Toward Understanding EHR Use in Small Physician Practices

Toward Understanding EHR Use in Small Physician Practices ? Suzanne Felt-Lisk, M.P.A., Lorraine Johnson, Sc.D., M.P.H, Christopher Fleming, M.P.H., ? Rachel Shapiro, M.P.P., and Brenda Natzke ? This article presents insights into the use of electronic health records (EHRs) by small physician practices participating in a CMS pay-for-performance demonstra - tion. Site visits to four States reveal slow movement toward improved EHR use. Factors facilitating use of EHRs include customization of EHR products and being owned by a larger organization. Factors limiting use of EHRs include system limi - tations, cost, and lack of strong incentives to improve. Practices in one State were moving more vigorously toward improved EHR use than those in the other States. Many practices also increased use of medical assistants after implementing EHRs. intrODUCtiOn As part of the 2009 American Recovery and Reinvestment Act, the Health Infor - mation Technology for Economic and Clin - ical Health (HITECH) Act involves a major national commitment to implementing health information technology (HIT). Spe - cifically, the HITECH Act promotes the use of electronic health records (EHRs) —including $30 billion in incentives for Medicare and Medicaid providers—as a means to improve quality, reduce cost growth, and stimulate the economy in the short term (Redhead, 2009; Congres - sional Budget Office, 2009). Implementers face a number of challenges, however, one Suzanne Felt-Lisk, Christopher Fleming, Rachel Shapiro, and Brenda Natzke are with Mathematica Policy Research. Lorraine Johnson is with the Centers for Medicare & Medicaid Services (CMS). The statements expressed in this article are those of the authors and do not necessarily reflect the views or policies of Mathematica Policy Research or CMS. of which is ensuring that small physician practices are not left behind (Lohr, 2009). While there has been some movement toward consolidation, small practices continue to provide a large proportion of physician care in the U.S.; about one- third of physicians still practice in solo and two-physician practices (Liebhaber and Grossman, 2007). At the same time, they lag behind larger physician groups in acquiring technology: in late 2007, only 9 percent of physicians in practices with 1 to 3 physicians had any electronic medical record system, compared with 29 percent of practices with 11 to 50 phy - sicians and 50 percent of practices with more than 50 physicians (DesRoches et al., 2008). Adoption of HIT is occurring more rapidly in medical groups than in independent practice associations (IPAs), and in medical groups the range of IT capability is proportional to the size of the organization (Robert Wood Johnson Foundation, 2009). The most authoritative evidence of the impact of health IT and EHR systems on quality of care is the systematic review of the literature prepared by Chaudhry et al. (2006). The authors found three major benefits on quality: increased adherence to guideline-based care, enhanced sur - veillance and monitoring, and decreased medication errors. However, much of the literature reviewed in the article came from the four leading institutions design - ing and implementing health IT during the last two decades, each of which developed its own EHR system. HealtH Care FinanCing review/Fall 2009/ Volume 31, Number 1 11 EHR system components, such as reminders from guidelines to providers and computerized physician order entry (a process of electronic entry of physician instructions for the treatment of patients, that includes electronic prescribing as well as other types of electronic ordering), are thought to have the ability to improve quality of care; however, literature on these components finds mixed results (Keyhani et al., 2008; Teich et al., 2000; Welch et al., 2007; Kaushal, Shojania, and Bates, 2003; Bizovi et al., 2002; and Bates et al., 1999). The mixed results may in part reflect dif - ferences in how EHRs are used. Robert Miller and colleagues (2005) conducted case studies of 14 solo or small-group practices with EHRs during 2004/2005. Although the study reported the extent of use of quality-related functions, its main purpose was to quantify financial costs and benefits, and to be eligible for case study, practices had to be using one of only two EHR vendors. Other studies have used surveys to identify the prevalence of use of various EHR features (DesRoches et al., 2008; Menachemi et al., 2007), but the categorical results do not leave the reader with an understanding of EHR use in practice. Other, larger-scale qualitative work examining the dynamics of EHR use and barriers to greater use in physi - cian practices dates back to the 2000-2002 timeframe, making it relatively dated in a decade characterized by rapid evolution of products and potentially the population of EHR users (Miller and Sim, 2004). In this article, we offer current insights into the barriers and facilitators of EHR use in small and medium-sized practices based on site visits to 32 small-to medium- sized physician practices in four States selected by CMS. Effective use of EHRs is widely believed to be a necessary means of improving care quality and efficiency; understanding barriers practices face and facilitators they experience is the first step to strengthening use. The selected practices, located in Arkansas, California, Massachusetts, and Utah, were among those that are participating in the Medi - care Care Management Performance Demonstration (MCMP), a pay-for - performance demonstration that encour - ages use of HIT to improve quality of care to eligible chronically ill, fee-for-service Medicare beneficiaries. 1 The site visits were performed as part of the evaluation of practices’ first year experience in the demonstration (Felt-Lisk et al., 2009). 2 Demonstration Background The 3-year MCMP demonstration was mandated by the Medicare Prescription Drug Improvement and Modernization Act of 2003. Begun July 1, 2007, MCMP provides an annual financial incentive to approximately 640 practices in Arkan - sas, California, Massachusetts, and Utah if they meet or exceed performance stan - dards established by CMS. The incen - tive payment is based on performance on 26 clinical quality measures per - taining to diabetes, congestive heart failure (CHF), coronary artery disease, and the provision of preventive health services, with an additional bonus if the data are submitted through an EHR cer - tified by the Certification Commission for Healthcare Information Technology. A practice can earn up to $192,500 over 3 years ($38,500 per physician). In the first year of the demonstration (prior to the site visits), practices received a maximum of $5,000 (depending on the 1 For more information on MCMP, see http://www.cms.hhs. gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID= CMS1198950. 2 A second round of site visits is planned for 2010, and the two rounds together will complement a quantitative analysis of program impacts, helping us understand what produced the impacts, or how the program logic intended to produce results did not occur as expected. HealtH Care FinanCing review/Fall 2009/ Volume 31, Number 1 12 THE BOOK REVIEW OR ARTICLE CRITIQUE: GENERAL GUIDELINES A review (or “critique”) of a book or article is not primarily a summary. Rather, it analyses, comments on and evaluates the work. As a course assignment, it situates the work in the light of specific issues and theoretical concerns being di scussed in the course. Your review should show that you can recognize arguments and engage in critical thinking about the course content. Keep questions like these in mind as you read, make notes, and then write the review or critique 1. What is the specific topic of the book or article? What overall purpose does it seem to have? For what readership is it written? (Look in the preface, acknowledgements, reference list and index for clues about where and how the piece was originally published, and about the author's background and position.) 2. Does the author state an explicit thesis ? Does he or she noticeably have an axe to grind? What are the theoretical assumptions ? Are they discussed explicitly? (Again, look for statements in the preface, etc. and follow them up in the rest of the work.) 3. What exactly does the work contribute to the overall topic of your course? What general problems and concepts in your discipline and course does it engage with? 4. What kinds of material does the work present (e.g. primary documents or secondary material, personal observations, literary analysis, quantitative data, biographical or historical accounts)? 5. How is this material used to demonstrate and argue the thesis? (As well as indicating the overall argumentative structure of the work, your review could quote or summarize specific passages to describe the author's presentation, including writing style and tone.) 6. Are there alternative ways of arguing from the same material? Does the author show awareness of them? In what respects does the author agree or disagree with them? 7. What theoretical issues and topics for further discussion does the work raise? 8. What are your own reactions and considered opinions regarding the work? • Browse in published scholarly book reviews to get a sense of the ways reviews function in intellectual discourse. Look at journals in your discipline or general publications such as University of Toronto Quarterly , London Review of Books , or New York Review of Books (online at www.nybooks.com/archives/ ). • Some book reviews summarize the book's content briefly and then evaluate it; others integrate these functions, commenting on the book and using summary only to give examples. Choose the method that seems most suitable according to your professor's directions. • To keep your focus, remind yourself that your assignment is primarily to discuss the book's treatment of its topic, not the topic itself. Your key sentences should therefore say "This book shows...the author argues" rather than "This happened...this is the case." Prepared by Dr. Margaret Procter, Uni versity of Toronto Coordinator, Writing Support Over 50 other files giving advice on university writing are available at www.writing.utoronto.ca PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET AN AMAZING DISCOUNT :)