Ryan Andrew M, McCullough Colleen M, Shih Sarah C, Wang Jason J, Ryan Mandy S, Casalino Lawrence P
*Department of Public Health, Weill Cornell Medical College †New York City Department of Health and Mental Hygiene, New York, NY.
Med Care. 2014 Sep;52(9):826-32. doi: 10.1097/MLR.0000000000000186.
Despite the rapid rise in the implementation of electronic health records (EHR), commensurate improvements in health care quality have not been consistently observed.
To evaluate whether the implementation of EHRs and complementary interventions-including clinical decision support, technical assistance, and financial incentives-improved quality of care.
The study included 143 practices that implemented EHRs as part of the Primary Care Information Project-a long-standing community-based EHR implementation initiative. A total of 71 practices were randomized to receive financial incentives and quality feedback and 72 were randomized to feedback alone. All practices received technical assistance and had clinical decision support in their EHR. Using data from 2009 to 2011, we estimated measure-level fixed effects models to evaluate the association between exposure to clinical decision support, technical assistance, financial incentives, and quality of care. Associations were estimated separately for 4 cardiovascular measures that were rewarded by the financial incentive program and 4 measures that were not rewarded by incentives.
Financial incentives for quality were consistently associated with higher performance for the incentivized measures [+10.1 percentage points at 18 mo of exposure (approximately +22%), P<0.05] and lower performance for the unincentivized measures [-8.3 percentage points at 12 mo of exposure (approximately -20%), P<0.05]. Technical assistance was associated with higher quality for the unincentivized measures, but not for the incentivized measures.
Technical assistance and financial incentives-alongside EHR implementation-can improve quality of care. Financial incentives for quality may not result in similar improvements for incentivized and unincentivized measures.
尽管电子健康记录（EHR）的实施迅速增加，但医疗质量并未始终如一地得到相应改善。
评估电子健康记录的实施以及包括临床决策支持、技术援助和经济激励在内的补充干预措施是否能提高医疗质量。
该研究纳入了143家将电子健康记录作为初级保健信息项目一部分实施的医疗机构，该项目是一项长期的基于社区的电子健康记录实施倡议。总共71家医疗机构被随机分配接受经济激励和质量反馈，72家被随机分配仅接受反馈。所有医疗机构都获得了技术援助，并在其电子健康记录中有临床决策支持。利用2009年至2011年的数据，我们估计了测量水平的固定效应模型，以评估接触临床决策支持、技术援助、经济激励与医疗质量之间的关联。分别对经济激励计划奖励的4项心血管指标和未获激励的4项指标估计关联。
质量方面的经济激励始终与激励指标的较高绩效相关[接触18个月时提高10.1个百分点（约+22%），P<0.05]，与未激励指标的较低绩效相关[接触12个月时降低8.3个百分点（约-20%），P<0.05]。技术援助与未激励指标的较高质量相关，但与激励指标无关。
技术援助和经济激励——与电子健康记录的实施一起——可以提高医疗质量。质量方面的经济激励可能不会使激励指标和未激励指标都得到类似的改善。
