Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Health Information Technologies (HITs) such as Electronic medical records (EMR) are widely believed to improve efficiency, quality of care, and patient safety in inpatient and ambulatory care. Expert opinion has posited that introduction of EMRs, systems such as computerized physician order entry (CPOE) and bar coding can not only avoid medical errors but improve the delivery of care and yield substantial cost savings.

However, findings to date come primarily from research locations and may not be generalizable to community settings with commercial software. Moreover, major issues exist with the adoption of HIT in both inpatient and outpatient settings. This makes it important to examine actual experiences. Further, it is also important to specifically consider the implications regarding key actors at the interface between HIT and the delivery of care. The papers in this session report on recent findings from the field on HIT adoption and its impacts focusing on physicians and nurses.

The first paper in the session draws on a 2006-7 sample survey of 1600 physicians in office based primary care and pediatric practices to examine factors associated with the adoption of HIT in their practices and relationships between HIT use and physicians' adherence to treatment guidelines in clinical vignettes. Findings indicate that overall HIT adoption is not only relatively low, but particular issues exist for minority physicians and those whose practices are small, have low revenues per physician and which serve low income populations. Coupled with findings that adherence to treatment guidelines tends to be higher in practices with high HIT use, this raises a range of policy concerns.

The second paper uses 2005 National Ambulatory Medical Care Survey (NAMCS) data to examine the effect of EMRs on physician prescribing patterns in ambulatory care. The implications of EMR functionality (electronic prescribing, clinical reminders, physician clinical notes) are considered for three sets of outcome measures: 1) drug utilization (number of Rx, new vs. continued); 2) prescribing decisions within therapeutic class (probability of multi-source, medication age); and 3) risk of medication error (potential drug-drug interaction (DDI), potential drug-disease contraindication (DDC)).

The third paper in this session uses quantitative and qualitative data from Veterans Affairs (VA) hospitals to examine the implications of the phased implementation of Computerized Patient Record Systems (CPRS) and Bar Code Medication Administration (BCMA) for selected clinical outcomes and for work conditions of the nursing staff. Implementation of CPRS was associated with a decline in risk-adjusted pneumonia mortality, while BCMA implementation was associated with declines in decubitus ulcer rates and gastrointestinal hemorrhage mortality. But for nurses, CPRS implementation was also associated with significant increases in accidental puncture/laceration rates. Qualitative findings suggest an important factor in the increase of puncture rates may have been increased responsibilities and effects on speed of workflow associated with introducing such systems. More generally, qualitative findings also suggest the importance of looking at coordination between key actors and departments as a determinate of the successful implementation of new HIT systems.