This month may well be remembered as put up or shut up time for physician practices when it comes to incorporating information technology in their operations.
An embarrassing report in the New England Journal of Medicine says that only 4% of physician practices have fully functional electronic health-record systems. At the same time, the public and private sector offered practices a way out of the paper woods with new IT initiatives, leaving physicians with fewer excuses to fully computerize their practices.
A summary report on a comprehensive survey, funded by government and private organizations, of physician adoption of EHR systems says that after more than four years of federal ballyhoo of health IT, only 17% of physicians in the ambulatory-care environment have access to an EHR. And it says that 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 a low adoption rate, researchers graded on a curve and gave 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 dont 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 survey in the June 19 issue of the New England Journal of Medicine. A copy of the full report is expected to be released early next month.
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 initial contract 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 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 Health Care Group at the Robert Wood Johnson Foundation, says that the not-for-profit organization contributed to the effort with 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 says.
The lead authors of the report are Institute for Health Policy Director David Blumenthal, M.D., 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 nonuserscost was cited by both as the most significant hurdlethe 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 anesthesiology, pathology, psychiatry and radiology 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 says. Bell says that the National Center for Health Statistics, Hyattsville, Md., will continue to monitor EHR adoption based on definitions developed by Blumenthals research group.
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 by 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 groups report said. Financial incentives, such as those proposed by the CMS for EHR use, could be important facilitators of adoption, they say. 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 says.
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 reported using all seven functions at least 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 note that physicians in groups of 50 or more physicians are three times as likely to report having a basic EHR as are physicians in groups of three or fewer and more than four times as likely to have a fully functional EHR as 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; and 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 says. Finding a way to defray some of the costs to physicians means we may significantly increase adoptions, she says, adding that this is particularly true for providers in one- or two-physician practices.
Eight days before the reports release, the federal government announced a new initiative to help physicians with the cost of buying, installing and operating IT in their practices. Under the five-year demonstration program, physician practices are eligible for tens of thousands of dollars in government incentive payments for using EHRs to measure and improve the quality of care that they deliver.
On June 10, HHS unveiled the participating communities in the demonstration project, which was first announced in February. They are: Alabama; Delaware; Georgia; Jacksonville, Fla.; Louisiana; Madison, Wis.; Maine; Maryland/Washington, D.C.; Oklahoma; Pittsburgh; South Dakota; and Virginia.
The demonstration specifically targets smaller doctors offices, federal health officials say, primarily because they are the ones most in need of a financial boost to help pay for the systems. The CMS says it expects upward of 1,200 primary-care physicians to enroll in the program. The announcement of the project follows the unveiling of the federal governments five-year timeline for implementing electronic records.
But because the government wants to make the program as scientific as possible, the CMS plans to name a control group consisting of practices that do not use EHRs. Those physicians wont be eligible for the higher reimbursement, though they could see some extra dollars for participating, according to the CMS.
Sterling Ransone, M.D., a family physician at Riverside-Fishing Bay Family Practice in Deltaville, Va., and president of the Virginia Academy of Family Physicians, says that he is concerned about the physicians who are randomly selected into the control group, but concedes that its a needed part of the study. I think that in order to prove it to the cynics and naysayers, you have to do it like this, Ransone says.
Many physician groups and private payers have endorsed the Medicare study even though the details so far have been fuzzy. The CMS is expected to release more information early next month.
Karen Feinstein, president and chief executive officer of the Pittsburgh Regional Health Initiative, which will administer the project locally, says, Now we, as a region, can move forward.
Physicians will be judged by the CMS as to whether they meet certain benchmarks. In each year of the project, doctors who use EHRs to meet or exceed the benchmarks are eligible for the highest incentive payments. Assuming that all practices achieve the highest scores, the CMS could spend $150 million over five years on the project. Individual physicians could earn up to $58,000 while some practices could see $290,000.
Meanwhile, the private sector pitched in to help physicians as well. The EHR Partners Program is a new initiative offered by the American College of Physicians to help its 125,000 members buy and install EHR systems that have been certified for meeting baseline standards for functionality, security and interoperability by the Certification Commission for Healthcare Information Technology.
Participating EHR vendors are providing product and pricing information, and ACP members can also review product evaluations and use the EHR Product Selector Tool that identifies which participating vendors match the criteria the ACP members select.
The evaluations were based on information collected from vendor responses to requests for information, an ACP member-satisfaction survey, a demonstration patterned on a patient visit and a site visit to a physician practice using a participating vendors product.