For the Record...
Abstract & Commentary
By Barbara A. Phillips, MD, MSPH Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington Dr. Phillips reports no financial relationship to this field of study. This article originally appeared in the July 29, 2008 issue of Internal Medicine Alert. It was edited by Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD. Dr. Brunton is Clinical Professor, University of California, Irvine, and Dr. Roberts is Clinical Professor, Albert Einstein College of Medicine. Dr. Brunton is a consultant for Sanofi-Aventis, Ortho-McNeil, McNeil, Abbott, Novo Nordisk, Eli Lilly, Endo, EXACT Sciences, and AstraZeneca, and serves on the speaker's bureau for McNeil, Sanofi-Aventis, and Ortho-McNeil. Dr. Roberts reports no financial relationships relevant to this field of study.
Synopsis: As of early 2008, a minority (about 17%) of physicians have a basic or extensive electronic health record (EHR) system. Those who use electronic health records believe they improve the quality of care, and tend to be primary physicians, those practicing in large groups, hospitals, or medical centers, and those located in the western region of the United States.
Source: DesRoches CM, et al. Electronic health records in ambulatory care a national survey of physicians. N Engl J Med. 2008;359:50-60.
This group of health policy leaders sought to learn the proportion of physicians who are currently using electronic health records, whether they were satisfied with the systems they used, and what impact the physicians believe that these systems have on quality of patient care. They developed a survey with extensive consultation from experts in survey research, health information technology, health care medicine, and in conjunction with physician and hospital groups. They defined a "fully functioning" electronic health record as one that: 1) records patients' clinical and demographical data; 2) views and manages laboratory and imaging tests; 3) manages order entry (including electronic prescriptions); and 4) supports clinical decisions (including warnings about drug interactions). For purposes of this survey, they also defined a "basic" electronic health record, which differed primarily from the fully functioning system in that it did not support all order-entry capabilities or provide clinical decision support.
They randomly selected 5000 physicians from the 2007 Physician Masterfile of the American Medical Association (AMA) and excluded those for whom it was impractical or inappropriate to administer this survey (eg, those who were retired, physicians in training, and those in federally owned hospitals). The survey was administered by RTI through direct mail between September 2007 and March 2008. The survey response rate was 62%. Respondents were 75% male, 77% white, 47% primary care, 83% urban. We are not told much about the ages of the respondents, but 59% of them had been in practice 20 or more years.
Overall, 17% of respondents reported having an electronic health record system, with only 4% reporting use of a fully functioning system. For those with a fully functional system, 71% reported that it was integrated with the electronic record system at the hospital(s) where they work. Among the 83% majority of respondents not using an electronic health system, 42% reported that their practice had either already purchased or had plans to purchase a system within the next two years.
Those who used electronic health systems tended to be younger, worked in large or primary care practices, worked in hospitals or medical centers, and lived in the western United States. Rates of use did not vary by payer or patient ethnic mix. The most commonly used function for both fully functioning and basic systems was to allow patients to request refills for prescriptions online. The most common prompt from electronic health systems was to alert the physician to a critical laboratory value, with preventing drug allergic reaction a close second. Physician satisfaction with electronic health records was high, especially with regard to the systems' ability to enhance communication with other providers, afford timely access to records, avoid medication errors, and refill prescriptions. Those who had fully functional systems tended to be more satisfied (93%) than those with basic systems (88%).
Physicians who did not have access to electronic health record systems cited capital costs (66%), finding a system that matched their needs (54%), uncertainty about return on investment (50%), and concern that the system would become obsolete (44%). Conversely, the factors that were most frequently cited as enhancing adoption were financial incentives for the purchase and payment for use of an electronic-records system. Protection of physicians from personal liability for record tampering by external parties was also mentioned by many as a potential facilitator of adoption.
Commentary
First of all, when did "electronic medical records (EMR)" become electronic health records? The terminology has recently changed, reflecting our culture's subtle switch in emphasis from "medical care" to "health care." Whatever you want to call it, the electronic health record has been slow to flourish in this country, with only 17% of a representative sample of physicians reporting access to such systems in the current study. This estimate is in line with those of previous smaller studies,1-3 and supports the notion that the capital cost of implementing such systems is daunting. In 2006, the National Ambulatory Medical Care Survey (NAMCS) found that 9.3% of respondents reported using systems similar to the basic electronic record, as defined in the current study;4 thus, DesRoches et al cautiously speculate that the use of electronic health records may be increasing slowly. Indeed, 42% of respondents in the current report have immediate plans to implement electronic health systems. Although physicians are notoriously resistant to change, those who have access to electronic health systems report both high levels of use and of satisfaction with these systems, and fully functional systems tended to be scored more highly than basic systems.
The size of the group (an indirect predictor of resources) is a critical factor influencing the adoption of electronic health records in this and other studies; in the current study, groups with 50 or more physicians were much more likely to have electronic records systems than were smaller groups. Further, the physicians in this study who do not yet have electronic health records overwhelmingly listed cost as the primary barrier.
The slow adoption of electronic health records in the United States lags behind that of many Western industrialized nations, where more than 90% of primary care physicians use electronic records in their offices.5 Other countries have used a variety of public and private incentives to encourage adoption of electronic records. Help may be on the way for physicians in the United States; Centers for Medicare and Medicaid Services has recently proposed incentives for adoption of health information technology by physicians in order to increase its use.6
My own experience with electronic health records has largely been at a Veterans' Administration (VA) hospital. Although the initial learning curve is steep and painful, the ease and timeliness in communication and reduction in potential errors is remarkably improved.
The current paper suggests that we have a long way to go, but we are definitely on the way, and that making the transition will be worth it.
References
1. Hing ES, et al. Electronic medical record use by office-based physicians and their practices: United States, 2006. Advanced data from vital and health statistics (DHHS publication no. (PHS) 2008-1250). No. 393. Hyattsville, MD: National Center for Health Statistics, October 26, 2007:1-7.
2. Jha AK, et al. How common are electronic health records in the United States? A summary of the evidence. Health Aff (Millwood). 2006;25:w496-w507.
3. Bates DW. Physicians and ambulatory electronic health records. Health Aff (Millwood). 2005;24:1180-1189.
4. Blumenthal D, et al. Health information technology in the United States: the information base for progress. Princeton, NJ: Robert Wood Johnson Foundation, 2006.
5. Protti D. Comparison of information technology in general practice in 10 countries. Healthc Q. 2007;10:107-116.
6. Armstrong D. Bush administration sends medicare legislation to Congress. Congressional Quarterly. February 15, 2008.
As of early 2008, a minority (about 17%) of physicians have a basic or extensive electronic health record (EHR) system. Those who use electronic health records believe they improve the quality of care, and tend to be primary physicians, those practicing in large groups, hospitals, or medical centers, and those located in the western region of the United States.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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