The summary report on a comprehensive survey, funded by government and private organizations, of physician adoption of electronic health-record systems finds that after more than four years of federal ballyhoo of health information technology, only 17% of physicians in the ambulatory-care environment have access to an EHR.
Just 4% of physicians in ambulatory care have available a “fully functional” EHR system, including patient-safety features such as drug-drug and drug-allergy alerts and full electronic prescribing.
Anticipating just such a low adoption rate, researchers graded on a curve, giving partial credit to physicians who have something less than the best EHR system in their offices. Another 13% of physicians surveyed have such “basic” EHRs with a minimum set of functions.
Given that 83% of ambulatory-care physicians don’t have an EHR, “the U.S. healthcare system faces major challenges in taking full advantage of EHRs to realize its health goals,” according to an executive summary of the published survey in the June 19 issue of the New England Journal of Medicine. A copy of the full report should be released July 2.
The survey was conducted between September 2007 and March 2008 by the Institute for Health Policy at Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International, working under a contract with the Office of the National Coordinator for Health Information Technology at HHS. The initialcontract was awarded in 2005 to develop a standardized methodology to measure the rate of adoption of EHRs among physicians and hospitals.
ONCHIT will spend $3.6 million on contracts to both develop methodology and conduct the initial surveys, according to Karen Bell, director of the ONCHIT office of health IT adoption. Speaking at a news conference Tuesday to announce the release of the report, Bell said that she did not have immediate access to a breakdown on how much the ambulatory-care portion of the survey cost.
John Lumpkin, senior vice president and director of the healthcare group at the Robert Wood Johnson Foundation, said that the not-for-profit organization contributed to the effort by an initial grant of $600,000 for a two-year project to analyze data from the survey and write up reports about it. The foundation has agreed to fund another two years of work at that amount, Lumpkin said.
The lead authors of the report were physician and Institute for Health Policy Director David Blumenthal and Catherine DesRoches, an assistant in health policy at the institute.
The report was not all gloom and doom. The surveyors also looked into whether physicians who use EHRs are satisfied with them and, generally speaking, they are. Of the barriers to faster EHR adoption that loomed largest to both users and nonusers—cost was cited by both as the most significant hurdle—the researchers noted that other Western industrialized nations have adopted strategies of cost sharing that have boosted EHR adoption into the 90% range. The researchers recommended policy leaders look to those other countries for guidance in developing a U.S. adoption incentive program.
The Blumenthal group relied on a randomized sample of U.S. physicians drawn from the American Medical Association's Physician Masterfile database. The researchers excluded osteopaths, as well as allopathic physicians practicing in the specialties of radiology, anesthesiology, pathology and psychiatry and those physicians not providing patient care.
Of 4,484 physicians approached between September 2007 and March 2008, 2,758, or 61%, responded and fully answered the survey questionnaire.
One severe failing of many previous surveys has been not addressing the definition of an EHR, drawing into question what exactly was being measured. As such, adoption rates in other recent surveys varied widely, from 9% to 29%, the researchers reported.
In an effort to address that problem, the investigators sought help from a panel of experts in the fields of survey research, healthcare IT, healthcare policy and representatives from hospital, physician groups and other healthcare organizations, as well as worked with focus groups and interviewed physicians and chief information officers.
One result was a definition of a “fully functional EHR” based on the presence of 16 system functions. They included advanced clinical decision-support features such as clinical guidelines and drug-interaction alerts. Researchers allowed physicians to get partial credit for a “basic EHR” with a minimum set of seven functions “that might merit using the term” EHR.
“The survey provides a definitive base line to future work to measure progress,” Blumenthal said. Bell said the National Center for Health Statistics, Hyattsville, Md., will continue to monitor EHR adoption based on definitions developed by Blumenthal’s research group.
A unique contribution
Back in October 2003, when David Brailer was still a very much a less well-known senior fellow with the San Francisco-based Health Technology Center, he authored a 42-page policy paper for the California HealthCare Foundation, Use and Adoption of Computer-based Patient Records. In it, Brailer said a first task in promoting healthcare IT would be to accurately measure how much IT is out there. Brailer noted that despite multiple studies on EHR penetration, including those conducted by the Healthcare Information Management Systems Society, the Medical Records Institute and Modern Physician magazine (Modern Healthcare’s sister publication), he concluded that because of various internal biases, including lack of random sampling, their findings should be reported only with "due caution."
“Study design raises serious questions about the reliability of nearly every study we examined and whether conclusions can be drawn from (them) individually or as a whole," he said.
In his first public speech after assuming leadership of ONCHIT in May 2004, Brailer said, "My personal view—and it's not policy—is it's time to address the physician issue head-on. Physicians are the flexion point. It's time to work with those who directly are ready."
More than four years later, however, most physicians are still not ready, although the numbers of those who are appears to be increasing, particularly in the largest group practices where a slight majority (50.5%) has access to some form of EHR. But a huge digital divide has opened between them and physicians in small-office practices, and Bell said that the latest survey numbers show “the gap … is continuing to widen.”
The NCHS has been measuring some form of physician EHR adoption since 2001. Its report on survey data gathered in 2007 should be out this fall. The NCHS uses a function-based approach to defining an EHR similar but not identical to that used the Blumenthal team. In 2006, an NCHS survey concluded that 9.3% of physicians had adopted an EHR with similar but not precisely the same functionality as the Blumenthal team used for its basic EHR. Using the NCHS functions, the Blumenthal researchers concluded that 14% of respondents to the more recent survey had adopted an NCHS-defined basic EHR.
“This suggests that the number of physicians with EHRs of some type has increased in the last year,” the Blumenthal group’s report said. Financial incentives, such as those proposed by the CMS for EHR use, “could be important facilitators of adoption,” they said. “However, the cost of achieving widespread adoption of EHRs in the U.S. could be high, likely in the tens or hundred(s) of billions of dollars, and whether any future administration, regardless of party, will be able to find the necessary resources is uncertain.”
Some other key findings of the latest research are: 71% of users of a fully functional EHR reported that their system was integrated with a hospital system where they admit patients compared with 56% of those users with a basic system who claimed such interoperability.
Of the 83% of respondents who used neither a basic nor a fully functional EHR, 16% had purchased a system but had not yet implemented it. Another 26% reported plans to purchase an EHR within the next two years. “If these intentions are realized, we could see a good increase in EHRs in three to five years,” DesRoches said.
EHR use was more prevalent among physicians who were younger, in primary care, in large practices and in the Western U.S. Adoption rates were not significantly different among physicians serving high numbers of patients who are minorities, uninsured or are covered by Medicaid.
Of the uses with a fully functional EHR, 97% of respondents reported using all of the 16 functions at least some of the time. Basic EHR users reporting using all seven functions at last some of the time.
Physicians not using EHRs most often cited capital costs (66%) as a barrier to EHR adoption, followed by finding an EHR that met their needs (54%), uncertainty about return on investment (50%) and worry that the system they buy will become obsolete (44%). EHR users cited the same concerns, but less frequently, the report said.
Financial subsidies for the purchase of EHR systems were most commonly cited by both groups (55% for EHR nonusers, 46% for EHR users) and ongoing support payments for EHR use (57% EHR nonusers, 52% EHR users) as potential “major facilitator(s) of adoption.”
Breaking down adoption rates by practice size, the researchers noted that physicians in groups of 50 or more physicians were three times as likely to report having a basic EHR as physicians in groups of three or fewer and more than four times as likely to have a fully functional EHR than their small-office counterparts. Even in the largest groups of more than 50 physicians, only 17% had access to a fully functional EHR, 33% had a basic EHR while 49.5% had no EHR at all. Adoption rates for the smallest practice of one to three physicians were 1.8% for fully functional EHRs and 6.8% for basic EHRs.
“Clearly, our findings point to the importance of cost as a barrier to adoption,” DesRoches said. Finding a way to defray some of the costs to physicians “means we may significantly increase adoptions,” she said, adding this is particularly true for providers in one- or two-physician practices.
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