Electronic health record clinical decision support linked to better care quality

According to a study published in the American Journal of Managed Care (, Health IT Analytics published in October 2014, "Using EHR clinical decision support is associated with improved quality of care. Most primary care practices are missing at least 1 “meaningful use” clinical decision support module." The study was conducted by Rebecca G. Mishuris, MD, MS; Jeffrey A. Linder, MD, MPH; David W. Bates, MD, MSc; and Asaf Bitton, MD, MPH.

Details of Study

For the study, researchers analyzed data from the 2006 to 2009 National Ambulatory and National Hospital Ambulatory Medical Care surveys on adult primary care visits to practices that met the requirement for Stage 1 of the meaningful use program. These practices had EHR systems with at least one of five CDS functions:

Electronic problem lists;

Lab result reports;

Notifications for out-of-range labs;

Reminders for preventive care; or

Warnings for drug interactions.

The researchers then divided the visits into three categories: Visits to practices with all CDS functions enabled;

Visits to practices with at least one CDS function disabled; and

Visits to practices with at least one missing CDS function (Bresnick, Health IT Analytics, 10/31).


The study found that 86% of patients who visited primary care clinics with all five types of CDS functions had controlled blood pressure, compared with 82% of patients who visited clinics with at least one missing function and 83% of patients who visited clinics that had disabled at least one function.

Further, researchers found that:

CDS functions were associated with blood pressure control and fewer visits for adverse drug events;

CDS functions were associated with better performance on indicators of quality of care and clinical decision support functions related to such quality measures (Mishuris et al., AJMC, 10/28); and

Decisions to disable CDS functions were associated with reduced quality of care improvements (Health IT Analytics, 10/31).

However, the researchers said they were unable to determine an association between disabling particular CDS functions and cancer screening, health education or influenza vaccinations because of limited data (AJMC, 10/28).


The researchers said, "Overall, meaningful use standards that include [CDS functions] appear to have a significant positive effect on some national quality-of-care indicators and health outcomes."

They added, "It will be important to evaluate the evolving impact of meaningful use as the stages continue to be more widely implemented and better integrated with care processes; we anticipate further gains in healthcare quality indicators and outcomes as a result" (Health IT Analytics, 10/31).


Objectives To determine whether clinical decision support (CDS) is associated with improved quality indicators and whether disabling CDS negatively affects these.

Study Design/Methods

Using the 2006-2009 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we performed logistic regression to analyze adult primary care visits for the association between the use of CDS (problem lists, preventive care reminders, lab results, lab range notifications, and drug-drug interaction warnings) and quality measures (blood pressure control, cancer screening, health education, influenza vaccination, and visits related to adverse drug events).


There were an estimated 900 million outpatient primary care visits to clinics with EHRs from 2006-2009; 97% involved CDS, 77% were missing at least 1 CDS, and 15% had at least 1 CDS disabled. The presence of CDS was associated with improved blood pressure control (86% vs 82%; OR 1.3; 95% CI, 1.1-1.5) and more visits not related to adverse drug events (99.9% vs 99.8%; OR 3.0; 95% CI, 1.3-7.3); these associations were also present when comparing practices with CDS against practices that had disabled CDS. Electronic problem lists were associated with increased odds of having a visit with controlled blood pressure (86% vs 80%; OR 1.4; 95% CI, 1.3-1.6). Lab result notification was associated with increased odds of ordering cancer screening (15% vs 10%; OR 1.5; 95% CI, 1.03-2.2).


The use of CDS was associated with improvement in some quality indicators. Not having at least 1 CDS was common; disabling CDS was infrequent. This suggests that meaningful use standards may improve national quality indicators and health outcomes, once fully implemented.

See American Journal of Managed Care. 2014;20(10):e445-e452

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