# Presentation: 532267

## 	
Environmental Scan Results

The HIT Adoption Initiative

**Environmental Scan Results**
**The HIT Adoption Initiative**

## Background

- Data on EHR adoption rate are limited and of varying quality. Problems with:
- EHR definitions including functionalities
- Sampling frames/respondents
- We identified surveys on EHR adoption and assessed their quality.

## Methods

- Searched for published and unpublished data of reports completed since 1995 using Ovid, Medline, Google, Google Scholar and other search engines, as well as expert review.
- Compiled list of surveys
- Attempted to collect the survey instruments
- successfully obtained 19 instruments.
- Abstracted key information

## Methods: Quality Ratings

- Rating scheme developed from published survey quality literature and ECP.
- Ratings included 4 reviewer assessments of methods and content

## Features Used in Grading the Quality of Surveys

| Methodological Item Disclosed | Content Rating--Survey addresses: |
| --- | --- |
| Source of Sample | Functionality |
| Sample size attempted | Barriers |
| Sample size completed | Incentives |
| Response rate, Response rate calculation | Disparities  |
| Field work dates | EHRs |
| Sponsor disclosed | Confidence that items will result in unbiased estimates |
| Prof survey or research org | Functionality |
| Representative | Barriers/Incentives |
| Response rate effort | Disparities |
| Pretested | EMR |
| Reliability/Validity |  |
| Sample Size Sufficient |  |

## Results: Summary of Quality Assessments

| Number of Surveys with complete instrument, results | 21 (of 35) |  |
| --- | --- | --- |
|  | MD’s or groups | Hospitals |
| Methodology Rating | N =16 | N=5 |
| High Quality | 7 | 2 |
| Medium Quality | 3 | 1 |
| Low Quality | 6 | 2 |
| Content Rating: Practice/Organization has EHR |  |  |
| High Quality | 6 | 2 |
| Medium Quality | 3 | 2 |
| Low Quality | 4 | 1 |
|  |  |  |
| High Rating in Methodology and EHR content | 4 | 0 |
| High Rating in EHR and Methodology content | 8 | 1 |

## Results: Quality of Content

|  | Physicians or Groups
N=16 | Hospitals
N=5 |
| --- | --- | --- |
| EHR Functionalities |  |  |
| High Quality Content Rating | 6 | 2 |
| Medium Quality Content Rating | 5 | 3 |
| Low Quality Content Rating | 1 | 0 |
| Not Reported | 4 | 0 |
| Barriers to Adoption |  |  |
| High Quality Content Rating | 4 | 1 |
| Medium Content Rating | 2 | 2 |
| Low Content Rating | 1 | 0 |
| Not Reported | 9 | 2 |

## Results: Quality of Content

|  | Physicians or Groups
N=16 | Hospitals 
N=5 |
| --- | --- | --- |
| Incentives for Adoption |  |  |
| High quality content rating | 4 | 0 |
| Medium quality content rating | 0 | 1 |
| Low quality content Rating | 0 | 1 |
| Not Reported | 12 | 3 |
| Disparities |  |  |
| High quality content rating | 0 | 1 |
| Medium quality content rating | 3 | 2 |
| Low Quality content rating | 0 | 0 |
| Not Reported | 13 | 2 |

## Highest Quality Surveys

|  | CMWF | NHMACS | NAMCS | Casalino |
| --- | --- | --- | --- | --- |
| Sufficient info to judge quality | Y | Y | Y | Y |
| Sample source | Y | Y | Y | Y |
| Sample | Physicians | Hospitals | Physicians | CEO, CFO or medical director |
| Representative | Y | N | Y | Y |
| Methodology
Score | HIGH | HIGH | HIGH | HIGH |
| Overall content |  |  |  |  |
| Functionality | MED | MED | MED | HIGH |
| Barriers | HIGH | N/A | N/A | HIGH |
| Incentives | HIGH | N/A | N/A | HIGH |
| Disparities | MED | N/A | N/A | MED |
| EMR | HIGH | HIGH | HIGH | HIGH |

## Best Estimates of EHR Adoption

|  | Range from Medium or High Quality Surveys | Best Estimates Based on High Quality Surveys |
| --- | --- | --- |
| EHRs in physician offices | 17 to 25% | 17% |
| Solo practitioners | 12.9 to 13% | 13% |
| Large physicians offices* | 19 to 57% | 39% |
| EHRs in hospitals | 16+ to 59% ++ | None |
| CPOE in hospitals | 4 to 21 % | 5% |

- * Large is defined as _>_ 20 physicians by one study (with an estimate of 39%) and _>_ 50 physicians (with an estimate of 57%).
**+**Estimate from a survey rated “low” in quality of methodology
- ++Estimate from a survey quality of content suggested “low” in confidence in the estimate

## Estimates of EMR Use in 2005 NAMCS

- The following NAMCS estimates are derived from two different NAMCS questions on the 2005 survey.
- Full/partial EMR:  “Does your practices use electronic medical records (not including billing records)?”
- Yes, all electronic
- Yes, part paper and part electronic
- No
- Minimal set of functionalities:  Respondents answering that their practice uses computerized orders for prescriptions, computerized orders for tests, test results, and physician notes.

## EMR Use in 2005 NAMCS

| Physician or practice characteristic | % distribution of all physicians | % of physicians reporting full/partial use of EMRsa (standard error) | % of physicians reporting minimum set of required features for EMRb (standard error) |
| --- | --- | --- | --- |
| All physiciansc | 100 | 23.9 (1.5) | 9.3 (1.1) |
| Age of physician |  |  |  |
| Under 35 years | 3.92 | 44.0 (8.5) | 15.2 (8.1) |
| 35-44 years | 27.2 | 26.8 (3.0) | 10.4 (2.0) |
| 45-54 years | 34.5 | 25.1 (2.5) | 10.5 (1.8) |
| 55-64 years | 24.5 | 18.1 (2.4) | 7.0 (1.6) |
| 65 years and over | 9.9 | 18.4 (4.2) | 5.7 (2.0) |
| Physician specialty type |  |  |  |
| Primary Care | 50.5 | 22.4 (2.3) | 9.2 (1.6) |
| Surgical | 21.7 | 22.3 (2.6) | 8.5 (1.8) |
| Medical | 27.8 | 28.1 (2.8) | 10.3 (2.0) |
| Physician Gender |  |  |  |
| Male | 76.4 | 24.1 (1.8) | 9.4 (1.2) |
| Female | 23.6 | 23.5 (2.7) | 9.2 (2.0) |

## Use of Electronic Medical Records by office-based physicians (continued)

| Practice Characteristic | % distribution of all physicians | % of physicians reporting full/partial use of EMRsa 
(standard error) | % of physicians reporting minimum set of required features for EMRb 
(standard error) |
| --- | --- | --- | --- |
| Practice Size |  |  |  |
| Solo | 38.5 | 16.0 (2.2)  | 4.4 (1.3) |
| Partner | 11.3 | 20.2 (4.2) | 6.0 (2.6) |
| 3-5 | 25.4 | 25.3 (2.9) | 10.2 (1.8) |
| 6-10 | 12.9 | 33.8 (4.7) | 16.5 (3.2) |
| 11 or more | 9.7 | 46.1 (5.8) | 20.8 (4.9) |
| Unknown | 2.2 | 12.0 (7.9) | 11.2 (7.8) |
| Scope of services |  |  |  |
| Solo and single specialty | 78.4 | 21.8 (1.5) | 7.5 ( 1.0 )
 |
| Multi-specialty | 20.0 | 34.2 (4.1) | 17.1 |
| Unknown | 1.4 | - | - |

## Use of Electronic Medical Records by office-based physicians (continued)

| Practice Characteristic | % distribution of all physicians | % of physicians reporting full/partial use of EMRsa 
(standard error) | % of physicians reporting minimum set of required features for EMRb (standard error) |
| --- | --- | --- | --- |
| Practice ownership |  |  |  |
| Physician/physician group | 83.3 | 20.3 (1.6) | 7.3 (1.0) |
| Health Maintenance Org | 2.9 | 66.5 (10.1) | 49.6 (11.5) |
| Other | 13.9 | 37.1 (5.1) | 13.2 (3.6) |
| Number of Managed Care Contracts |  |   |   |
| None | 9.7 | 15.4 (3.5) | 6.8 (2.6) |
| 1-2 | 9.8 | 38.2 (5.4) | 22.6 (4.4) |
| 3-10 | 35.6 | 23.0 (2.2) | 5.4 (1.2) |
| More than 10 | 39.3 | 23.7 (2.4) | 9.8 (1.7) |
| Unknown | 5.5 | 22.0 (6.0) | 11.8 (4.7) |

## Projected diffusion of EHRs among office-based physicians: United States, 2001-2014

*** 2006-2014 %’s are estimated based on current rate of adoption.**

**3% annual increase**

**6% annual increase**

## Conclusions

- Understanding current levels of adoption is critical in developing policies designed to promote the spread of EHR and in estimating cost of widespread adoption efforts.
- Our ability to make reliable estimates of the rate of EHR adoption is limited by the quality of the available survey data.
- Keeping policy makers informed regarding the effectiveness of efforts to improve EHR adoption will require ongoing tracking efforts and high quality surveys.

## Dissemination Activities

- Environmental scan report was submitted to ONC and presented to the ECP.
- A manuscript based on the scan was submitted for consideration at Health Affairs in June 2006.