Meaningful Use and Quality of Care

The American Recovery and Reinvestment Act of 2009 included $30 billion for implementation of the Electronic Health Record (EHR) Meaningful Use (MU) incentive program with a goal of increasing EHR adoption and improving quality of care. Stage 1 of the EHR MU incentive program specified required core objectives, menu objectives, and clinical quality measures.¹ We assessed if being a “meaningful user” (defined as meeting 15 core objectives, eg, computerized order entry, safe electronic prescribing, clinical decision support, and providing health information to patients, as well as meeting 5 of 10 optional menu objectives) was associated with improved quality on 7 measures for 5 chronic diseases. (See the eAppendix and eReferences in the Supplement.)

We evaluated physicians who used a homegrown advanced EHR (ie, with integrated clinical decision support) and provided care for adult outpatients at Brigham and Women’s Hospital and affiliated ambulatory practices. In our institution, physicians do not choose whether to participate in the MU program, but rather the objectives are calculated centrally by the organization and reported to physicians and to the federal government. As specified by the MU criteria, we used a 90-day reporting period, September through November 2012. We assessed MU status by physician age, sex, and specialty (using the same categories as the National Ambulatory Medical Care Survey–Primary Care, Medical, and Surgical Specialties) (Table 1). We compared mean physician performance on 7 quality measures for 5 chronic diseases—hypertension, diabetes mellitus, coronary artery disease, asthma, and depression—between meaningful users and non–meaningful users. We used a t test to compare the distribution of proportions between meaningful users and non–meaningful users. We excluded physicians with zero patients in the denominator for each of the 7 quality measures. We did not control for confounders because all physicians must meet the same MU criteria regardless of practice, physician, or patient characteristics. Analyses were performed using SAS statistical software (SAS Inc). Brigham and Women’s Hospital institutional review board approved the study.

Of 858 physicians, 540 (63%) were meaningful users. Meaningful use was associated with marginally better quality for 2 measures, worse quality for 2 measures, and not associated with better or worse quality for 3 measures (Table 2).

Despite hope that achieving meaningful use improves quality, we found that meaningful users did not consistently provide higher quality care. A limitation of our analysis is that we cannot establish whether EHR use preceded clinical care. Also, we have presented MU among all eligible physicians because organizations hope to see higher quality for meaningful users regardless of physician specialty or other demographic characteristics. A strength of our study is that both groups of users were using the same advanced EHR.

Electronic health record use likely helps more for some conditions than others. We found better control of cholesterol in patients with diabetes mellitus and better control of blood pressure in patients with hypertension, but worse treatment of asthma and depression. Other studies of EHR use found no consistent association with quality for given chronic conditions.^2-5 Likewise, specific EHR functions (ie, reminders, test results, order entry, visit notes, problem lists, and medication lists) have been associated with higher quality for some conditions and not others.^4,5

Federal policy for stage 1 of MU set a low bar; for example, for 1 measure, physicians using an EHR function 50% of the time were grouped with physicians using the same EHR function 100% of the time. The fact that we found no consistent benefit in quality for stage 1 supports the implementation of more stringent criteria in MU stages 2 and 3.¹ Throughout implementation, MU should be monitored to ensure the large investment in effort, time, and money translates into improved quality for patients.

Corresponding Author: Lipika Samal, MD, MPH, Division of General Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, Ste OBC-03-02V, Boston, MA 02120-1613 (lsamal@partners.org).

Published Online: April 14, 2014. doi:10.1001/jamainternmed.2014.662.

Author Contributions: Dr Samal had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Samal, Linder.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Samal, Linder.

Critical revision of the manuscript for important intellectual content: Wright, Healey, Linder, Bates.

Statistical analysis: Samal, Linder.

Administrative, technical, or material support: Samal.

Study supervision: Wright, Linder, Bates.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Julie Fiskio, BS, Division of General Medicine, Brigham and Women’s Hospital, provided assistance with data acquisition. She was compensated for her assistance.