Health Information Technology: An Updated Systematic ...

Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities

Prepared for: Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services 200 Independence Avenue S.W. Suite 729-D Washington, D.C. 20201

Contract No. HHSP23337020T

Prepared by: Southern California Evidence-based Practice Center RAND Corporation 1776 Main Street Santa Monica, CA 90407

Investigators:

Evidence-Based Practice Center Director and Principal Investigator Paul G. Shekelle, MD, PhD

Co-Principal Investigator and Project Manager Spencer S. Jones, PhD

Programming and data entry Martha Timmer, MS

Staff Assistants Aneesa Motala, BA Tanja Perry, BHM

Literature Reviewer Robert S. Rudin, PhD

Librarian Roberta Shanman, MLS

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.

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Acknowledgments

The authors gratefully acknowledge the following individuals for their contributions to this project:

Technical Expert Panel

Louise L. Liang, MD Senior Vice President Quality and Clinical Systems Support - Retired Kaiser Permanente, Oakland, CA Paul Tang, MD, MS Vice President, Chief Innovation and Technology Officer Palo Alto Medical Foundation Palo Alto, CA Philip Aponte, MD Vice President of Informatics Baylor Health Care System Dallas, TX David W. Bates, MD, MSC Senior Vice President for Quality and Safety and Chief Quality Officer Brigham and Women's Hospital Boston, MA George Hripcsak, MD, MS Chair, Department of Biomedical Informatics Vivian Beaumont Allen Professor of Biomedical Informatics Director, Medical Informatics Services, NYP/Columbia Columbia University New York, NY

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Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities

Structured Abstract

Objectives

The purpose of the project described in this report was to update previous systematic reviews focusing on the effects of health information technology (health IT) on key aspects of care, including health care quality, safety, and efficiency. This report provides our current understanding of the effects of health IT across a number of dimensions of care. Unlike reviews conducted prior to the introduction of the federal Meaningful Use Incentive Programs, this review focused specifically on identifying and summarizing the evidence relating to the use of health IT as outlined in the Meaningful Use regulations.

Data Sources

We performed a systematic search of the English-language literature indexed in MEDLINE from January 2010 to August 2013. We also searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database; and hand-searched personal libraries kept by content experts and project staff. We also asked content experts to identify evidence outside the peer-reviewed literature. Finally, a technical expert panel identified additional published articles and non-peer reviewed resources.

Review Methods

The systematic review was carried out in three stages by two health IT subject matter experts, with input from a panel of five nationally-known health IT experts. The reviewers used a webbased system to conduct the screening process. The first stage involved independent, dual-rater screening of articles based on their titles against a set of defined on the inclusion/exclusion criteria. The next stage involved screening each article at the abstract level using a standardized abstraction form. The final stage of the screening process involved a full text review and classification using a standardized abstraction form. Inclusion/exclusion or classification discrepancies between the two reviewers were resolved by consensus. We conducted multiple update searches using the same search terms through October 2013 using a computer-aided screening system that extends a previously described approach for facilitating systematic review updating.

Results

The systematic review identified 12,678 titles, and through the screening process, we identified 236 studies meeting the eligibility criteria: assessing the effect of health IT on healthcare quality,

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safety, and efficiency in ambulatory and non-ambulatory care settings. Approximately 77 percent of studies reported positive or mixed-positive findings. The effects of health IT are thought to be sensitive to the particulars of the IT system itself, the implementation process, and the context in which it is implemented, and therefore generalizations across systems and contexts must be made cautiously. Nevertheless, analyses found that neither study setting (ambulatory vs. nonambulatory), nor recognition as a health IT leader, nor commercial status were significantly associated with outcome results. However, studies of efficiency were significantly less likely to report positive results than studies of safety or quality, and studies that evaluated e-prescribing and multifaceted health IT interventions were significantly less likely to report positive results than studies of more targeted clinical decision support or computerized physician order entry interventions. Studies of multifaceted health IT interventions and studies of efficiency have structural challenges that make conclusive results more difficult to obtain than more studies of more narrowly targeted health IT interventions assessing quality or safety outcomes

Conclusions

Overall, a majority of studies that evaluated the effects of health IT on healthcare quality, safety, and efficiency reported findings that were at least partially positive. These studies evaluated several forms of health IT: metrics of satisfaction, care process, and cost and health outcomes across many different care settings. Our findings agree with previous health IT literature reviews suggesting that health IT, particularly those functionalities included in the Meaningful Use regulation, can improve healthcare quality and safety. The relationship between health IT and efficiency is complex and remains poorly documented or understood, particularly in terms of healthcare costs, which are highly dependent upon the care delivery and financial context in which the technology is implemented.

We identified two broad themes in this review. First, the published literature on health IT is expanding rapidly, driven primarily by studies of commercial health IT systems. Second, much of the health IT literature still suffers from methodological and reporting problems that limit our ability to draw firm conclusions about why the intervention and/or its implementation succeeded or failed to meet expectations, and their generalizability to other contexts. Studies of health IT must be designed, conducted, and reported in ways that allow stakeholders to understand study results and how they can replicate or improve on those results.

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Health Information Technology: An Updated Systematic Review with a focus on Meaningful Use Functionalities

Contents

Chapter 1. Background and Introduction .................................................................................. 9 1.1 Context and Summary of Previous Systematic Reviews .................................................... 9

Need for Updates to Previous Systematic Reviews ........................................................................ 9 Summary of Previous Systematic Reviews .................................................................................. 10

1.2 Topic Refinement.............................................................................................................. 11 Chapter 2. Methods .................................................................................................................... 13

2.1 Search Strategy and Terms ............................................................................................... 13 2.2 Study Selection and Classification.................................................................................... 15 Step 1: Title Screening.................................................................................................................. 15 Step 2: Abstract Screening............................................................................................................ 15 Step 3: Full Text Screening........................................................................................................... 15 2.3 Inclusion/Exclusion Criteria ............................................................................................. 15 Step 1: Title Screening.................................................................................................................. 15 Step 2: Abstract Screening............................................................................................................ 16 Step 3: Full Text Screening........................................................................................................... 16 2.4 Data Synthesis................................................................................................................... 18 Chapter 3. Results ....................................................................................................................... 19 3.1 Search Results ............................................................................................................... 19 Figure 1. Systematic Review Flow ............................................................................................... 19 3.2 Description of the Evidence.............................................................................................. 20 3.2.1 Summary of Article Characteristics..................................................................................... 20 Table 3.2.1 Article Count by Study Design .................................................................................. 20 Table 3.2.2 Article Count by Study Organizational Setting ......................................................... 20 Table 3.2.3 Article Count by health IT-type (Commercial/Homegrown) .................................... 21 Table 3.2.4 Article-Outcome Count by Type of Outcome ........................................................... 22 Table 3.2.5 Article-Outcome Count by Meaningful Use Functionality ....................................... 22 3.2.2 Classifying Article Outcome Results................................................................................... 22 3.2.3 Cross-Tabulations of Article Characteristics and Study Results ......................................... 23 Table 3.2.6 Cross-tabulation, Article-outcomes by Outcome Type and Outcome Result............ 24 3.3. Narrative Summary: Health IT and Quality of Care........................................................ 25 3.3.1 Ambulatory Care Settings.................................................................................................... 25 3.3.2 Non-Ambulatory Care Settings............................................................................................ 33 3.3.3 Summary: All Care Settings ................................................................................................ 39 3.4. Narrative Summary: Health IT and Safety of Care ......................................................... 41 3.4.1 Ambulatory Care Settings.................................................................................................... 41 3.4.2 Non-Ambulatory Care Settings............................................................................................ 41 3.4.3 Summary: All Care Settings ................................................................................................ 43

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3.5. Narrative Summary: Health IT and Efficiency of Care ................................................... 44 3.5.1 Ambulatory Care Settings.................................................................................................... 44 3.5.2 Non-Ambulatory Care Settings............................................................................................ 46 3.5.3 Summary: All Care Settings ................................................................................................ 49 Chapter 4. Discussion ................................................................................................................. 51

Quality..................................................................................................................................... 51 Safety ...................................................................................................................................... 52 Efficiency................................................................................................................................ 52 Limitations .............................................................................................................................. 54 Chapter 5. Conclusions............................................................................................................... 56 References .................................................................................................................................... 59 Appendix...................................................................................................................................... 75 Web Based Questionnaire............................................................................................................. 75 Literature Search Strategy............................................................................................................. 77 Search Terms ................................................................................................................................ 77 Abstract Screening Form .............................................................................................................. 78 Full Text Screening Form ............................................................................................................. 80 Evidence Table 1: Health IT and Quality of Care in Ambulatory Settings .................................. 83 Evidence Table 2: health IT and Quality of Care in Non-ambulatory Settings.......................... 100 Evidence Table 3: health IT and Safety of Care in Ambulatory Settings................................... 111 Evidence Table 4: health IT and Safety of Care in Non-ambulatory Settings............................ 114 Evidence Table 5: health IT and Efficiency of Care in Ambulatory Settings ............................ 120 Evidence Table 6: health IT and Efficiency of Care in Non-ambulatory Settings ..................... 129 Health Information Technology: An Updated Systematic Review with a focus on Meaningful Use Functionalities - Disposition of Comments Report ............................................................. 135

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