Electronic health record process of care functionalities not associated with lower cost per discharge for three coronary surgical procedures

Background: Electronic health records (EHR) have been promoted as a tool to streamline processes of care, reduce complications, and improve patient outcomes, while realizing cost savings. Evidence regarding actual EHR effects, however, is mixed.

Objective/purpose: Determine whether advanced levels of select EHR functionalities implementation were associated with lower estimated cost per discharge for three inpatient coronary surgical procedures: abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), and percutaneous coronary intervention (PCI).

Methods: We used patient discharge data from the Nationwide Inpatient Sample 2009-2010, merged with the American Hospital Association Information Technology Supplement 2009-2010. Of 440 hospitals present in the merged sample, 131 performed AAA (28,968 discharges), 76 performed CABG (28,884 discharges), and 110 performed PCI (81,023 discharges). We examined the association between level of implementation of electronic clinical documentation (ECD), computerized provider order entry (CPOE), and clinical decision support (CDS) and log-transformed cost per discharge for the three procedures, adjusting for patient and hospital characteristics. Implementation was measured at three levels, with the highest level including hospitals who implemented the nine sub-functions of interest across all clinical units. The sub-functions of interest were categorized into their respective functionalities ECD (problem and medication lists), CPOE (medications), and CDS (drug-allergy alerts, drug-drug interaction alerts, clinical guidelines, clinical reminders, drug-lab interaction alerts, drug dosing support). The three key independent variables were the average implementation score of the nine sub-functions categorized by their respective functionalities. Covariates included both patient and hospital characteristics. The dependent variables were estimated cost per discharge.

Results: Mean estimated cost per discharge was $12,863 for AAA, $59,449 for CABG, and $22,556 for PCI.  Multivariate regression for each of the three procedures modeled failed to detect a relationship among average level of ECD, CPOE, and CDS implementation scores and estimated cost per discharge for all three models, adjusting for patient and hospital characteristics. 

Discussion/conclusions: There were no significant relationships detected between level of implementation and estimated log-transformed cost per discharge. These preliminary findings prompt further investigation in determining how EHR implementation can generate lower costs in this context and how future policy may be shaped to realize these savings.