Healthcare 3 (2015) 38–42
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Do family physicians electronic health records support meaningful use? Lars E. Peterson a,b,n, Brenna Blackburn a, Douglas Ivins c, Jason Mitchell d,1, Christine Matson e, Robert L. Phillips Jr.a a
The American Board of Family Medicine, Lexington, KY, USA Department of Family and Community Medicine, University of Kentucky, Lexington, KY, USA c Department of Family Medicine, University of Oklahoma-Tulsa, Tulsa, OK, USA d Cerner Corporation, Kansas City, KS, USA e Department of Family Medicine, Eastern Virginia Medical School, Norfolk, VA, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 4 March 2014 Received in revised form 25 July 2014 Accepted 4 November 2014 Available online 20 December 2014
Background: Spurred by government incentives, the use of electronic health records (EHRs) in the United States has increased; however, whether these EHRs have the functionality necessary to meet meaningful use (MU) criteria remains unknown. Our objective was to characterize family physician access to MU functionality when using a MU-certified EHR. Methods: Data were obtained from a convenience survey of family physicians accessing their American Board of Family Medicine online portfolio in 2011. A brief survey queried MU functionality. We used descriptive statistics to characterize the responses and bivariate statistics to test associations between MU and patient communication functions by presence of a MU-certified EHR. Results: Out of 3855 respondents, 60% reported having an EHR that supports MU. Physicians with MUcertified EHRs were more likely than physicians without MU-certified EHRs to report patient registry activities (49.7% vs. 32.3%, p-value o0.01), tracking quality measures (74.1% vs. 56.4%, p-value o 0.01), access to labs or consultation notes, and electronic prescribing; but electronic communication abilities were low regardless of EHR capabilities. Conclusions: Family physicians with MU-certified EHRs are more likely to report MU functionality; however, a sizeable minority does not report MU functions. Implications: Many family physicians with MU-certified EHRs may not successfully meet the successively stringent MU criteria and may face significant upgrade costs to do so. Level of evidence: Cross sectional survey. & 2014 Elsevier Inc. All rights reserved.
Keywords: Electronic health records Meaningful use Family physicians
1. Introduction The adoption of electronic health record (EHR) technology by primary care practices has increased in recent years,1,2 in conjunction with incentives from the Centers for Medicare and Medicaid Services (CMS) for the “meaningful use” of certified health information technology (HIT) products.3,4 However, success in meeting the policy priorities of “meaningful use” and realization of the projected cost savings from EHR technology have remained elusive.5,6 The federal meaningful use (MU) program was born of the Health Information Technology for Economic and Clinical Health (HITECH) Act, with the goal of promoting “the spread of electronic health records to improve
n Correspondence to: American Board of Family Medicine, 1648 McGrathiana Parkway, Suite 550 Lexington, KY 40511-1247, USA. Tel.: þ1 859 269 5626; fax: þ1 859 335 7509. E-mail address: [email protected] (L.E. Peterson). 1 Was at American Academy of Family Physicians, Leawood, KS, USA during the writing of the manuscript.
http://dx.doi.org/10.1016/j.hjdsi.2014.11.002 2213-0764/& 2014 Elsevier Inc. All rights reserved.
health care in the United States”.7 Incentive programs for MU for eligible professionals, and standards and certification criteria for EHR vendors and their products increased adoption of certified EHR technology (CEHRT). The MU program claims that the benefits will be complete and accurate information, better access to information, and patient empowerment. The implementation plan for MU was conceived as three progressive stages that focus on (1) data capture and sharing, including initial quality reporting and sharing data for care coordination, (2) advanced clinical processes, including comprehensive information exchange across settings, and (3) improved outcomes, including measuring and improving quality for patients and populations and patient access to self-management tools. Though vendors may incorporate specific, required MU functionality in their products, the implementation of the system by a practice or a third-party implementation team can potentially block access to or render unusable these functions during the clinical workflow. Alternately, such additional functions may be packaged as “add-ons” with additional fees to purchase and implement. Thus,
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
it is unclear how many certified EHRs currently in use actually deliver expected MU functions. From 2005 to 2011 the percentage of U.S. family physicians using an EHR in ambulatory practice nearly doubled from 37% to 68%.1 However, previous national surveys during this time found that only one-third of physicians had an EHR that met MU criteria.8,9 There is real concern that broad adoption of EHRs by family physicians prior to MU certification may leave practices at risk for having EHRs that are not capable of supporting the advancing functions required in MU Stage 2 and MU Stage 3. As such, these practices may be required to make significant investments in EHR upgrades or even purchase and implement entirely new systems that results in substantial cost, effort, and disruptions to practice and patient care. Currently, it remains unclear if the previously reported trends in the adoption of EHR technology by family physicians have been accompanied by MU functionality. The objective of our study was to characterize family physician access to MU functions when MU Stage 1 criteria were just starting in 2011.
2. Materials and methods 2.1. Data and sample We used data from a two-week survey conducted by the American Board of Family Medicine (ABFM) in fall 2011. Any physician who accessed their secure online portfolio during this time was redirected to a brief survey before entering their portfolio, yielding a 100% response rate. For this analysis our inclusion criteria included residence in the United States and having practice demographic and characteristics data available. These data were obtained from the ABFM demographic data which are routinely collected during the application for the Maintenance of Certification for Family Physicians (MC-FP) examination. Physicians first take the MC-FP examination 7 or 10 years after residency graduation and thus physicians just out of residency are excluded. County-level data were obtained from the 2011 Area Resource File. 2.2. Variables Physician demographic variables from the ABFM data included age, international medical graduate (IMG) status, degree type (MD or DO), practice organization and practice composition. Physician addresses were geocoded to classify practice location in a metropolitan, non-metropolitan, or rural county and to determine the county-level Health Professional Shortage Area (HPSA) designation. Survey questions concerning MU were adapted from the National Ambulatory Medical Care Survey (NAMCS).10 The primary outcome was determined using the question “Do you have a Certified EHR that supports meaningful use?” Functionality of a respondent's EHR was determined using the questions: (1) “Does your EHR give you electronic access to most lab tests done in your local hospital/lab company?”; (2) “Does your EHR give you electronic access to most consultation and diagnostic procedural information?”; (3) “In the last year, have you reviewed measured quality of care for your patients with a chronic disease (for example, diabetes)?”; and (4) “In the last year, have you reviewed the records of all patients with a specific condition, such as diabetes, in order to plan care for the population and/or contact patients to invite them in for care?” How the practice transmits prescriptions was determined by the question “In your primary clinical site, do you routinely prescribe electronically?” Table 1 details the links between each question and MU criteria.
39
An additional survey question was used to assess the ability of respondents to communicate electronically with patients. We created a summary score from 0 to 5 reflecting the number of positive responses to five queried features of electronic communication: patients can routinely access lab results directly; patients can request appointments from staff; patients can routinely directly schedule appointments; patients can ask questions of their provider or other practice personnel; and patients can access health information, practice protocols, and similar health education information. 2.3. Analytic strategy Descriptive statistics were used to characterize the demographics and survey question responses of the sample and bivariate associations between demographics and survey responses were tested using Chi-Square and t-tests. We also tested bivariate associations between responding positively to having an EHR that supports MU and reported MU functions. SAS Version 9.3 (Cary, NC) was used for all analyses. The use of these data secondarily was approved as exempt research by the American Academy of Family Physicians Institutional Review Board.
3. Results Of the 5818 physicians who completed the survey, 3855 (66%) had demographic data available and were located within the 50 United States. Compared to other physicians in the ABFM database likely to access their portfolio during the survey period, survey respondents were slightly younger and were more likely to be female (data not shown). The majority of respondents were 40–60 years old (less than 5% were o40 years old), 35.5% were female, and 14.5% were IMGs (Table 2). Nearly half of respondents worked in a single-specialty group practice, 15.9% worked in a solo practice, 3.7% worked in a Health Maintenance Organization (HMO), and 34.5% worked in a multi-specialty group practice. A majority of respondents resided in counties that were a full or a partial HPSA (84.0%) or that were metropolitan (83.1%). 60% of respondents reported having CEHRT that supports MU, another 7.4% responded “don't know” and 8.1% responded “not applicable” (Table 3). Additionally, 37% of respondents reported having reviewed records for all patients with a specific disease to plan care and 58.3% had measured the quality of care for patients with a chronic disease in the past year. A majority of respondents (60.4%) reported that their EHR provided them access to most lab test results and slightly less than half (49.3%) reported that their EHR granted electronic access to most consultation and diagnostic procedural information. Most respondents (69.6%) reported that their EHR allowed them routine electronic prescribing either via fax or electronic transmission. Only one-quarter of respondents reported secure or encrypted electronic communication with patients and fewer than 20% of respondents reported that their EHR allowed patients routine access to labs or health information. When responses were limited to respondents answering only “yes” or “no” to functionality questions, having CEHRT was associated with greater performance of MU functionality (Table 4). For example, those with EHRs that support MU were more likely to measure quality of care (74.1% vs. 56.4%, po0.01), plan care for a patient panel (49.7% vs. 32.3%, po0.01), have access to labs and consultation notes, and prescribe electronically. More than half of respondents reported no patient communication capabilities (55%); 14.1% reported having only one function and only 6.5% reported having all five patient communication capabilities. Respondents who reported using an EHR that supports MU had a higher mean summary score [1.4 (standard
40
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
Table 1 Overlay of survey questions with meaningful use (MU) criteria and objectives. Survey questions
MU 1 objective
MU 2 objective
Do you have a certified electronic health record (EHR) that supports meaningful use?
Certified EHR is a general MU requirement for program participation by EPs
Certified EHR is a general MU requirement for program participation by EPs
In the last year, have you reviewed measured quality of care for your patients with a chronic disease (for example, diabetes)?
(Core-10) Report ambulatory clinical quality measures
Submission of clinical quality measures is a general MU requirement for program participation by EPs
In the last year, have you reviewed the records of all patients with a specific (Menu-3) Generate lists of patients condition, such as diabetes, in order to plan care for the population and/or by specific conditions contact patients to invite them in for care? (Menu-4) Send patient reminders
(Core-11) Generate lists of patients by specific conditions (Core-12) Use clinically relevant information to identify patients and send reminders for preventive/ follow-up care
Does your EHR give you electronic access to most lab tests done in your local hospital/lab company?
(Menu-2) Incorporate clinical labtest results
(Core-10) Incorporate clinical lab-test results
Does your EHR give you electronic access to most consultation and diagnostic procedural information?
(Menu-8) Provide summary care record
(Core-15) Provide summary care record for each transition of care or referral
In your primary clinical site, do you routinely prescribe electronically?
(Core-4) Generate and transmit permissible prescriptions electronically (eRx)
(Core-2)Generate and transmit permissible prescriptions electronically (eRx)
Electronic communication with patients is routinely encrypted/secure
N/A
(Core-17) Use secure electronic messaging
Patients can routinely access lab results electronically
(Core-12) Provide patients with an electronic copy of their health information (Menu-5) Provide patients with timely electronic access
(Core-7) Provide patients the ability to view online, download and transmit their health information
Patients can request appointments from staff electronically
N/A
N/A
Patients can routinely directly schedule appointments electronically
N/A
N/A
Patients can ask questions of their provider or other practice personnel electronically
N/A
(Core-17) Use secure electronic messaging
Patients can access health information, practice protocols, and similar health education information electronically
(Menu-6) Identify and provide patient-specific education resources (Core-12) Provide patients with an electronic copy of their health information (Menu-5) Provide patients with timely electronic access
(Core-13) Identify and provide patient-specific education resources (Core-7) Provide patients the ability to view online, download and transmit their health information
Table 2 Demographic Characteristics of the Physician Sample. Percentage or mean (standard deviation) (n ¼3855) Age in years, mean (standard deviation) Gender – Female Degree Type – MD International Medical Graduate
52.0 (7.8) 35.3 91.7 14.5
Organization type Administration Educator Government Group HMO Solo Practice Partnership Other Multispecialty practice site Geographic Health Professional Shortage Area (HPSA)
1.2 4.3 6.4 46.6 3.7 15.9 12.7 9.3 34.5 84.0
Rurality Metropolitan Non-metropolitan Completely rural
83.1 15.6 1.3
deviation ¼1.7)] than those without [0.4 (SD ¼0.9)] (p-value ¼ o0.05). Additionally, we found an association between having an EHR that supports MU and having a higher electronic communication score (Fig. 1). Of respondents with an electronic communication score of zero, only 60% reported having an EHR that supports MU compared with over 90% for those with scores of 4 or 5.
4. Discussion Family physicians who report having an EHR that supports MU are more likely to report MU capabilities. However, a sizeable minority of these physicians lacked key MU capabilities in 2011, which may limit their ability to meet more stringent MU Stages 2 and 3 standards. These early adopters of EHR technology may need to make a sizeable reinvestment or upgrade of existing software in order to meet more stringent MU standards. Though there are some demographic differences between our study sample and the larger population of family physicians, these results provide a window into the MU functionality of EHRs well after MU Stage 1 was underway, but before the launch of MU
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
Stage 2 requirements. Our exclusion of the youngest cohort of physicians suggests that the findings may be generous estimates of actual practice, considering the increased EHR adoption among younger physicians.11 However, younger physicians in group practices may have less influence on what EHR their practice adopts which may lower our estimates. That fewer than two-thirds of family physicians identified that their EHR was MU certified, in 2011, presents a significant concern that a large minority may now be at risk of not meeting new MU requirements and may need to make additional and substantial HIT investments. However, with physicians increasingly joining group practices and consolidating with large healthcare systems, this may enable upgrading of EHRs. Our concern is bolstered by the striking difference between the summary functionality scores of those with and those without certified EHRs. For the 60% with an EHR that supports MU, it is disconcerting to find so many who could not fulfill some of the more important functionalities under MU Stage 1: 30–50% lacked basic functions such as accessing lab data, consultations notes, and electronic prescribing. A sizeable majority could not grant patients access to their own information or communicate with patients securely. The ability to measure quality was reported by 75% of respondents but only half used chronic disease registries, despite both being vital to the future MU requirements. Federal policy makers, particularly CMS, are moving aggressively toward value-based payment models that rely heavily on the robust functionality of EHR systems and their skilled use.12 CMS has proposed changes regarding physician quality reporting for 2014 that will require physicians to submit 9 quality measures in 3 domains of the National Quality Strategy including one clinical outcome measure. These measures will be publicly reported on the Physician Compare website in 2015 and will be used to adjust Medicare payments in 2016, leveraging penalties rather than incentives. Other payers are moving in a similar direction, with some providing quality measures that they have generated which may be better than not having any measures, but begs the question whether physicians will be able to use their EHRs to verify these results. The Office of the National Coordinator for HIT has begun to de-certify EHRs that do not comply with MU Stage 2, and this is an important step in assuring that EHRs will be able to fulfill the functions that payers expect – and, indeed, that our patients need. As of September 9, 2013, there were no certified and verified EHR products capable of producing all of the Ambulatory Clinical Quality Measures under MU Stage 2.12 The concern that follows is that policy is very far in front of capacity of EHR vendors and physicians to comply. In partial recognition of this, CMS extended MU Stage 2 requirements to 2016. However, t urgency remains to keep the
Table 3 Family physician use of electronic health records and associated meaningful use functions. Percentage Do you have a certified EHR that supports meaningful use? Yes No Don't know Not applicable
60.3 24.2 7.4 8.1
In the last year, have you reviewed measured quality of care for your patients with a chronic disease (for example, diabetes)? Yes No Not applicable
58.3 27.3 14.4
In the last year, have you reviewed the records of all patients with a specific condition, such as diabetes, in order to plan care for the population and/or contact patients to invite them in for care? Yes 37.3 No 47.4 Not applicable 15.3 Does your EHR give you electronic access to most lab tests done in your local hospital/lab company Yes 60.4 No 16.0 Not applicable 23.5 Does your EHR give you electronic access to most consultation and diagnostic procedural information? Yes 49.3 No 26.3 Not applicable 24.4 In your primary clinical site, do you routinely prescribe electronically? Yes, via fax 9.1 Yes, via fax electronic transmission 60.5 No 22.0 Not applicable 8.4 With respect to electronic communication between you and your patients, which of the following apply? (% answering yes) Communications is routinely encrypted/secure 25.8 Patients can routinely access lab results directly 15.0 Patients can request appointments from staff 30.4 Patients can routinely directly schedule appointments 12.1 Patients can ask questions of their provider or other 28.4 Practice personnel Patients can access health information, practice Protocols and similar health education information
16.6
100 90 80
Percentage
70 60 50
Has EHR with Meaningful Use
40
Does Not Have EHR with Meaningful Use
30 20 10 0 0
1
2
3
41
4
5
Electronic Communication Score Fig. 1. Electronic communication score by electronic health record (EHR) with meaningful use.
42
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
Table 4 Performance of population management and quality improvement activities by having an electronic health record (EHR) with meaningful use (MU) capability. % Responding “Yes” to the questions below by having a certified EHR
Reports a certified EHR that supports MU
In the last year, have you reviewed measured quality of care for your patients with a chronic disease? (n¼ 3002) In the last year, have you reviewed the records of all patients with a specific condition, such as diabetes, in order to plan care for the population and/or contact patients to invite them in for care? (n¼2974) Does your EHR give you electronic access to most lab tests done in your local hospital/lab company? (n ¼2715) Does your EHR give you electronic access to most consultation and diagnostic procedural information? (n¼2688) In your primary clinical site, do you routinely prescribe electronically? (Yes, via fax electronic transmission) (n¼ 2865)
p-Value
Yes
No
74.1 49.7
56.4 32.3
o 0.01 o 0.01
87.6 73.6 89.5
33.4 20.6 37.3
o 0.01 o 0.01 o 0.01
p-Value for Chi-Square test.
momentum for making HIT more robust for healthcare, and particularly for the capacity to measure and improve care for patients and populations. Some of the federally-funded support systems that helped speed EHR implementation, such as the HIT Regional Extensions Centers, are expiring at the very time that we are entering a period of escalating expectations for MU. It remains unknown if EHR vendors or other private entities can step up to meet this need but some promising solutions are being implemented.13 These policy decisions could lead to a great deal of frustration in the coming years. In the meantime, certifying boards can play an important role by continuing to shed light on the success and risks of EHR and MU implementation, as well as in supporting the capacity for quality measurement and improvement. For example, the ABFM operates a certified PQRS registry with the goal of helping physicians make Maintenance of Certification more meaningful, reduce reporting burden, and align incentives for real improvement. In the last 2 years, more than 2400 family physicians availed themselves of this opportunity. Certifying boards should continue to step into this breach as they have a fiduciary responsibility to the public and direct relationships with their diplomates. As such, the ABFM has dedicated $2 million to helping find solutions for extracting data from EHRs and then using the information to drive quality improvement.14 Despite our questions mapping to MU criteria, there may be bias in our data as many respondents may not fully know the capabilities of their EHR through routine clinical use. For example, physicians simply assume their EHR uses secure communication. Also, many of the questions used words such as “routinely” or “most” and these were left to the respondents' interpretation. Thus, it is possible that two respondents each accessing outside lab reports 60% of the time may have answered a question differently. We were unable to externally verify answers to the questions but prior work found high agreement between ABFM and NAMCS data regarding EHR utilization.1 Our findings should be considered in the context of several limitations. First, we used a large cross sectional sample of family physicians and our results may not reflect the larger population of family physicians. Second, ideally we would compare those with EHRs vs. those with EHRs that support MU; however these data were not available to us. Future work should investigate whether physicians are meeting MU functions without a certified appropriate EHR. 4.1. Conclusion Our research suggests a non-trivial disconnect between certification of EHRs for MU and the availability of those certified functions to end-users at the point of care in 2011. Compliance may have increased since our survey due to the efforts of Regional Extensions Centers and private companies but this remains uncertain. Our findings have important consequences for policy makers and frontline clinicians as each tries to increase use of HIT to improve patient care.
Conflict of interest None. Funding No external sources of funding. Acknowledgments Ms. Nichole Lainhart provided copy editing assistance with the manuscript. Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.hjdsi.2014.11.002. References 1. Xierali IM, Hsiao CJ, Puffer JC, et al. The rise of electronic health record adoption among family physicians. Ann Fam Med. 2013;11(1):14–19. 2. Patel V, Jamoom E, Hsiao CJ, Furukawa MF, Buntin M. Variation in electronic health record adoption and readiness for meaningful use: 2008–2011. J Gen Intern Med. 2013;28(7):957–964. 3. Analytics H. HIMSS analytics: data show that meaningful use is affecting EHR adoption. 〈http://www.himssanalytics.org/about/NewsDetail.aspx?nid=81801〉; 2013 Accessed 13.08.13. 4. CMS. Electronic health record incentive program – Stage 2. 〈http://www.cms. gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2. html〉; 2012 Accessed 13.08.13. 5. Desroches CM, Worzala C, Bates S. Some hospitals are falling behind in meeting ‘meaningful use’ criteria and could be vulnerable to penalties in 2015. Health Aff. 2013;32(8):1355–1360. 6. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff. 2013;32(1):63–68. 7. Meaningful Use. 〈http://www.healthit.gov/policy-researchers-implementers/ meaningful-use〉; 2013 Accessed 20.09.13. 8. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care – a national survey of physicians. N Engl J Med. 2008;359 (1):50–60. 9. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628–1638. 10. National Ambulatory Medical Care Survey (NAMCS). Electronic medical records supplement 2010. 〈http://www.cdc.gov/nchs/data/ahcd/2010EMRSurveyfinal. pdf〉; 2010 Accessed 20.09.13. 11. Xierali IM, Phillips Jr RL, Green LA, Bazemore AW, Puffer JC. Factors influencing family physician adoption of electronic health records (EHRs). J Am Board Fam Med. 2013;26(4):388–393. 12. Search for Certified EHR Products. 〈http://oncchpl.force.com/ehrcert/ehrproduct criteriasearch〉; 2013 Accessed 09.09.13. 13. EPIC. Community connect: extending to independent physicians and hospitals. Available at: 〈https://www.epic.com/services-community.php〉 Accessed 09.07.14. 14. ABFM. A message from the President. American Board of Family Medicine (ABFM); 2012.
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Do family physicians electronic health records support meaningful use? Lars E. Peterson a,b,n, Brenna Blackburn a, Douglas Ivins c, Jason Mitchell d,1, Christine Matson e, Robert L. Phillips Jr.a a
The American Board of Family Medicine, Lexington, KY, USA Department of Family and Community Medicine, University of Kentucky, Lexington, KY, USA c Department of Family Medicine, University of Oklahoma-Tulsa, Tulsa, OK, USA d Cerner Corporation, Kansas City, KS, USA e Department of Family Medicine, Eastern Virginia Medical School, Norfolk, VA, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 4 March 2014 Received in revised form 25 July 2014 Accepted 4 November 2014 Available online 20 December 2014
Background: Spurred by government incentives, the use of electronic health records (EHRs) in the United States has increased; however, whether these EHRs have the functionality necessary to meet meaningful use (MU) criteria remains unknown. Our objective was to characterize family physician access to MU functionality when using a MU-certified EHR. Methods: Data were obtained from a convenience survey of family physicians accessing their American Board of Family Medicine online portfolio in 2011. A brief survey queried MU functionality. We used descriptive statistics to characterize the responses and bivariate statistics to test associations between MU and patient communication functions by presence of a MU-certified EHR. Results: Out of 3855 respondents, 60% reported having an EHR that supports MU. Physicians with MUcertified EHRs were more likely than physicians without MU-certified EHRs to report patient registry activities (49.7% vs. 32.3%, p-value o0.01), tracking quality measures (74.1% vs. 56.4%, p-value o 0.01), access to labs or consultation notes, and electronic prescribing; but electronic communication abilities were low regardless of EHR capabilities. Conclusions: Family physicians with MU-certified EHRs are more likely to report MU functionality; however, a sizeable minority does not report MU functions. Implications: Many family physicians with MU-certified EHRs may not successfully meet the successively stringent MU criteria and may face significant upgrade costs to do so. Level of evidence: Cross sectional survey. & 2014 Elsevier Inc. All rights reserved.
Keywords: Electronic health records Meaningful use Family physicians
1. Introduction The adoption of electronic health record (EHR) technology by primary care practices has increased in recent years,1,2 in conjunction with incentives from the Centers for Medicare and Medicaid Services (CMS) for the “meaningful use” of certified health information technology (HIT) products.3,4 However, success in meeting the policy priorities of “meaningful use” and realization of the projected cost savings from EHR technology have remained elusive.5,6 The federal meaningful use (MU) program was born of the Health Information Technology for Economic and Clinical Health (HITECH) Act, with the goal of promoting “the spread of electronic health records to improve
n Correspondence to: American Board of Family Medicine, 1648 McGrathiana Parkway, Suite 550 Lexington, KY 40511-1247, USA. Tel.: þ1 859 269 5626; fax: þ1 859 335 7509. E-mail address: [email protected] (L.E. Peterson). 1 Was at American Academy of Family Physicians, Leawood, KS, USA during the writing of the manuscript.
http://dx.doi.org/10.1016/j.hjdsi.2014.11.002 2213-0764/& 2014 Elsevier Inc. All rights reserved.
health care in the United States”.7 Incentive programs for MU for eligible professionals, and standards and certification criteria for EHR vendors and their products increased adoption of certified EHR technology (CEHRT). The MU program claims that the benefits will be complete and accurate information, better access to information, and patient empowerment. The implementation plan for MU was conceived as three progressive stages that focus on (1) data capture and sharing, including initial quality reporting and sharing data for care coordination, (2) advanced clinical processes, including comprehensive information exchange across settings, and (3) improved outcomes, including measuring and improving quality for patients and populations and patient access to self-management tools. Though vendors may incorporate specific, required MU functionality in their products, the implementation of the system by a practice or a third-party implementation team can potentially block access to or render unusable these functions during the clinical workflow. Alternately, such additional functions may be packaged as “add-ons” with additional fees to purchase and implement. Thus,
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
it is unclear how many certified EHRs currently in use actually deliver expected MU functions. From 2005 to 2011 the percentage of U.S. family physicians using an EHR in ambulatory practice nearly doubled from 37% to 68%.1 However, previous national surveys during this time found that only one-third of physicians had an EHR that met MU criteria.8,9 There is real concern that broad adoption of EHRs by family physicians prior to MU certification may leave practices at risk for having EHRs that are not capable of supporting the advancing functions required in MU Stage 2 and MU Stage 3. As such, these practices may be required to make significant investments in EHR upgrades or even purchase and implement entirely new systems that results in substantial cost, effort, and disruptions to practice and patient care. Currently, it remains unclear if the previously reported trends in the adoption of EHR technology by family physicians have been accompanied by MU functionality. The objective of our study was to characterize family physician access to MU functions when MU Stage 1 criteria were just starting in 2011.
2. Materials and methods 2.1. Data and sample We used data from a two-week survey conducted by the American Board of Family Medicine (ABFM) in fall 2011. Any physician who accessed their secure online portfolio during this time was redirected to a brief survey before entering their portfolio, yielding a 100% response rate. For this analysis our inclusion criteria included residence in the United States and having practice demographic and characteristics data available. These data were obtained from the ABFM demographic data which are routinely collected during the application for the Maintenance of Certification for Family Physicians (MC-FP) examination. Physicians first take the MC-FP examination 7 or 10 years after residency graduation and thus physicians just out of residency are excluded. County-level data were obtained from the 2011 Area Resource File. 2.2. Variables Physician demographic variables from the ABFM data included age, international medical graduate (IMG) status, degree type (MD or DO), practice organization and practice composition. Physician addresses were geocoded to classify practice location in a metropolitan, non-metropolitan, or rural county and to determine the county-level Health Professional Shortage Area (HPSA) designation. Survey questions concerning MU were adapted from the National Ambulatory Medical Care Survey (NAMCS).10 The primary outcome was determined using the question “Do you have a Certified EHR that supports meaningful use?” Functionality of a respondent's EHR was determined using the questions: (1) “Does your EHR give you electronic access to most lab tests done in your local hospital/lab company?”; (2) “Does your EHR give you electronic access to most consultation and diagnostic procedural information?”; (3) “In the last year, have you reviewed measured quality of care for your patients with a chronic disease (for example, diabetes)?”; and (4) “In the last year, have you reviewed the records of all patients with a specific condition, such as diabetes, in order to plan care for the population and/or contact patients to invite them in for care?” How the practice transmits prescriptions was determined by the question “In your primary clinical site, do you routinely prescribe electronically?” Table 1 details the links between each question and MU criteria.
39
An additional survey question was used to assess the ability of respondents to communicate electronically with patients. We created a summary score from 0 to 5 reflecting the number of positive responses to five queried features of electronic communication: patients can routinely access lab results directly; patients can request appointments from staff; patients can routinely directly schedule appointments; patients can ask questions of their provider or other practice personnel; and patients can access health information, practice protocols, and similar health education information. 2.3. Analytic strategy Descriptive statistics were used to characterize the demographics and survey question responses of the sample and bivariate associations between demographics and survey responses were tested using Chi-Square and t-tests. We also tested bivariate associations between responding positively to having an EHR that supports MU and reported MU functions. SAS Version 9.3 (Cary, NC) was used for all analyses. The use of these data secondarily was approved as exempt research by the American Academy of Family Physicians Institutional Review Board.
3. Results Of the 5818 physicians who completed the survey, 3855 (66%) had demographic data available and were located within the 50 United States. Compared to other physicians in the ABFM database likely to access their portfolio during the survey period, survey respondents were slightly younger and were more likely to be female (data not shown). The majority of respondents were 40–60 years old (less than 5% were o40 years old), 35.5% were female, and 14.5% were IMGs (Table 2). Nearly half of respondents worked in a single-specialty group practice, 15.9% worked in a solo practice, 3.7% worked in a Health Maintenance Organization (HMO), and 34.5% worked in a multi-specialty group practice. A majority of respondents resided in counties that were a full or a partial HPSA (84.0%) or that were metropolitan (83.1%). 60% of respondents reported having CEHRT that supports MU, another 7.4% responded “don't know” and 8.1% responded “not applicable” (Table 3). Additionally, 37% of respondents reported having reviewed records for all patients with a specific disease to plan care and 58.3% had measured the quality of care for patients with a chronic disease in the past year. A majority of respondents (60.4%) reported that their EHR provided them access to most lab test results and slightly less than half (49.3%) reported that their EHR granted electronic access to most consultation and diagnostic procedural information. Most respondents (69.6%) reported that their EHR allowed them routine electronic prescribing either via fax or electronic transmission. Only one-quarter of respondents reported secure or encrypted electronic communication with patients and fewer than 20% of respondents reported that their EHR allowed patients routine access to labs or health information. When responses were limited to respondents answering only “yes” or “no” to functionality questions, having CEHRT was associated with greater performance of MU functionality (Table 4). For example, those with EHRs that support MU were more likely to measure quality of care (74.1% vs. 56.4%, po0.01), plan care for a patient panel (49.7% vs. 32.3%, po0.01), have access to labs and consultation notes, and prescribe electronically. More than half of respondents reported no patient communication capabilities (55%); 14.1% reported having only one function and only 6.5% reported having all five patient communication capabilities. Respondents who reported using an EHR that supports MU had a higher mean summary score [1.4 (standard
40
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
Table 1 Overlay of survey questions with meaningful use (MU) criteria and objectives. Survey questions
MU 1 objective
MU 2 objective
Do you have a certified electronic health record (EHR) that supports meaningful use?
Certified EHR is a general MU requirement for program participation by EPs
Certified EHR is a general MU requirement for program participation by EPs
In the last year, have you reviewed measured quality of care for your patients with a chronic disease (for example, diabetes)?
(Core-10) Report ambulatory clinical quality measures
Submission of clinical quality measures is a general MU requirement for program participation by EPs
In the last year, have you reviewed the records of all patients with a specific (Menu-3) Generate lists of patients condition, such as diabetes, in order to plan care for the population and/or by specific conditions contact patients to invite them in for care? (Menu-4) Send patient reminders
(Core-11) Generate lists of patients by specific conditions (Core-12) Use clinically relevant information to identify patients and send reminders for preventive/ follow-up care
Does your EHR give you electronic access to most lab tests done in your local hospital/lab company?
(Menu-2) Incorporate clinical labtest results
(Core-10) Incorporate clinical lab-test results
Does your EHR give you electronic access to most consultation and diagnostic procedural information?
(Menu-8) Provide summary care record
(Core-15) Provide summary care record for each transition of care or referral
In your primary clinical site, do you routinely prescribe electronically?
(Core-4) Generate and transmit permissible prescriptions electronically (eRx)
(Core-2)Generate and transmit permissible prescriptions electronically (eRx)
Electronic communication with patients is routinely encrypted/secure
N/A
(Core-17) Use secure electronic messaging
Patients can routinely access lab results electronically
(Core-12) Provide patients with an electronic copy of their health information (Menu-5) Provide patients with timely electronic access
(Core-7) Provide patients the ability to view online, download and transmit their health information
Patients can request appointments from staff electronically
N/A
N/A
Patients can routinely directly schedule appointments electronically
N/A
N/A
Patients can ask questions of their provider or other practice personnel electronically
N/A
(Core-17) Use secure electronic messaging
Patients can access health information, practice protocols, and similar health education information electronically
(Menu-6) Identify and provide patient-specific education resources (Core-12) Provide patients with an electronic copy of their health information (Menu-5) Provide patients with timely electronic access
(Core-13) Identify and provide patient-specific education resources (Core-7) Provide patients the ability to view online, download and transmit their health information
Table 2 Demographic Characteristics of the Physician Sample. Percentage or mean (standard deviation) (n ¼3855) Age in years, mean (standard deviation) Gender – Female Degree Type – MD International Medical Graduate
52.0 (7.8) 35.3 91.7 14.5
Organization type Administration Educator Government Group HMO Solo Practice Partnership Other Multispecialty practice site Geographic Health Professional Shortage Area (HPSA)
1.2 4.3 6.4 46.6 3.7 15.9 12.7 9.3 34.5 84.0
Rurality Metropolitan Non-metropolitan Completely rural
83.1 15.6 1.3
deviation ¼1.7)] than those without [0.4 (SD ¼0.9)] (p-value ¼ o0.05). Additionally, we found an association between having an EHR that supports MU and having a higher electronic communication score (Fig. 1). Of respondents with an electronic communication score of zero, only 60% reported having an EHR that supports MU compared with over 90% for those with scores of 4 or 5.
4. Discussion Family physicians who report having an EHR that supports MU are more likely to report MU capabilities. However, a sizeable minority of these physicians lacked key MU capabilities in 2011, which may limit their ability to meet more stringent MU Stages 2 and 3 standards. These early adopters of EHR technology may need to make a sizeable reinvestment or upgrade of existing software in order to meet more stringent MU standards. Though there are some demographic differences between our study sample and the larger population of family physicians, these results provide a window into the MU functionality of EHRs well after MU Stage 1 was underway, but before the launch of MU
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
Stage 2 requirements. Our exclusion of the youngest cohort of physicians suggests that the findings may be generous estimates of actual practice, considering the increased EHR adoption among younger physicians.11 However, younger physicians in group practices may have less influence on what EHR their practice adopts which may lower our estimates. That fewer than two-thirds of family physicians identified that their EHR was MU certified, in 2011, presents a significant concern that a large minority may now be at risk of not meeting new MU requirements and may need to make additional and substantial HIT investments. However, with physicians increasingly joining group practices and consolidating with large healthcare systems, this may enable upgrading of EHRs. Our concern is bolstered by the striking difference between the summary functionality scores of those with and those without certified EHRs. For the 60% with an EHR that supports MU, it is disconcerting to find so many who could not fulfill some of the more important functionalities under MU Stage 1: 30–50% lacked basic functions such as accessing lab data, consultations notes, and electronic prescribing. A sizeable majority could not grant patients access to their own information or communicate with patients securely. The ability to measure quality was reported by 75% of respondents but only half used chronic disease registries, despite both being vital to the future MU requirements. Federal policy makers, particularly CMS, are moving aggressively toward value-based payment models that rely heavily on the robust functionality of EHR systems and their skilled use.12 CMS has proposed changes regarding physician quality reporting for 2014 that will require physicians to submit 9 quality measures in 3 domains of the National Quality Strategy including one clinical outcome measure. These measures will be publicly reported on the Physician Compare website in 2015 and will be used to adjust Medicare payments in 2016, leveraging penalties rather than incentives. Other payers are moving in a similar direction, with some providing quality measures that they have generated which may be better than not having any measures, but begs the question whether physicians will be able to use their EHRs to verify these results. The Office of the National Coordinator for HIT has begun to de-certify EHRs that do not comply with MU Stage 2, and this is an important step in assuring that EHRs will be able to fulfill the functions that payers expect – and, indeed, that our patients need. As of September 9, 2013, there were no certified and verified EHR products capable of producing all of the Ambulatory Clinical Quality Measures under MU Stage 2.12 The concern that follows is that policy is very far in front of capacity of EHR vendors and physicians to comply. In partial recognition of this, CMS extended MU Stage 2 requirements to 2016. However, t urgency remains to keep the
Table 3 Family physician use of electronic health records and associated meaningful use functions. Percentage Do you have a certified EHR that supports meaningful use? Yes No Don't know Not applicable
60.3 24.2 7.4 8.1
In the last year, have you reviewed measured quality of care for your patients with a chronic disease (for example, diabetes)? Yes No Not applicable
58.3 27.3 14.4
In the last year, have you reviewed the records of all patients with a specific condition, such as diabetes, in order to plan care for the population and/or contact patients to invite them in for care? Yes 37.3 No 47.4 Not applicable 15.3 Does your EHR give you electronic access to most lab tests done in your local hospital/lab company Yes 60.4 No 16.0 Not applicable 23.5 Does your EHR give you electronic access to most consultation and diagnostic procedural information? Yes 49.3 No 26.3 Not applicable 24.4 In your primary clinical site, do you routinely prescribe electronically? Yes, via fax 9.1 Yes, via fax electronic transmission 60.5 No 22.0 Not applicable 8.4 With respect to electronic communication between you and your patients, which of the following apply? (% answering yes) Communications is routinely encrypted/secure 25.8 Patients can routinely access lab results directly 15.0 Patients can request appointments from staff 30.4 Patients can routinely directly schedule appointments 12.1 Patients can ask questions of their provider or other 28.4 Practice personnel Patients can access health information, practice Protocols and similar health education information
16.6
100 90 80
Percentage
70 60 50
Has EHR with Meaningful Use
40
Does Not Have EHR with Meaningful Use
30 20 10 0 0
1
2
3
41
4
5
Electronic Communication Score Fig. 1. Electronic communication score by electronic health record (EHR) with meaningful use.
42
L.E. Peterson et al. / Healthcare 3 (2015) 38–42
Table 4 Performance of population management and quality improvement activities by having an electronic health record (EHR) with meaningful use (MU) capability. % Responding “Yes” to the questions below by having a certified EHR
Reports a certified EHR that supports MU
In the last year, have you reviewed measured quality of care for your patients with a chronic disease? (n¼ 3002) In the last year, have you reviewed the records of all patients with a specific condition, such as diabetes, in order to plan care for the population and/or contact patients to invite them in for care? (n¼2974) Does your EHR give you electronic access to most lab tests done in your local hospital/lab company? (n ¼2715) Does your EHR give you electronic access to most consultation and diagnostic procedural information? (n¼2688) In your primary clinical site, do you routinely prescribe electronically? (Yes, via fax electronic transmission) (n¼ 2865)
p-Value
Yes
No
74.1 49.7
56.4 32.3
o 0.01 o 0.01
87.6 73.6 89.5
33.4 20.6 37.3
o 0.01 o 0.01 o 0.01
p-Value for Chi-Square test.
momentum for making HIT more robust for healthcare, and particularly for the capacity to measure and improve care for patients and populations. Some of the federally-funded support systems that helped speed EHR implementation, such as the HIT Regional Extensions Centers, are expiring at the very time that we are entering a period of escalating expectations for MU. It remains unknown if EHR vendors or other private entities can step up to meet this need but some promising solutions are being implemented.13 These policy decisions could lead to a great deal of frustration in the coming years. In the meantime, certifying boards can play an important role by continuing to shed light on the success and risks of EHR and MU implementation, as well as in supporting the capacity for quality measurement and improvement. For example, the ABFM operates a certified PQRS registry with the goal of helping physicians make Maintenance of Certification more meaningful, reduce reporting burden, and align incentives for real improvement. In the last 2 years, more than 2400 family physicians availed themselves of this opportunity. Certifying boards should continue to step into this breach as they have a fiduciary responsibility to the public and direct relationships with their diplomates. As such, the ABFM has dedicated $2 million to helping find solutions for extracting data from EHRs and then using the information to drive quality improvement.14 Despite our questions mapping to MU criteria, there may be bias in our data as many respondents may not fully know the capabilities of their EHR through routine clinical use. For example, physicians simply assume their EHR uses secure communication. Also, many of the questions used words such as “routinely” or “most” and these were left to the respondents' interpretation. Thus, it is possible that two respondents each accessing outside lab reports 60% of the time may have answered a question differently. We were unable to externally verify answers to the questions but prior work found high agreement between ABFM and NAMCS data regarding EHR utilization.1 Our findings should be considered in the context of several limitations. First, we used a large cross sectional sample of family physicians and our results may not reflect the larger population of family physicians. Second, ideally we would compare those with EHRs vs. those with EHRs that support MU; however these data were not available to us. Future work should investigate whether physicians are meeting MU functions without a certified appropriate EHR. 4.1. Conclusion Our research suggests a non-trivial disconnect between certification of EHRs for MU and the availability of those certified functions to end-users at the point of care in 2011. Compliance may have increased since our survey due to the efforts of Regional Extensions Centers and private companies but this remains uncertain. Our findings have important consequences for policy makers and frontline clinicians as each tries to increase use of HIT to improve patient care.
Conflict of interest None. Funding No external sources of funding. Acknowledgments Ms. Nichole Lainhart provided copy editing assistance with the manuscript. Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.hjdsi.2014.11.002. References 1. Xierali IM, Hsiao CJ, Puffer JC, et al. The rise of electronic health record adoption among family physicians. Ann Fam Med. 2013;11(1):14–19. 2. Patel V, Jamoom E, Hsiao CJ, Furukawa MF, Buntin M. Variation in electronic health record adoption and readiness for meaningful use: 2008–2011. J Gen Intern Med. 2013;28(7):957–964. 3. Analytics H. HIMSS analytics: data show that meaningful use is affecting EHR adoption. 〈http://www.himssanalytics.org/about/NewsDetail.aspx?nid=81801〉; 2013 Accessed 13.08.13. 4. CMS. Electronic health record incentive program – Stage 2. 〈http://www.cms. gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2. html〉; 2012 Accessed 13.08.13. 5. Desroches CM, Worzala C, Bates S. Some hospitals are falling behind in meeting ‘meaningful use’ criteria and could be vulnerable to penalties in 2015. Health Aff. 2013;32(8):1355–1360. 6. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff. 2013;32(1):63–68. 7. Meaningful Use. 〈http://www.healthit.gov/policy-researchers-implementers/ meaningful-use〉; 2013 Accessed 20.09.13. 8. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care – a national survey of physicians. N Engl J Med. 2008;359 (1):50–60. 9. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628–1638. 10. National Ambulatory Medical Care Survey (NAMCS). Electronic medical records supplement 2010. 〈http://www.cdc.gov/nchs/data/ahcd/2010EMRSurveyfinal. pdf〉; 2010 Accessed 20.09.13. 11. Xierali IM, Phillips Jr RL, Green LA, Bazemore AW, Puffer JC. Factors influencing family physician adoption of electronic health records (EHRs). J Am Board Fam Med. 2013;26(4):388–393. 12. Search for Certified EHR Products. 〈http://oncchpl.force.com/ehrcert/ehrproduct criteriasearch〉; 2013 Accessed 09.09.13. 13. EPIC. Community connect: extending to independent physicians and hospitals. Available at: 〈https://www.epic.com/services-community.php〉 Accessed 09.07.14. 14. ABFM. A message from the President. American Board of Family Medicine (ABFM); 2012.
