Source: iHealthBeat (California Healthcare Foundation)
By: Kate Ackerman, iHealthBeat Associate Editor
October 09, 2007
Health IT insiders disagree on the attainability of President Bush's goal for most U.S. residents to have electronic health records by 2014. Numerous studies have assessed the state of EHR adoption in the U.S., but the findings vary significantly depending on how the studies define both "EHRs" and "adoption."
A new study in the American Journal of Medical Quality suggests that more focus should be given to the type -- not the number -- of EHR systems that are being adopted. The study, called "Incomplete EHR Adoption: Late Uptake of Patient Safety and Cost Control Functions," found that Florida physicians who recently adopted EHR systems were more likely than early adopters to use incomplete systems that lack key patient-safety and cost-control functions.
The study noted that by failing to account for partial adoption scenarios, policymakers potentially could threaten achievement of their goal to use health IT to boost clinical outcomes, increase patient safety and control costs.
Early Adopters vs. Recent Adopters
As is the case with most technology, there have been different groups of adopters in the health IT world -- including those who were quick to jump on the bandwagon and those who took more of a "wait and see" approach, comprising the second wave of adoption. However, most studies on EHR adoption have looked at EHR adopters as one general group.
For the American Journal of Medical Quality study, researchers looked at various types of adopters to evaluate EHR implementation and the degree of functionality in the systems. Those who installed their EHR systems 10 or more years ago were considered "innovators," while "early adopters" were defined as physicians whose systems were installed three to nine years ago. The study considered "recent adopters" to be providers who adopted two or fewer years ago. The study looked at 4,203 physicians in Florida, 995 of whom reported use of an EHR system.
After controlling for practice type, size and scope, the study found that innovators and early EHR adopters were more likely than recent adopters to have EHRs with key patient-safety and cost-control functionalities, such as the ability to prescribe medications and access pharmacy information electronically.
Nir Menachemi, an author of the study and director of the Center on Patient Safety at Florida State University, said he would expect similar results for the rest of the country. "Certainly, Florida is unique just like any other state is, but when you sort of consider these trends in the explanatory framework that we've developed, there's no reason to believe that it's not this way elsewhere," he said.
Menachemi said that while recent adopters have access to more sophisticated, off-the-shelf systems, "they are not selecting certain functions and are probably looking at a situation that is explainable by the technology acceptance model." In such a model, providers are "less likely to take risks and are looking for products that definitely work and won't be disruptive to their workflows," he said.
Karen Bell, director of health IT adoption at the Office of the National Coordinator for Health IT, said early adopters largely built their own systems to their own specifications, while the next batch of adopters "really didn't know what they were getting, it was buyer beware." She added, "A vendor would come out and say, 'This will take care of all your problems,' and frankly, 30% of all of those purchases ended up going on the back shelf because they were not what the physicians wanted."
Bell noted that the study looked at data from 2005 -- before the existence of the Certification Commission for Healthcare IT, which aims to accelerate health IT adoption through a credible certification program. She explained that CCHIT in 2006 began certifying EHRs for a set of key functionalities identified by the Institute of Medicine.
"So, if that study were done today, with all of the physicians who have purchased the certified EHRs, they would all have the functionalities," she said.
However, Menachemi said that "even with CCHIT certification, there is no guarantee that a physician purchasing a new system would: a) elect to purchase a specific functionality even though it is offered, b) know that the functionality is available." Providers are not required to purchase CCHIT-certified systems.
Stephen Downs, deputy director of the health group at the Robert Wood Johnson Foundation, said he didn't find the study "all that surprising." He said, "Because of the sort of complexity of the implementation and the cultural changes that go into [adopting an EHR system], my sense is that you tend to layer on functions over time." Downs added, "You ... sort of start with getting the system and get people comfortable with it and then you sort of kick it up a notch to the next thing."
Accounting for Differences in Motivation
Menachemi said that the study's findings have led him and his colleagues to believe that while other factors may be involved, providers' intrinsic motivation influences the type of system they adopt.
Gordon Moore, a professor at Harvard Medical School, agreed, saying, "I would be quite willing to bet that doctors are acting rationally. In other words, this is not an irrational resistance to change decision, but a decision that is based on some very real considerations of their time, effort and income."
By acknowledging that physicians' motivation for adopting EHRs differs, policymakers could develop a more effective strategy to reach health IT adoption goals, according to several stakeholders.
Moore said, "I think one of the biggest problems that we've had so far with [EHR] adoption is that, by and large, the extra effort of using these records lies with the doctors, but the value of [EHRs] lies elsewhere in the system." He said that redistributing some of the savings to physicians could encourage adoption.
"The most important thing we could do to help facilitate [health IT adoption] is to help correct the value proposition," Michael Painter, a senior program officer and a senior member of the Robert Wood Johnson Foundation Quality/Equality Team, said. He added that the quality and value movement needs health IT to help drive it, but the quality and value movement is needed to sustain the business case for implementing health IT in the first place.
Downs said, "For me, the bottom line is that unless we successfully incentivize and pay for much better care, there is not really a great reason to invest in something that will provide better care."
He also hypothesized that for certain practices, such as smaller offices, "a fairly light touch of health IT intervention ... without going to a full-blown [EHR] might have a greater yield in terms of cost and benefits." Downs said that scenario would be worth examining rather than focusing solely on how to increase EHR adoption.
Achieving Bush's 2014 Goal
"Having a drop-dead date for anything in my opinion is probably not the best way of doing it," Menachemi said, adding that "if we have to have a date, it should probably be readjusted based on how things are going."
Bush's "goal holds a lot of value as far as organizing energy and activity towards moving in that direction," Downs said. But whether the goal ends in most patients being treated by providers with EHRs seems to be less important than if it ends up driving momentum, he added.
Moore said that achieving Bush's goal "depends on the incentives that you put in and how good these systems are at helping doctors to do their work more easily and ... maintain good quality and maintain their incomes. I think if those nuts are cracked, I don't see any reason why it couldn't be adopted."
Given the progress made so far, meeting the 2014 goal is "very possible," Bell said, adding, "Frankly, I've set my own personal goal of delivering it two years earlier."
Menachemi and his colleagues have received funding to repeat the study in 2008 to assess how adoption of EHR functionality has changed in the past three years.
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