Now that the functional components of the electronic record have been defined, it is vital to understand the way in which the record has come to be used to drive forward initiatives in overall quality of care. Much as in clinical decision support associated with medication ordering, the judicious use of alerts and reminders is intended to prompt the physician to take action (to order) in a manner consistent with established, evidence-based guidelines (see Chapter 13).
These schema have been well studied in the ambulatory arena where key quality indica- tors exist in the domain of cancer screening, glycemic management for persons with dia- betes, and lipid management for those with coronary artery disease. A common scenario is that of a provider seeing a patient with identified coronary artery disease on the problem list. The EHR “knows” the most recent lipid levels as well as whether the patient is taking a medication to lower lipid levels. If the patient is not currently on an antilipemic agent or does not have a serum lipid level consistent with national guidelines, an alert will display (see Figure 6.7). Another screen will prompt the prescriber to order appropriate lipid-low- ering therapy (see Figure 6.8). Although previous indirect evidence indicated the benefits of alerting, more direct randomized, controlled trial evidence now shows improved lipid management through these systems.26
On a more global level, the record provides an aggregation of all care delivered and can target specific providers or practices that appear to be delivering care less consistent with national guidelines. Many institutions embark on the creation of a “clinical data ware- house” to capture all clinical data derived from an electronic record for later analysis (see Chapter 16). The benefit of analyzing data after they have been moved out of the EHR is that the data can be reviewed without affecting the performance of the database used to
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FIGuRE 6.8 Provider is being assisted in complying with lipid-lowering guidelines. (Courtesy of Epic Systems, Madison, Wisconsin.)
FIGuRE 6.7 Provider being alerted that lipid-lowering medication is indicated. (Courtesy of Epic Systems, Madison, Wisconsin.)
care for patients. This also allows for merging clinical data with financial, genomic, or other data not in the EHR.
Although systematic reviews have identified that electronic records have improved the consistency, accuracy, and completeness of the chart, it is less clear what the impact has been on patient outcomes.27 In fact, in one review of care delivered at ambulatory sites in
2003 and 2004 in which 18% of visits were associated with an EHR, no statistical differ- ence was found in 14 of 17 nationally established quality indicators between visits with and without EHR use.28 Thus, there is evidence on a local level of improved care quality, but
this has yet to translate across a large group of heterogeneous users.
6.8 SuMMARy
The EHR is now the established communication tool for healthcare delivery in the twenty- first century. Electronic health records are based on structured healthcare terminology, accommodate the practices of documentation and provider–provider and patient–provider communication, and provide for order management. The new frontier of patient health records and the intersection with clinic- or hospital-based electronic records is as yet to be fully explored, but will likely define the next generation of clinical informatics. To date, the EHR has a proven track record of improving medication safety and record accuracy, legibility, and completeness. However, the jury is still out on the large majority of patient- level outcomes that were to be improved by the advent of electronic records and electronic orders. The full potential of these novel tools in improving outcomes remains to be proved in multisite, randomized, controlled trials.
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