EHRs often not used to their full potential

Study's findings are a 'wake-up call'

Electronic health records (EHRs) made little or no difference on 14 of 17 quality measures examined, and quality was worse for one measure, a recent study found. The findings were based on 1.8 billion physician visits in 2003 and 2004, with 18% of the visits utilizing electronic health records. EHRs were associated with better quality on only two of the 17 measures that were looked at.1

The results may surprise some politicians and leaders in EHR development, but shouldn't come as a surprise to quality professionals, says Randall S. Stafford, MD, PhD, one of the study's authors and director of Stanford (CA) Prevention Research Center's Program on Prevention Outcomes and Practices.

"First of all, it is important to recognize that the data are for 2004 and that the EHR systems in widespread use at that time were not as sophisticated as today," he notes. In addition, it's not known how many of the EHR-using physicians had access to or were using features that might have affected the quality indicators examined.

"And on a very basic level, we wouldn't expect EHRs to affect quality unless these systems are designed with this role in mind," Stafford says. "Despite these caveats attached to our findings, our results should be a wake-up call to those who see EHRs as the sole solution to current problems with health care quality."

While EHRs are a "very important tool," attaining high quality is going to require many strategies, says Stafford. Some of these may involve EHRs, but others need to deal with more fundamental issues, such as who provides chronic disease care and how patients interact with physicians, he says.

"Many of those pushing for rapid expansion of EHR use need to make sure that physicians are prepared to use those features that could lead to better quality," says Stafford. "They also need to make certain that other quality improvement strategies are not neglected."

Electronic health records alone do not guarantee improved clinical care process and outcomes, says Crystal K. Kallem, RHIT, director of practice leadership for the Chicago-based American Health Information Management Association.

"Quality improvement requires a wide variety of ongoing interventions and techniques," says Kallem. "Information technology is one tool that will assist with improving the quality of patient care. This tool must be utilized to its full potential to gain the level of improvement the industry wants and needs."

To gain the full benefits of EHRs, the appropriate functionality must be used to capture essential clinical data elements. Clinical decision support should be used to maximize the use of widely accepted clinical guidelines, engage the patient, and be incorporated into the natural workflow of the clinicians providing care, says Kallem.

"We are at a rudimentary stage in the evolution of using EHRs," says William Hersh, MD, professor and chair of the department of medical informatics and clinical epidemiology at Oregon Health & Science University in Portland.

Most organizations use EHRs to replace paper processes and do not take advantage of advanced features, such as clinical decision support and physician order entry, says Hersh.

"This study used a coarse measure of EHR adoption, which was whether physicians used them in any capacity," notes Hersh. "A much better approach would have been to focus on those who have made optimal use of them."

To improve care, users must implement features known to be beneficial, says Hersh. "There is a growing body of research that shows specific aspects of electronic health records improve care, such as use of clinical decision support," he says. "If electronic health records are just used to replace paper documentation, then they will not necessarily improve care. We also need more training of health care personnel in medical informatics."

This includes physicians and other clinicians, who need to know how to optimally use health information technology in their work, and informaticians, who will guide those clinicians in best practices for implementation. "Quality improvement is a process," says Hersh. "Just putting electronic health records into clinical practices is not enough."


  1. Linder JA, Ma J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med 2007; 167: 1400 - 1405.

[For more information, contact:

William Hersh, MD, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239-3098. E-mail:

Crystal K. Kallem, RHIT, Director, Practice Leadership, The American Health Information Management Association, 233 N. Michigan Ave., 21st Floor, Chicago, IL 60601-5800. Phone: (312) 233-1537. E-mail:

Randall S. Stafford, MD, PhD, Director, Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Hoover Pavilion, Mail Code 5705, 211 Quarry Rd., Room N229, Stanford, CA 94305-5705. Phone: (650) 724-2400. E-mail:]