Context Electronic health records (EHRs) are increasingly used by U.S. outpatient physicians. EHRs could improve clinical care via clinical decision support (CDS), electronic guideline-based reminders and alerts. Objective Using nationally representative data, we assessed the relationship of EHR and CDS use to ambulatory care quality, hypothesizing that higher quality of care would be associated with EHRs and CDS. Design Retrospective, cross-sectional analysis of physician survey data on patient visits. Setting Ambulatory care physician practices in non-federal offices and hospitals. Participants National estimates were based on 190,314 patient visits from the 2005–07 National Ambulatory Medical Care Survey and 2005–06 National Hospital Ambulatory Medical Care Survey. Main Outcome Measures We used a previously developed set of 20 visit-based quality indicators to assess the provision of guideline recommended care with a focus on appropriate pharmacotherapy and preventive counseling. Results EHRs were connected with 28% of an estimated 1.0 billion annual U.S. patient visits. CDS was present in 57% of the visits where an EHR was used (16% of all visits). Use of EHR and CDS varied with provider and patient characteristics, including significantly increased use in the West and in multi-physician settings compared with solo practices. For 19 of 20 quality indicators, visits associated with EHRs had similar quality compared with visits conducted without EHR. Higher quality was noted only for diet counseling in high risk adults (p=0.002). Among the EHR visits, 19 of the 20 quality indicators showed no significant difference in quality between visits with and without CDS. CDS was associated with significantly better performance for only one indicator, lack of routine ECG ordering in low risk patients (p=0.001). Conclusions Our finding of no consistent association between EHR and CDS use and better quality raises concern about the ability of EHR, in isolation, to fundamentally alter outpatient care quality.

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Background The 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHC) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency. Purpose To compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures. Methods The study was a cross-sectional analysis of visits in the 2006–2008 National Ambulatory Medical Care Survey. Performance of FQHCs and Look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011. Results Compared to private practice PCPs, FQHCs and look-alikes performed better on 6 measures (p<0.05), worse on diet counseling in at-risk adolescents (26 % vs. 36%, p=0.05), and no differently on 11 measures. Higher performance occurred in: ACE inhibitors use for congestive heart failure (51% vs. 37%, p=0.004); aspirin use in coronary artery disease (CAD) (57% vs. 44%, p=0.004); beta blocker use for CAD (59% vs. 47%, p=0.01); no use of benzodiazepines in depression (91% vs. 84%, p=0.008); blood pressure screening (90% vs. 86%, p<0.001); and screening electrocardiogram (EKG) avoidance in low-risk patients (99% vs. 93%, p<0.001). Adjusting for patient characteristics yielded similar results except private practice PCPs no longer performed better on any measures. Conclusions FQHCs and look-alikes demonstrated equal or better performance than private practice primary care physicians on select quality measures despite serving patients with more chronic disease and socioeconomic complexity. These findings can provide policymakers with some reassurance as to the quality of chronic disease and preventive care at Federally Qualified Health Centers and Federally Qualified Health Center look-alikes, as they plan to use these health centers to serve 20 million newly insured individuals.