Impact Of Electronic Health Record Research Articles

The impact of electronic health records on ambulatory costs among Medicaid beneficiaries.

Broad adoption of electronic health records (EHRs) is a potential strategy for curbing healthcare cost growth, which is particularly vital for Medicaid. Despite limited evidence for EHR-related cost savings, the 2009 HITECH Act included incentives for providers to become meaningful users of EHRs. We evaluated a large Massachusetts EHR pilot to obtain early insight into the potential for the national strategy to reduce short-run healthcare costs in the Medicaid population. We calculated monthly ambulatory cost and visit measures from Medicaid claims data for beneficiaries receiving the majority of their care in the three Massachusetts eHealth Collaborative (MAeHC) pilot communities or in six matched control communities. Using a difference-in-differences of slope analysis, we assessed whether cost and visit trajectories differed in the pre-implementation period compared to the post-implementation period for intervention and control community members. We found evidence that EHR adoption impacted ambulatory medical cost in two of the three communities, but the effects were in opposite directions. Ambulatory medical costs increased more slowly in one intervention compared to its control communities in the pre-to-post period (difference-in-differences=-1.98%, p<0.001; PMPM savings of $41.60). In contrast, for a second pilot community, ambulatory medical cost increased more slowly in the control communities (difference-in-differences=2.56%, p=0.005; PMPM increase of $43.34). As a stand-alone approach, adoption of commercially-available EHRs in community practices did not consistently impact Medicaid costs in the short-run. This suggests that future meaningful use criteria may need to specifically target cost savings and coordinate with payment reform efforts.

Electronic Health Records: Current Issues in Oncology

The electronic world continues to advance in the 21st century. In 2009, the American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act were enacted; in response, hospitals and oncology physician offices have or are implementing electronic health records (EHRs). As with any new technology or process, a steep learning curve is associated with the implementation of EHRs. Often, the full impact of a sweeping, nationwide change such as EHRs is not realized for many years after implementation, and many suppositions about the usefulness and benefits of EHRs still exist. The current article focuses on the initial impact of EHRs, their role in diagnosis, and the responses of healthcare providers in patient outcomes and in research.

Impact of electronic health records on malpractice claims in a sample of physician offices in Colorado: a retrospective cohort study.

Electronic health records (EHRs) might reduce medical liability claims and potentially justify premium credits from liability insurers, but the evidence is limited. To evaluate the association between EHR use and medical liability claims in a population of office-based physicians, including claims that could potentially be directly prevented by features available in EHRs ("EHR-sensitive" claims). Retrospective cohort study of medical liability claims and analysis of claim abstracts. The 26 % of Colorado office-based physicians insured through COPIC Insurance Company who responded to a survey on EHR use (894 respondents out of 3,502 invitees). Claims incidence rate ratio (IRR); prevalence of "EHR-sensitive" claims. 473 physicians (53 % of respondents) used an office-based EHR. After adjustment for sex, birth cohort, specialty, practice setting and use of an EHR in settings other than an office, IRR for all claims was not significantly different between EHR users and non-users (0.88, 95 % CI 0.52-1.46; p = 0.61), or for users after EHR implementation as compared to before (0.73, 95 % CI 0.41-1.29; p = 0.28). Of 1,569 claim abstracts reviewed, 3 % were judged "Plausibly EHR-sensitive," 82 % "Unlikely EHR-sensitive," and 15 % "Unable to determine." EHR-sensitive claims occurred in six out of 633 non-users and two out of 251 EHR users. Incidence rate ratios were 0.01 for both groups. Colorado physicians using office-based EHRs did not have significantly different rates of liability claims than non-EHR users; nor were rates different for EHR users before and after EHR implementation. The lack of significant effect may be due to a low prevalence of EHR-sensitive claims. Further research on EHR use and medical liability across a larger population of physicians is warranted.

Electronic Health Record Impact on Work Burden in Small, Unaffiliated, Community-Based Primary Care Practices

The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices. To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices. We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach. All practice members and selected patients in seven community-based primary care practices in the Northeastern US. The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care. The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Impact of Electronic Health Records on Nurses’ Productivity

As the use of electronic health records increases, it becomes necessary to address their global impact on nurses' productivity in hospitals. A retrospective cross-sectional study was conducted to explore the impact of electronic health records on nurses' productivity and to examine whether the impacts are moderated through case-mix index or adjusted patient-days. Two sources of data were linked and analyzed for years 2007 and 2008: the American Hospital Association survey and the Centers for Medicare & Medicaid Services data. Almost two-thirds of the respondent hospitals in both years (63.9% in 2007 and 68.4% in 2008) had a high electronic health record index (≥5). Hospitals with higher penetration of electronic health records had more RNs employed (coefficient=0.234, P=.002) compared with hospitals with low penetration of electronic health records, even when controlling for adjusted patient-day volumes. This difference decreased for hospitals with higher case-mix index values. The study findings fail to suggest any financial savings or superior productivity in nurses due to usage of electronic health records.

Cost-effectiveness of informatics and health IT: impact on finances and quality of care

This issue of the journal focuses on an important but often underpublished area of biomedical informatics: the cost-effectiveness of informatics interventions in healthcare. The adoption of electronic health records (EHR) across the USA has been accelerated in response to legislation, but there is still much uncertainty regarding costs as well as short and long-term effects, given the many different ways in which systems are implemented and the high diversity of institutions served. A systematic review by O'Reilly ( see page 423 ) covers economic evaluations of medication management systems, and the author also describes the cost-effectiveness of a clinical decision support system (CDSS) for diabetes in another article ( see page 341 ). Frisse ( see page 328 ) reports on the financial impact of EHR in an emergency department, and Subramanian ( see page 439 ) analyzes the financial impact of a CDSS for renal dose adjustments. The financial aspects are not sufficient to assess the full impact of information systems and informatics interventions. Several articles relate to the impact of systems in the quality of care. Connelly ( see page 334 ) describes …

Error in Figure in: Impact of Electronic Health Records on Racial and Ethnic Disparities in Blood Pressure Control at US Primary Care Visits

Error in Figure in: Impact of Electronic Health Records on Racial and Ethnic Disparities in Blood Pressure Control at US Primary Care Visits

Impact of Electronic Health Records (EHR) on Screening Colonoscopy Rates in Primary Care Clinics

Ambulatory Care clinics are increasingly investing in Electronic Health Records (EHR) in an effort to improve the efficiency of primary care which includes primary prevention of diseases like colon cancer. The U.S. Preventive Services Task Force (USPSTF) recommends screening colonoscopy beginning at the age 50. While use of EHR is expected to improve the rate of screening colonoscopies through careful tracking, this is yet to be proven. To compare the rate of screening colonoscopies between EHR and non-EHR implemented clinics across different genders, races and ethnicities and to compare the screening rates in EHR implemented clinics across different regions, specialty clinics and insurances. We performed a retrospective analysis of the limited access dataset from the National Ambulatory Medical Care Survey from 2003 (when EHR was introduced) to 2009. All patients above 50 years of age were included in the analysis. Multivariate logistic regression was used to investigate discrepancies in the rate of colonoscopies based on gender, race, ethnicity, region, type of insurance and type of specialty clinic. All statistical analysis was performed using SAS. 98,104 patients above 50 years of age were included in the study. Overall, there was no significant difference in the rate of colonoscopies among patients visiting EHR clinics compared to non-EHR clinics [OR 0.93, 95% CI (0.73-1.19)]. On sub-group analysis, there was no significant difference in the rate of colonoscopies between EHR clinics and non-EHR clinics based on gender or ethnicity. However, African Americans had a significantly lower rate of colonoscopy in EHR clinics [OR 0.47, 95% CI (0.22-0.98)] compared to non-EHR clinics (Table). Among the patients in EHR clinics who underwent colonoscopy, there was no significant difference in the colonoscopy rates based on region or patient's insurance. However in the same population, colonoscopy rate was significantly lower in Internal-Medicine clinics [OR 0.49, 95% CI (0.25-0.96)] compared to Family-Medicine clinics.TableColonoscopy Rates in EHR vs Non-EHR Implemented Clinics Based on Race and EthnicityCharacteristics (Age >50)EHR use, % of all visitsNon EHR use, % of all visitsAdjusted odds ratio (95% CI)*Hispanic Colonoscopy No41.658.41 (Reference) Colonoscopy Yes48.251.81.16 (0.55 to 2.45)Non Hispanics Colonoscopy No44.355.71 (Reference) Colonoscopy Yes41.358.70.80 (0.62 to 1.05)Caucasians Colonoscopy No43.556.41 (Reference) Colonoscopy Yes43.256.80.91 (0.71 to 1.16)African Americans Colonoscopy No38.961.21 (Reference) Colonoscopy Yes30.269.80.47 (0.22 to 0.98) Open table in a new tab Implementation of EHR in ambulatory care does not change the rate of screening colonoscopy. This is consistent with previously published data on EHR with regard to other areas of preventative care. Our results highlight the need for improving EHR features to prompt physicians to obtain colonoscopies. Lower rates of colonoscopy in African American patients points to a need for better utilization of primary care resources for this subgroup. Our study also shows that there is a need for improving colonoscopy rates in Internal-Medicine clinics when compared to Family-Medicine clinics.

The Effectiveness of Implementing an Electronic Health Record on Diabetes Care and Outcomes

To assess the impact of electronic health record (EHR) implementation on primary care diabetes care. Charts were abstracted semi-annually for 14,051 diabetes patients seen in 34 primary care practices in a large, fee-for-service network from January 1, 2005 to December 31, 2010. The study sample was limited to patients aged 40 years or older. A naturalistic experiment in which GE Centricity Physician Office-EMR 2005 was rolled out over a staggered 3-year schedule. Chart audits were conducted using the AMA/Physician Consortium Adult Diabetes Measure set. The primary outcome was the HealthPartners' "optimal care" measure: HbA1c ≤ 8 percent; LDL cholesterol < 100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and documented aspirin use in patients ≥ 40 years of age. After adjusting for patient age, sex, and insulin use, patients exposed to the EHR were significantly more likely to receive "optimal care" when compared with unexposed patients (p < .001), with an estimated difference of 9.20 percent (95% CI: 6.08, 12.33) in the final year between exposed patients and patients never exposed. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <80 mmHg, diastolic blood pressure <130 mmHg, aspirin prescription, and smoking cessation. Among patients exposed to EHR, all process and outcome measures except HbA1c and lipid control showed significant improvement. Implementation of a commercially available EHR in primary care practice may improve diabetes care and clinical outcomes.

Impact of Electronic Health Records on Racial and Ethnic Disparities in Blood Pressure Control at US Primary Care Visits

Prior literature suggests that practice level characteristics mediate racial/ethnic disparities in clinical outcomes.1 One such practice level characteristic, use of electronic health records (EHRs) with clinical decision support (CDS), has been associated with improved blood pressure (BP) control in a national study.2 However, we do not know whether these effects differ across racial/ethnic groups.3 We sought to determine whether physician use of EHRs with and without CDS is associated with a reduction in racial/ethnic disparities in BP control in a nationally representative sample. Methods We examined data from primary care visits in the 2007-2008 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of nonhospital-based ambulatory visits administered by the National Center for Health Statistics (NCHS).4 In a recent article, we examined visits to NAMCS physicians who answered questions about EHRs and electronic guideline-based reminders.2 Primary care . . .

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes. Interrupted time series analysis, 2003-2009. A large US not-for-profit integrated health care organization. 29 hospitals in Northern and Southern California. An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools. Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures). EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72). The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.

A New Instrument for Measuring Clinician Satisfaction With Electronic Health Records

A new survey instrument was developed and validated to measure clinician (nurse) satisfaction with electronic health record impact on clinical process. The Health Information Technology Reference-Based Evaluation Framework guided the selection of evaluation dimensions for the survey. Survey questions were gathered from existing health information technology satisfaction surveys that reflected individual evaluation concepts, such as efficiency or benefits. Decisions about data-gathering methods (e.g., item selection) were made based on reviews of literature and surveys of clinician satisfaction with health information technology and expert input. Preliminary instrument validation was accomplished using qualitative and statistical analysis of five repeated sets of responses from clinicians at the pilot site and field administrations repeated twice at electronic health record implementation and paper-based comparison sites and by analyzing convergent evidence from observations and interviews. Reliability was assessed on one sample: 30 graduate nursing students at the single pilot site. Validity was assessed on three separate samples: (1) graduate nursing students (n = 30), (2) field test at a site with electronic health record (n = 39 participants), and (3) field test at a paper-based site (n = 17). The implementation and comparison sites are Program of All-Inclusive Care for the Elderly that provide managed day care for frail elderly. Survey responses were assessed for test-retest reliability, internal consistency, and content and construct validity. The instrument design enables its administration before and after electronic health record implementation. Work to date suggests the instrument is reliable and valid; it is offered to electronic health record evaluators for further testing and application.

Impact of an Electronic Health Record on Follow-up Time for Markedly Elevated Serum Potassium Results

Follow-up of abnormal ambulatory laboratory results is often suboptimal. The impact of an ambulatory electronic health record (EHR) on follow-up of markedly elevated blood potassium (K( +)) results was investigated via a retrospective medical record review-before and after EHR implementation-of patients at an adult primary care practice who had a nonhemolyzed K(+) ≥ 6.0 mEq/L. In all, 188 patients in the pre-EHR group and 30 in the EHR group satisfied inclusion criteria. The mean K(+) for the 2 groups was 6.3 mEq/L. The EHR group had 4.5 times the odds (95% confidence interval = 1.3-15.8) of having their episodes of hyperkalemia followed up within 4 days. Patients in the EHR group were also more likely to have their blood K(+) rechecked within 4 days (63.3% vs 43.6%; P = .044). An ambulatory EHR with a results management system improves documentation and time to follow-up for patients with markedly abnormal lab results.

Electronic Health Record Adoption – Maybe It’s not about the Money

The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by tech-savvy physicians where resistance and expense are not at issue. Two EHR systems were examined - the paperless VistA / Computerized Patient Record System used at the Veterans' Administration, and the General Electric Centricity Enterprise system used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multiinstitutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze the transcribed data and build themes. The relevance and importance of themes were constructed by examining their frequency, convergence, and intensity. Despite eliminating resistance to both adoption and technology as drivers of acceptance, these two robust EHR's are still viewed as having an adverse impact on two aspects of patient care, physician workflow and team communication. Both EHR's had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians' needs. Difficulties related to physician acceptance reflect real concerns about EHR impact on patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated with the non-intuitive interfaces and cumbersome data searches of existing EHRs.

The Impact of Health Information Technology on the Quality of Medical and Health Care: A Systematic Review

The aim of this study was to systematically review the published evidence of the impact of health information technology (HIT) or health information systems (HIS) on the quality of healthcare, focusing on clinicians's; adherence to evidence-based guidelines and the corresponding impact this had on patient clinical outcomes. The review covered the use of health information technologies and systems in both medical care (i.e. clinical and surgical) and other areas such as allied health and preventive services. Studies were included in the review if they examined the impact of Electronic Health Record (EHR), Computerised Provider Order-Entry (CPOE), or Decision Support System (DS); and if the primary outcomes of the studies were focused on the level of compliance with evidence-based guidelines among clinicians. Measurements considered relevant to the review were either of changes in clinical processes resulting from a change of the providers' behaviour, or of specific patient outcomes that demonstrated the effectiveness of a particular treatment given by providers. Of 23 studies included in the current review, 17 assessed the impact of HIT/HIS on health care practitioners' performance. A positive improvement, in relation to their compliance with evidence-based guidelines, was seen in 14 studies. Studies that included an assessment of patient outcomes, however, showed insufficient evidence of either clinically or statistically important improvements. Although the number of studies reviewed was relatively small, the findings demonstrated consistency with similar previous reviews of this nature in that wide scale use of HIT has been shown to increase clinician's adherence to guidelines.

Datapoints: Psychotropic Drug Prescriptions by Medical Specialty

1167 T important role of general practitioners in prescribing antidepressant medications and treating depression has been documented. However, the extent to which general practitioners are prescribing other types of psychotropic medications has received less emphasis. This study used data from August 2006 to July 2007 from the National Prescription Audit (NPA) Plus database of IMS to examine this question. IMS collects transaction information each month from approximately 36,000 retail pharmacies, representing about 70% of all retail pharmacies, which when weighted represent all prescriptions filled in retail outlets in the United States. Using a separate sample of retail pharmacy transactions that includes the physician’s Drug Enforcement Administration number, IMS assigns physician specialty information to obtain an estimate of the total number of prescriptions filled in retail pharmacies by medical specialty. As shown Figure 1, of the 472 million prescriptions for psychotropic medications, 59% were written by general practitioners, 23% by psychiatrists, and 19% by other physicians and nonphysician providers. General practitioners wrote prescriptions for 65% of the anxiolytics in the sample, 62% of the antidepressants, 52% of the stimulants, 37% of the antipsychotics, and 22% of the antimania medications. Conversely, psychiatrists and addiction specialists wrote prescriptions for 66% of the antimania medications, 49% of the antipsychotics, 34% of the stimulants, 21% of the antidepressants, and 13% of the anxiolytics. Pediatricians were included as general practitioners and wrote 25% of all stimulant prescriptions but only 3% of all other types of psychotropic medications (data not shown). Prescribing of psychotropic medications by nonpsychiatrists improves access to treatment. However, concerns remain about whether patients treated in the general medical setting are receiving treatment concordant with evidence-based guidelines, psychotherapy, adequate medication monitoring, and appropriate intensity of treatment. Psychotropic Drug Prescriptions by Medical Specialty

Datapoints: Psychotropic Drug Prescriptions by Medical Specialty

Datapoints: Psychotropic Drug Prescriptions by Medical Specialty

The Impact of the Electronic Health Record on an Academic Pediatric Primary Care Center

Many hospitals and practices are transitioning to electronic health records (EHR), but there is little information on the impact on patient care in a busy pediatric academic setting. The objective of this study was to determine the impacts of EHR on documentation, clinical processes, billing, ancillary staff responsibilities, scheduling, and cycle time. A descriptive study to assess the impact of EHR implementation and subsequent use on documentation, clinical processes, and patient access and flow was performed in a large urban academic pediatric primary care health center. Six months and 2 years after implementation, EHR impact on documentation was collected and compared with baseline value by measuring the percentage of charts with problem lists present. Several clinical improvement processes were collected at baseline and 6 months later including medication refill turnaround time, percentage of charts without attending signature at 3 days, and type of appointment billed on ill visits. The volume of appointments and cycle time were measured at regular intervals from baseline to 2 years after implementation. The percentage of paper charts attempted to be pulled for patient visits was obtained at baseline and 1 year later. Of the 500 charts audited before implementation, and 25 charts audited 6 months and 2 years after the implementation, the percentage of the presence of problem lists improved from 29% to 84%. Medication refill turnaround time improved from an average of 48 hours to 12 hours. Charts with incomplete documentation at 3 days postvisit decreased from 3% to 1.6%. Visit coding for detailed level visits (99214) increased by 13% and for problem-focused visits (99212) decreased by 7%, resulting in increased revenue collected. Medical records support staff needs decreased from 1 full-time equivalent to 0.5 full-time equivalent. One year after the EHR implementation, the medical records staff pulled and refiled 5.2% of paper charts compared with 100% at baseline. Despite plans to return to full volume of scheduling patients by 4 weeks postimplementation, volume continued to be reduced by 10% for 3 additional months because of user inefficiency and high number of new learners/users. Patient cycle time was increased from 76 minutes preimplementation to 119 minutes immediately postimplementation and decreased to 85 to 90 minutes 2 years later. EHR can be successfully implemented in a large urban academic pediatric healthcare center. EHR implementation improved documentation of patient care, improved clinical processes, and resulted in increased revenue. However, the implementation of the EHR also led to short-term decreased appointment availability and a persistent longer cycle time. Ongoing information system training support is a key for maintaining efficiency due to the large number of new learners.

Electronic health records: Use, barriers and satisfaction among physicians who care for black and Hispanic patients

Electronic health records (EHRs) are a promising tool to improve the quality of health care, although it remains unclear who will benefit from this new technology. Given that a small group of providers care for most racial/ethnic minorities, we sought to determine whether minority-serving providers adopt EHR systems at comparable rates to other providers. We used survey data from stratified random sample of all medical practices in Massachusetts in 2005. We determined rates of EHR adoption, perceived barriers to adoption, and satisfaction with EHR systems. Physicians who reported patient panels of more than 40% black or Hispanic had comparable levels of EHR adoption than other physicians (27.9% and 21.8%, respectively, P = 0.46). Physicians from minority-serving practices identified financial and other barriers to implementing EHR systems at similar rates, although these physicians were less likely to be concerned with privacy and security concerns of EHRs (47.1% vs. 64.4%, P = 0.01). Finally, physicians from high-minority practices had similar perceptions about the positive impact of EHRs on quality (73.7% vs. 76.6%, P = 0.43) and costs (46.9% vs. 51.5%, P = 0.17) of care. In a state with a diverse minority population, we found no evidence that minority-serving providers had lower EHR adoption rates, faced different barriers to adoption or were less satisfied with EHRs. Given the importance of ensuring that minority-serving providers have equal access to EHR systems, we failed to find evidence of a new digital divide.

Electronic Health Record Components and the Quality of Care

Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care. Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of all visits with an established primary care provider and examined the association between presence of EHR components and: (1) blood pressure control; and (2) receipt of appropriate therapy for chronic conditions. We examined similar associations for complete EHRs which we defined as one that includes physician and nursing notes, electronic reminder system, computerized prescription order entry, test results, and computerized test order entry. We constructed multivariate models to examine the association between EHR components and each outcome controlling for patient sociodemographic, health, physician practice, and geographic factors. We found no association between electronic physician notes and blood pressure control or receipt of appropriate therapies, with the exception of inhaled steroids among asthmatics (adjusted odds ratio 2.86; 95% confidence interval, 1.12-7.32). We found no association between electronic reminder systems and blood pressure control or receipt of appropriate therapies, with the exception of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients with diabetes with hypertension (odds ratio 2.58; 95% confidence interval, 1.22-5.42). We found no association between electronic physician notes and any measure of quality. We found no relationship between having a complete EHR and any of the quality measures investigated. We found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components. Future research focusing on how an EHR is implemented and used and how care is integrated through an EHR will improve our understanding of the impact of EHRs on the quality of care.