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Studies elaborate on the potential use of health information technology to improve care delivery
Health information technology (Health IT) has been promoted as an important vehicle for improving health care quality while also controlling care costs. Yet it remains underused by the health care community. A special issue of the April 2008 Journal of General Internal Medicine 23(4) highlights the potential uses of Health IT to improve care delivery. The studies included in the issue address various forms of Health IT, such as electronic health records, datamarts and electronic disease registries, automated telephone outreach, and patient portals. These efforts may target multiple components of a health care system or focus on individual patients, clinicians, or other providers.
Following are summaries of studies that were supported by the Agency for Healthcare Research and Quality.
Fischer, M.A., Vogeli, C., Stedman, M.R., and others. "Uptake of electronic prescribing in community-based practices," pp. 358-363. (AHRQ grant HS15175).
This study of a large health plan's Statewide initiative to support physicians' use of handheld prescribing devices found that less than one-third of clinicians (30 percent) used this technology at the end of one year (an increase from 15 percent before the initiative). Younger clinicians, pediatricians, and clinicians in larger practices all wrote e-prescriptions at a rate higher than the average. This slow adoption of e-prescribing, which can improve medication safety, may be due to problems with unusual doses or compounded medications, technical issues with the e-prescribing system, inability to access e-prescribing at all practice locations, and clinician preference for paper prescribing, note the researchers.
Crosson, J.C., Isaacson, N., Lancaster, D., and others. "Variation in electronic prescribing implementation among twelve ambulatory practices," pp. 364-371. (AHRQ grant HS16391).
Several factors may influence which ambulatory practices implement e-prescribing, suggests this study. The researchers studied 12 practices scheduled to implement an e-prescribing program. Staff of the five practices that implemented the system were more familiar with the capabilities of Health IT and had more modest expectations about the benefits likely to accrue from e-prescribing. Staff of the four practices who failed to implement the system had limited understanding of e-prescribing capacity, expected that the program would increase the speed of clinical care, and had difficulties with the technical aspects of the implementation and insufficient technical support. Three of the practices installed the system, but it was only used by some staff.
Love, T.E., Cebul, R.D., Einstadter, D., and others. "Electronic medical record-assisted design of a cluster-randomized trial to improve diabetes care and outcomes," pp. 383-391. (AHRQ grant HS15123).
Electronic medical records (EMRs) can facilitate rigorous cluster-randomized trial (CRT) design by identifying large numbers of patients with diabetes and enabling fair comparisons through preassignment balancing of practice sites, concludes this study. In designing a trial of clinical decision support to improve diabetes care and outcomes, the researchers used the same vendor's EMR to identify and balance characteristics of 12,675 patients with diabetes cared for by 147 physicians in 24 practices of 2 systems. By explicitly balancing practice characteristics within study groups before patient assignment, the researchers minimized baseline differences. This substantially reduced the potential for selection bias, need for extensive covariate adjustment in the final models, and the impact on effective sample size.
Weber, V., White, A., and McIlvried, R. "An electronic medical record (EMR)-based intervention to reduce polypharmacy and falls in an ambulatory rural elderly population," pp. 399-404. (AHRQ grant HS15457).
This study found that electronic messages targeting physicians of elderly patients who had been prescribed potentially harmful psychoactive medications decreased the use of such medications. However, they did not reduce falls that are often due to dizziness or sedation related to psychoactive drugs. The researchers used an electronic medical record (EMR) to review the medications and fall-related diagnoses (for example, hip fracture) of 620 elderly community-dwelling patients at risk for falls. Based on this information, they sent recommendations to the primary care doctor to reduce polypharmacy and falls. This approach was linked to a smaller number of psychoactive medications, but the impact on falls was mixed.
Kern, L.M., Barron, Y., Blair, A.J., and others. "Electronic result viewing and quality of care in small group practices," pp. 405-410. (AHRQ grant HS16316).
Electronic viewing of outpatient laboratory results is associated with higher outpatient care quality, according to this study. The researchers examined use of an electronic portal for laboratory result viewing among 168 physicians in small group practices in New York. They compared use of the portal with performance on 15 quality of care measures reflecting preventive care, chronic disease management, and patient satisfaction. One-third of physicians used the portal at least once over a 6-month period. Use of the portal was linked with higher overall care quality and care quality of those performance measures expected to be impacted by laboratory result viewing (mammography, Pap smears, and colonoscopy). Portal use was not associated with care quality for measures not expected to be impacted by result viewing.
Dollarhide, A.W., Rutledge, T., Weinger, M.B., and Dresselhaus, T.R. "Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians," pp. 418-422. (AHRQ grant HS14283).
A handheld reporting tool is a feasible method to record adverse medication events in inpatient hospital care units. It may also augment existing hospital reporting systems, concludes this study. The researchers examined the ability of a handheld computer-based Medication Event Reporting Tool (MERT), when used by 185 physicians and 119 nurses on the medical wards of 4 teaching hospitals, to capture self-reported medication events. A total of 76 events were reported over the course of 2,311 days. Nurses had a significantly higher reporting rate compared with physicians (0.045 vs. 0.026 reports per shift). Only 5 percent of MERT medication events were reported to require increased monitoring or treatment.
Hicks, L.S., Sequist, T.D., Ayanian, J.Z., and others. "Impact of computerized decision support on blood pressure management and control: A randomized controlled trial," pp. 429-441. (AHRQ grant HS11046).
Computerized decision support (CDS) can improve appropriate antihypertensive medication prescribing, according to this study. A research team randomized 2,027 adult patients with hypertension in 14 primary care practices providing care for many minority patients. The team randomized patients to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without CDS. There was no difference between groups in blood pressure control 18 months later. However, the use of CDS by providers significantly improved guideline-adherent medication prescribing compared with usual care (7 vs. 5 percent), an effect that did not differ by patients' race and ethnicity.
Lapane, K.L., Waring, M.E., Schneider, K.L., and others. "A mixed method study of the merits of e-prescribing drug alerts in primary care," pp. 442-446. (AHRQ grant HS16394).
More than 40 percent of prescribers override drug interaction alerts, most often citing problems with "oversensitive" alerts, according to this study. The authors surveyed 157 clinicians working in 1 of 64 practices using 1 of 6 e-prescribing technologies and held focus groups with 276 prescribers and staff. The primary care prescribers recognized the value of drug alerts for patient safety, but suggested that alerts be more specific and mentioned the need to reduce alert overload. They recommended that the e-prescribing system run drug alerts on an active medication list and allow prescribers to set the threshold for the severity of alerts.
Wolfstadt, J.I., Gurwitz, J.H., Field, T.S., and others. "The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: A systematic review," pp. 451-458. (AHRQ grants HS10481 and HS1543).
Few studies have measured the effect of computerized physician order entry (CPOE) with clinical decision support (CDS) on the rates of adverse drug events (ADEs), reveals this systematic review of studies on the topic. Of 543 citations identified, only 10 studies met inclusion criteria. Some studies examined use of CPOE with CDS in the hospital or ambulatory setting, but none examined use in the long-term care setting. CPOE with CDS contributed to a significant decrease in ADEs in half of the studies. Four studies reported a nonsignificant reduction in ADE rates, and one study demonstrated no change in ADE rates. The authors call for more studies to evaluate the efficacy of CPOE with CDS across various clinical settings.
Sarkar, U., Handley, M.A., Gupta, R., and others. "Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients," pp. 459-465. (AHRQ grant HS14864).
Between-visit surveillance of 111 outpatients with diabetes using an interactive telephone technology and targeted nurse follow-up detected 111 adverse events and 153 potential adverse events, according to this study. Events were most often detected through health information technology-facilitated triggers (59 percent), followed by nurse elicitation (30 percent), and patient callback requests (11 percent). Primary care providers were often unaware of these adverse events, the majority of which were preventable or ameliorable. These findings suggest that this type of surveillance, with appropriate system-level intervention, can improve patient safety for chronic disease patients.
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