Greater In-hospital Use of Clinical IT is Associated with Better Patient Outcomes
Abstract & Commentary
By David J. Pierson, MD, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle. Dr. Pierson reports no financial relationships relevant to this field of study. This article originally appeared in the April 2009 issue of Critical Care Alert. It was edited by William Thompson, MD. Dr. Thompson is Staff Pulmonologist, VA Medical Center; Associate Professor of Medicine, University of Washington; he reports no financial relationships relevant to this field of study.
Synopsis: In this study of physician use of clinical information technology in relation to 4 common diagnoses in 41 urban hospitals in Texas, inpatient outcomes were better the more extensive the use of computerized order entry, test results, physician charting, and decision support. Increased use of IT was also associated with significantly lower costs for all hospital admissions.
Source: Amarasingham R, et al. Clinical information technologies and inpatient outcomes: A multiple hospital study. Arch Intern Med 2009;169:108-114.
To determine whether relationships existed between the use of clinical information technology (CIT) and measures of patient outcomes, Amarasingham et al conducted a cross-sectional study of urban hospitals in Texas using the questionnaire-based Clinical Information Technology Assessment Tool, which measures a hospital's level of automation based on the interactions of its physicians with the information system. They sent surveys to 7,432 randomly selected physicians practicing at 72 hospitals in 10 targeted urban areas in Texas, and included in the data analysis only hospitals from which five or more attending physicians returned the questionnaire. They then merged the results with data from a comprehensive hospital claims data file on 167,233 patients older than age 50 who were admitted to those hospitals with any of four diagnoses: myocardial infarction, congestive heart failure, coronary artery bypass grafting, and pneumonia. Dependent variables studied in relation to CIT use were inpatient mortality, complications, costs, and length of stay. The aspects of hospital CIT examined were computerized order entry, test results, automation of notes and records, and decision support.
Sufficient responses for inclusion were received from 41 (58%) of the hospitals. Considering the four targeted medical conditions together, a 10-point increase in the automation of notes and records was associated with a 15% decrease in hospital mortality (adjusted odds ratio [AOR], 0.85; 95% confidence interval [CI], 0.74-0.97). Hospitals with higher scores on computerized order entry had 55% decreases in hospital mortality for coronary artery bypass grafting, and 9% decreases for myocardial infarction. Higher usage of computerized decision support was associated with a 16% decrease in complications (AOR, 0.84; 95% CI, 0.79-0.90) for all four diagnoses. In addition, higher scores on computerization of test results, order entry, and decision support were associated with lower costs per hospital admission (reductions of $110, $132, and $538, respectively; p < 0.05). Thus, hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, decreased inpatient mortality, and lower costs.
While perhaps not surprising, the results of this study provide solid support for the concept that CIT in hospitals is a positive development. An important strength of this study is that the findings were derived not just on the basis of which hospitals had more extensively developed CIT systems, but from data on actual use of these systems by the physicians caring for patients in those hospitals or, at least, on how those physicians indicated on a questionnaire that they used them.
Of course, the fact that outcomes were better in hospitals with more extensive use of CIT does not establish causality. In fact, it is very likely that, overall, hospitals with more highly-developed CIT systems are also better at many other things, such as staff recruitment and training, physician continuing education, interdisciplinary interaction, infection control, and provision of up-to-date diagnostic and therapeutic technology. Nonetheless, it is also likely that increasing integration of CIT into daily practice is an important contributor to higher standards of care.
This was not an ICU study, although all four of the included medical conditions involve care in the ICU for the majority of patients. One would expect that the advantages accruing from the use of CIT would be amplified in the ICU, where the numbers of assessments and intervention are greater, the quantity of data generated is far greater,1 and the pace is faster in nearly all respects than that on the regular floors.
1. Manor-Shulman O, et al. Quantifying the volume of documented clinical information in critical illness. J Crit Care 2008;23:245-250.