Objective. To evaluate the quality of pediatric primary care, including preventive services, before and after the introduction of an electronic medical record (EMR) developed for use in an urban pediatric primary care center.
Methods. A pre-postintervention analysis was used in the study. The intervention was a pediatric EMR. Routine health care maintenance visits for children <5 years old were reviewed, and documentation during preintervention (paper-based, 1998) and postintervention visits (computer-based, 2000) was compared.
Results. A total of 235 paper-based visits and 986 computer-based visits met study criteria. Twelve clinicians (all attendings or nurse practitioners) contributed an average of 19.4 paper-based visits (range: 5–39) and 7 of these clinicians contributed an average of 141 computer-based visits each (range: 61–213). Computer-based clinicians were significantly more likely to address a variety of routine health care maintenance topics including: diet (relative risk [RR]: 1.09), sleep (RR: 1.46), at least 1 psychosocial issue (RR: 1.42), smoking in the home (RR: 15.68), lead risk assessment (RR: 106.54), exposure to domestic or community violence (RR: 35.19), guns in the home (RR: 58.11), behavioral or social developmental milestones (RR: 2.49), infant sleep position (RR: 9.29), breastfeeding (RR: 1.99), poison control (RR: 3.82), and child safety (RR: 1.29). Trends toward improved lead exposure, vision, and hearing screening were seen; however, differences were not significant. Users of the system reported that its use had improved the overall quality of care delivered, was well-accepted by families, and improved guidance quality; however, 5 of 7 users reported that eye-to-eye contact with patients was reduced, and 4 of 7 reported that use of the system increased the duration of visits (mean: 9.3 minutes longer). All users recommended continued use of the system.
Conclusion. Use of the EMR in this study was associated with improved quality of care. This experience suggests that EMRs can be successfully used in busy urban pediatric primary care centers and, as recommended by the Institute of Medicine, must play a central role in the redesign of the US health care system.
This paper raises a number of interesting questions about assessment of quality in pediatric primary care. The most obvious, of course, is what definition of quality is appropriate in this study and whether the outcome studied is of itself an adequate assessment of quality. The authors address the perspective of the provider physician whose main concern understandably is the effectiveness of their clinical practice. Little attention is paid to the dimensions of quality care from the other stake holders perspective such as access, safety and acceptability for the patient and efficiency, including cost, from the funder’s (government and taxpayers) point of view. In fact the authors point out that the users of the EMR system noted an increase in time of consultation, a negative effect on efficiency and therefore access to other patients and reduced eye to eye contact during the consult. No assessment is made as to whether the patients perceived this reduced access to the physician as far as both waiting times and interpersonal communication and attention during the consult as a reduction in the quality of their care. Users of the EMR demonstrated an improvement in risk assessment due to the prompting in the computerized system and an improvement in anticipatory guidance with the use of multilingual handouts. The paper based records did not have the risk assessment prompts. Could the same be achieved simply by updating the paper records to include better prompting in key areas and by providing adequate educational handouts in each clinic room without sacrificing other aspects of quality. As the authors point out there is no evidence that an increase in risk assessment translates to any better health outcomes. Widespread health reforms throughout the developed world are pushing for changes in clinician behaviors and new technological approaches to patient care in order to improve quality of care. We must be sure that in our haste to implement change we do not neglect to address all dimensions of care.