpose of this concept paper is to propose an innovative multifaceted patient navigation module embedded in the Electronic Health Record (EHR) to address barriers to efficient and effective colorectal cancer (CRC) care. The EHR-based CRC patient navigation module will include several patient navigation features: (1) CRC screening registry; (2) patient navigation data, including CRC screening data, outcomes of patient navigation including navigation status (CRC screening referrals, fecal occult blood test (FOBT) completed, colonoscopy scheduled and completed, cancelations, reschedules, and no-shows); (3) CRC counseling aid; and 4) Web-based CRC education application including interactive features such as a standardized colonoscopy preparation guide, modifiable CRC risk factors, and links to existing resources. An essential component of health informatics is the use of EHR systems to not only provide a system for storing and retrieval of patient health data but can also be used to enhance patient decision-making both from a provider and patient perspective.

Impact of Longitudinal Electronic Health Record Training for Residents Preparing for Practice in Patient-Centered Medical Homes.

Competence in using an electronic health record (EHR) is considered a critical skill for physicians practicing in patient-centered medical homes (PCMHs), but few studies have examined the impact of EHR training for residents preparing to practice in PCMHs. This study explored the educational outcomes associated with comprehensive EHR training for family medicine residents. The PCMH EHR training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants completed an EHR competency self-assessment between 2011 and 2016 (N = 127), examining 6 EHR/PCMH core skills. We compared baseline characteristics for residents by low vs high exposure to EHR training. Multivariate regression estimated whether self-reported competencies improved over time and whether high PCMH EHR training exposure was associated with incremental improvement in self-reported competencies over time. Residents completed an average of 8.2 sessions: low-exposure residents averaged 5.3 sessions (standard deviation = 1.5), and high-exposure residents averaged 9.0 sessions (standard deviation = 0.9). High-exposed residents had higher posttest scores at training completion (84.4 vs 70.7). Over time, adjusted mean scores (confidence interval) for both groups improved (p < 0.001) from 12.2 (9.6-14.8), with low-exposed residents having greater score improvement (p < 0.001) because of their much lower baseline scores. Comprehensive training designed to improve EHR competencies among residents practicing in a PCMH resulted in improved assessment scores. Our findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.

Predicting Severe Pneumonia Outcomes in Children

Substantial morbidity and excessive care variation are seen with pediatric pneumonia. Accurate risk-stratification tools to guide clinical decision-making are needed. We developed risk models to predict severe pneumonia outcomes in children (<18 years) by using data from the Etiology of Pneumonia in the Community Study, a prospective study of community-acquired pneumonia hospitalizations conducted in 3 US cities from January 2010 to June 2012. In-hospital outcomes were organized into an ordinal severity scale encompassing severe (mechanical ventilation, shock, or death), moderate (intensive care admission only), and mild (non-intensive care hospitalization) outcomes. Twenty predictors, including patient, laboratory, and radiographic characteristics at presentation, were evaluated in 3 models: a full model included all 20 predictors, a reduced model included 10 predictors based on expert consensus, and an electronic health record (EHR) model included 9 predictors typically available as structured data within comprehensive EHRs. Ordinal regression was used for model development. Predictive accuracy was estimated by using discrimination (concordance index). Among the 2319 included children, 21% had a moderate or severe outcome (14% moderate, 7% severe). Each of the models accurately identified risk for moderate or severe pneumonia (concordance index across models 0.78-0.81). Age, vital signs, chest indrawing, and radiologic infiltrate pattern were the strongest predictors of severity. The reduced and EHR models retained most of the strongest predictors and performed as well as the full model. We created 3 risk models that accurately estimate risk for severe pneumonia in children. Their use holds the potential to improve care and outcomes.

Hospital information systems: experience at the fully digitized Seoul National University Bundang Hospital

The different levels of health information technology (IT) adoption and its integration into hospital workflow can affect the maximization of the benefits of using of health IT. We aimed at sharing our experiences and the journey to the successful adoption of health IT over 13 years at a tertiary university hospital in South Korea. The integrated system of comprehensive applications for direct care, support care, and smart care has been implemented with the latest IT and a rich user information platform, achieving the fully digitized hospital. The users experience design methodology, barcode and radio-frequency identification (RFID) technologies, smartphone and mobile technologies, and data analytics were integrated into hospital workflow. Applications for user-centered electronic medical record (EMR) and clinical decision support (CDS), closed loop medication administration (CLMA), mobile EMR and dashboard system for care coordination, clinical data warehouse (CDW) system, and patient engagement solutions were designed and developed to improve quality of care, work efficiency, and patient safety. We believe that comprehensive electronic health record systems and patient-centered smart hospital applications will go a long way in ensuring seamless patient care and experience.

Does electronic health record use improve hospital financial performance? Evidence from panel data.

The aim of this study was to examine the impact of electronic health record (EHR) adoption on hospital financial performance. We constructed a longitudinal panel using data from the three secondary sources: (a) the 2007-2010 American Hospital Association (AHA) Annual Survey, (b) the 2007-2010 AHA Annual Survey Information Technology Supplement, and (c) the 2007-2011 Medicare Cost Reports from Centers for Medicare and Medicaid Services. Because potential financial benefits attributable to EHR adoption may take some time to accrue, we ran regressions with lags of 1 and 2 years that included hospital and year fixed effects to examine the relationship between the level of EHR adoption and three hospital financial performance measures. A change in the level of EHR adoption was not associated with changes in operating margin or return on assets within hospitals. However, total margin was significantly improved, after 2 years, in hospitals that moved from no EHR to having a comprehensive EHR in all areas of their hospital (β = 0.030, p < .034). On the other hand, hospitals that increased their level of EHR adoption but did not achieve hospital-wide comprehensive adoption did not experience changes in any financial performance measures examined. The improvements in total margin, as opposed to operating margin, are likely due to hospital incentive payments under the Health Information Technology for Economic and Clinical Health Act that are reflected in nonpatient revenues and therefore show up in total margin calculations. Thus, after 2 years of EHR adoption, hospital financial performance is observed to improve based only on meaningful use incentive payments. More research will be needed to determine whether EHR adoption impacts financial performance on a longer time horizon.

Accuracy of Adverse Drug Reaction Documentation upon Implementation of an Ambulatory Electronic Health Record System.

BackgroundDetection, monitoring and treatment of adverse drug reactions (ADRs) are paramount to patient safety. The use of a comprehensive electronic health record (EHR) system has the potential to address inadequacies in ADR documentation and to facilitate ADR reporting to health agencies. However, effective methods to maintain the quality of documented ADRs within an EHR have not been well studied.ObjectiveTo evaluate the accuracy and effectiveness of ADR documentation transfer throughout the implementation of a comprehensive EHR system.MethodsRetrospective analysis of ADR documentation at a tertiary care pediatric hospital between January 2013 and June 2014. ADRs documented in the newly implemented ambulatory EHR, pharmacy system and hybrid health record system were extracted. Documentation inconsistencies and processes for managing ADR documentation within the EHR were reviewed.ResultsA total of 115 patients with 260 unique ADRs were identified. Only 155 (60 %) of the identified ADRs were found in the ambulatory EHR system. The remaining 105 ADRs (40 %) were missing from the EHR when it was compared with the other systems. Seventy-two patients (63 %) returned for a follow-up visit, and each had their ADR documentation reviewed in the ambulatory EHR. Following the visit, 44 % of these ambulatory EHR records still included incorrect information.ConclusionsWe identified discrepancies in ADR documentation within hospital systems, which need to be addressed as healthcare institutions transition to EHRs. Processes related to the transfer of ADR information into the EHR should be clearly defined. To improve the quality of ADR documentation, steps to force complete and continual ADR verification should be introduced at early stages of implementation of a new EHR, and all responsible providers should play a role.Electronic supplementary materialThe online version of this article (doi:10.1007/s40801-016-0071-8) contains supplementary material, which is available to authorized users.

Impact of laboratory cost display on resident attitudes and knowledge about costs

AimCost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have...

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program

ABSTRACTEarly HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

Factors Associated with Clinician Perception of Improved Patient Safety Following Transition to a Comprehensive Electronic Health Record

Factors Associated with Clinician Perception of Improved Patient Safety Following Transition to a Comprehensive Electronic Health Record

Advances in pain management for Veterans: Current status of research and future directions

Military Veterans have been identified as being particularly vulnerable to the development and perpetuation of [1]. Among the 23 million U.S. military Veterans, it has been estimated that as many as 50 percent of male Veterans and as many as 75 percent of female Veterans experience chronic [2]. Painful musculoskeletal conditions are the most common disorders among Veterans returning from the recent conflicts in Iraq and Afghanistan, surpassing the rates of all mental health conditions combined [3]. Pain among these Veterans is highly comorbid with the signature injuries of these conflicts, namely posttraumatic stress disorder (PTSD) and traumatic brain injury [4]. Although not unique to Veterans, compounding the challenges associated with successful management of chronic is continued evidence of a provider workforce that is ill-prepared to assess and manage common conditions [5], limited effectiveness of analgesic medications and other nonpharmacological approaches [6], and growing concerns about harms associated with long-term opioid therapy [7]. In 2011, the Institute of Medicine (IOM) published its seminal report, Relieving in America: A blueprint for transforming prevention, care, education, and research, and called on the Department of Veterans Affairs (VA) and other Government and stakeholder groups to renew their commitment to this national transformational effort [1]. Research on among Veterans is not new. In fact, some of the early pioneering work to advance the multidimensional assessment of chronic and establish the efficacy of psychological approaches for management was conducted in the VA [8-9]. By 1998, former VA Undersecretary for Health Kenneth Kizer, MD, identified the need for more research as one of the objectives of a VA Pain Management Strategy [10]. A special topic issue of the Journal of Rehabilitation Research and Development (JRRD) in 2007 highlighted sustained growth in the VA research portfolio [11], and annual reports since that time provide evidence of yearly growth in terms of the number, scope, and financial expenditures in support of the VA's research portfolio. This special topic issue of JRRD presents results from research projects taking place in the VA healthcare system, with a focus on innovative research and its practice and policy implications. The specific objectives of the issue are to educate readers about (1) special issues faced by Veterans with pain, especially Veterans of the recent wars in Iraq and Afghanistan; (2) potential sources of inequities in care that may have special relevance for Veterans; and (3) novel approaches to the assessment and treatment of and comorbid conditions for Veterans with pain. As such, contributions to this special issue come from the VA clinical, rehabilitation, and health services research communities as opposed to investigators conducting basic laboratory science and preclinical research. Ultimately, we hope that the series of original articles that comprise this special issue will convey a sense of the robust pain-relevant research program in the VA and inform an agenda for further research addressing the management of in Veterans and other groups. Contributions to this special topic issue offer a window into the exciting, innovative, and important pain-relevant research being conducted in the VA that directly informs the VA's efforts to address the challenge of the IOM. As just one example, a key finding of the IOM was the lack of consistent data that document the incidence and prevalence of and its effects on activities of daily living and work, use of healthcare and social services, and costs of and care and the recommendation to improve the collection and reporting of data on pain [1]. The VA is ideally positioned to address this recommendation because it has one of the most comprehensive electronic health record (EHR) systems in the United States, which includes longitudinal clinical assessments (e. …

Agreement Between HEDIS Performance Assessments in the VA and Medicare Advantage: Is Quality in the Eye of the Beholder?

Medicare Advantage (MA) plans and the Veterans Affairs (VA) health care system assess quality of care using standardized Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. Little is known, however, about the relative accuracy of quality indicators for persons receiving care in more than one health care system. Among Veterans dually enrolled in an MA plan, we examined the agreement between MA and VA HEDIS assessments. Our study tested the hypothesis that private health plans underreport quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Despite assessing the same individuals using identical measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. The VA’s performance advantage ranged from 9.8% (glycosylated hemoglobin [HbA1c] < 7.0% in diabetes) to 54.7% (blood pressure < 140/90 mm Hg in diabetes). The overall agreement between VA and MA HEDIS assessments ranged from 38.5% to 62.6%. Performance rates derived from VA and MA aggregate data were 1.6% to 14.3% higher than those reported by VA alone. This analysis suggests that neither MA plans nor the VA fully capture quality of care information for dually enrolled persons. However, the VA’s system-wide electronic health record may allow for more complete capture of quality information across multiple providers and settings.

A Note from the Executive Editor

The theme of this edition of JADE, "The Impact of the EHR on Dental Education" has special resonance for NYUCD as we transition to a comprehensive electronic health record.

Diabetes quality of care at a university community in Beirut.

To assess the quality of diabetes mellitus (DM) care provided by a group of family doctors in Beirut. An observational study, conducted at the American University of Beirut Medical Center-Family Medicine Clinics (AUBMC-FMC), examined the electronic health records (EHRs) of the beneficiaries of the Health Insurance Plan at the American University of Beirut (AUB-HIP) who were older than 20 years (n = 9469) in 2009. The eligible population included patients with DM (n = 701). Several provider/patient-directed interventions were introduced in the late 2000s, including a comprehensive EHRs system with point-of-care computer reminders, a provider financial incentive based on an annual performance appraisal ranked against that of the US Healthcare Effectiveness Data and Information Set (HEDIS) Comprehensive Diabetes Care indicators, as well as periodic up-to-date training. Optimal control for HbA1c, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides and blood pressure were found in 58.6%, 51.0%, 22.4%, 53.3% and 60.2% of the population, respectively. 64.1% and 70.0% received screening for diabetic nephropathy and a dilated eye examination, respectively. When benchmarked against the HEDIS Comprehensive Diabetes Care indicators, the AUB-HIP's quality of care was 13% higher than the average of all plans in the United States. Screening for nephropathy, however, did not reach the above benchmark. Benchmarking served as an important tool in evaluating the current DM care offered and in detecting gaps, yet interventions are recommended for further improvement.

The influence of institutional pressures on hospital electronic health record presence

Electronic health records (EHR) are a promising form of health information technology that could help US hospitals improve on their quality of care and costs. During the study period explored (2005–2009), high expectations for EHR diffused across institutional stakeholders in the healthcare environment, which may have pressured hospitals to have EHR capabilities even in the presence of weak technical rationale for the technology. Using an extensive set of organizational theory-specific predictors, this study explored whether five factors – cause, constituents, content, context, and control – that reflect the nature of institutional pressures for EHR capabilities motivated hospitals to comply with these pressures. Using information from several national data bases, an ordered probit regression model was estimated. The resulting predicted probabilities of EHR capabilities from the empirical model's estimates were used to test the study's five hypotheses, of which three were supported. When the underlying cause, dependence on constituents, or influence of control were high and potential countervailing forces were low, hospitals were more likely to employ strategic responses that were compliant with the institutional pressures for EHR capabilities. In light of these pressures, hospitals may have acquiesced, by having comprehensive EHR capabilities, or compromised, by having intermediate EHR capabilities, in order to maintain legitimacy in their environment. The study underscores the importance of our assessment for theory and policy development, and provides suggestions for future research.

Utilization of the Electronic Health Record to Improve Provision of Smoking Cessation Resources for Vascular Surgery Inpatients.

Identification of hospitalized patients who smoke has shown significant improvement in recent years, but provision of evidence-based tobacco cessation treatment remains a challenge. This study evaluated the utilization of an electronic health record (EHR) to facilitate implementation of evidence-based clinical practice guidelines for smoking cessation on a vascular surgery inpatient unit. A pre-and post-intervention cohort study was conducted over 6 months at a single academic medical center with a comprehensive EHR. All patients admitted to the vascular surgery service and documented as current smokers were included. A vascular surgery discharge order set with an evidence-based smoking cessation module was developed and implemented. The primary outcome was prescription of nicotine replacement therapy (NRT) at the time of discharge. The secondary outcome was referral for smoking cessation counseling at the time of discharge. There were 52 and 42 smokers in the pre-and post-intervention cohorts, respectively. Over the 3 months following implementation of the EHR order set, prescription of NRT at the time of discharge did not change significantly (27% vs 19%, p=0.30). Referral for outpatient smoking cessation counseling increased in the post-intervention group, but did not reach significance (64% vs 72%, p=0.20). Implementation of a brief tobacco dependence treatment order set in an existing EHR increased cessation counseling referrals on a vascular surgery inpatient unit. One potential limitation of the study was the modest sample size. Not being able to make smoking cessation treatment a mandatory component in discharge orders may also have contributed to the modest effect. Assessing the differential effect of EHR-based order implementation will be important in future research on this topic.

Level of EHR adoption and quality and cost of care - evidence from vascular conditions and procedures

This study examined relationships of electronic health record (EHR) adoption to both the cost of care and quality outcomes in the acute care hospital setting. Data were mainly obtained from the 2009 National Inpatient Sample and the 2009 American Hospital Association EHR implementation survey. Two sets of dependent variables were identified. The first set included quality indicators of five cardiovascular and three cerebrovascular conditions and procedures. The second set included cost of care for the eight quality indicators. The independent variables were levels of EHR adoption. The results did not identify many differences in quality indicators across levels of EHR adoption, but consistently showed that patients in hospitals with EHR systems incurred lower costs than patients in hospitals without a comprehensive or basic EHR system. It was concluded that EHR adoption is more likely to be associated with the cost of patient care than improving quality indicators and clinical outcomes.