Physicians' Use of Key Functions in Electronic Health Records from 2005 to 2007: A Statewide Survey
- Steven R Simon, MD, MPHa,
- Christine S Soranb,
- Rainu Kaushal, MD, MPHc,
- Chelsea A Jenter, MPHd,
- Lynn A Volk, MHSb,
- Elisabeth Burdick, MSd,
- Paul D Cleary, PhDf,
- EJohn Orav, PhDd,e,
- Eric G Poon, MD, MPHd,
- David W Bates, MD, MScb,d
- aDepartment of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA
- bClinical and Quality Analysis, Partners Healthcare, Wellesley, MA
- cDepartments of Pediatrics, Public Health and Medicine, Weill Cornell Medical College, New York, NY
- dDivision of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
- eHarvard Medical School, Boston, MA
- fSchool of Public Health, Yale University, New Haven, CT
- Correspondence: Steven R. Simon, MD, MPH Department of Ambulatory Care and Prevention; 133 Brookline Avenue, Sixth Floor; Boston, MA 02215; e-mail: < >
- Received 25 November 2008
- Accepted 25 March 2009
Objective Electronic health records (EHRs) have potential to improve quality and safety, but many physicians do not use these systems to full capacity. The objective of this study was to determine whether this usage gap is narrowing over time.
Design Follow-up mail survey of 1,144 physicians in Massachusetts who completed a 2005 survey.
Measurements Adoption of EHRs and availability and use of 10 EHR functions.
Results The response rate was 79.4%. In 2007, 35% of practices had EHRs, up from 23% in 2005. Among practices with EHRs, there was little change between 2005 and 2007 in the availability of nine of ten EHR features; the notable exception was electronic prescribing, reported as available in 44.7% of practices with EHRs in 2005 and 70.8% in 2007. Use of EHR functions changed inconsequentially, with more than one out of five physicians not using each available function regularly in both 2005 and 2007. Only electronic prescribing increased substantially: in 2005, 19.9% of physicians with this function available used it most or all the time, compared with 42.6% in 2007 (p < 0.001).
Conclusions By 2007, more than one third of practices in Massachusetts reported having EHRs; the availability and use of electronic prescribing within these systems has increased. In contrast, physicians reported little change in the availability and use of other EHR functions. System refinements, certification efforts, and health policies, including standards development, should address the gaps in both EHR adoption and the use of key functions.
The Institute of Medicine has recommended the wide-scale adoption of electronic health records (EHRs) as an essential component of a National Health Information infrastructure.1 2 With nearly US$20 billion allocated in the American Recovery and Reinvestment Act of 2009 toward health information technology (HIT) adoption,3 there is palpable excitement about the broad expansion of EHRs among practicing physicians.4 Despite this enthusiasm, several studies have failed to provide convincing evidence that the adoption of EHRs as they are routinely used is associated with improved quality of care.5 6 One explanation for this finding is that many EHRs lack key features, such as built-in decision support, that have been associated with improved quality and safety.7 8
Alternatively, while key features may be present, physicians may not be using them to their full potential. Most physicians whose EHRs have such features fail to use them regularly.9 10 Fewer than 5% of physicians nationwide have a fully functional EHR, and most physicians do not use their systems to full capacity.9 As the adoption of EHRs slowly begins to increase,9 11 12 greater attention will be directed to the features available within those EHRs and whether physicians are using them maximally to improve quality of care. It is, therefore, important to determine whether physicians are increasing their use of these key features.
To address these issues, we undertook statewide surveys of physicians in Massachusetts in 2005 and in 2007 to assess the changes in EHR adoption and whether, among physicians with EHRs, the availability and use of key functions had increased by 2007. The 2007 survey included a panel of respondents who participated in 2005 as well as a sample of physicians new to Massachusetts since that time.
The sampling methods of the 2005 survey, as well as the methods of survey development and administration, have been reported previously10 11 and are described briefly below in the context of the 2007 survey.
We identified the population of all physicians practicing in Massachusetts in spring 2005. After excluding physicians who were residents in training, retired, or without direct patient-care responsibilities, the total population of physicians was 20,227. These physicians practiced in 6,174 unique practice sites. We drew a stratified random sample of 1,921 practices and randomly selected one physician per practice. After excluding practices that had closed, the final sample size was 1,884 physicians. A total of 1,345 physicians responded to the 2005 survey, but we determined that one of those physicians had responded with two separate surveys; thus, the sample size for the 2007 survey was 1,344 physicians. We excluded 198 physicians (15%) who had moved (n = 169), retired (n = 25), or died (n = 4), leaving 1,146 eligible physicians who practiced in 2005 and were still practicing in Massachusetts in 2007.
To estimate the overall EHR adoption rate among all physicians practicing in Massachusetts in 2007, we drew an additional random sample of 628 physicians among the 1,769 physicians who had become newly licensed to practice in Massachusetts in 2006. We excluded physicians with in-training licenses (n = 91; 15%), had moved (n = 89; 14%), or retired (n = 2; < 1%), resulting in 537 newly practicing eligible physicians in the sample.
The 2007 survey was designed as a follow-up to a 2005 survey consisting of an 8-page questionnaire; the original questionnaire was based on a review of the literature and pilot tested for relevance and clarity. The survey measured practice characteristics, including number of physicians, primary care versus specialty, and the presence of financial incentives for quality and specifically for the use of health information technology. We asked, “Does your main practice have components of any EHR, that is, an integrated clinical information system that tracks patient health data, and may include such functions as visit notes, prescriptions, lab orders, etc.?” We asked those responding affirmatively to indicate the presence or absence of 10 specified functions in their EHR and to indicate the degree to which they used each function (most or all the time, some of the time, or none of the time).
The University of Chicago Survey Lab administered the survey between March and July 2007. The initial survey was sent via express mail with a US$20 cash honorarium. Second and third mailings were sent to nonrespondents, without remuneration, via first class and express mail, respectively. Between these mailings, multiple telephone reminder contacts were attempted. The study protocol was approved by the Human Research Committee of Partners Healthcare.
Our 2005 study design employed a stratified random sample, oversampling hospital-based practices, large practices, and rural practices to ensure their adequate representation among our survey respondents. Therefore, our data analyses used sampling weights so the study results were representative of all Massachusetts practices. The sampling weights were used to adjust for stratification by specialty, category of practice size, hospital affiliation, and urban/nonurban location. The sampling weights also incorporated strata-specific rates of nonresponse to the survey. We calculated the proportion of practices with EHRs in 2007 (i.e., the EHR adoption rate), accounting for the different sampling weights among the panel participants from 2005 and the physicians newly licensed since 2005.
Analyses comparing the availability and usage of key EHR features in 2005 and 2007 were restricted to the panel of physicians who completed both the 2005 and 2007 surveys. Physicians newly sampled for the 2007 survey were not included in these analyses, because we were unable to determine their EHR characteristics and use in 2005.
We compared the functions available among physicians with EHRs in 2005 with physicians who had EHRs in 2007 using McNemar's test. We classified EHR users as “early adopters”—those who reported in 2005 that their practice had EHR—and “recent adopters”—those who indicated that their practice had adopted EHR since 2005. In a longitudinal analysis limited to the early adopters, we compared the availability and usage of EHR features in 2005 and in 2007, also with McNemar's test. With respect to usage, we compared the proportion of physicians in each year who used each available function most or all of the time.
We stratified respondents into categories as “high” EHR users and “low” EHR users based on their level of use of all available key EHR functions, as done previously.10 Among physicians who had EHRs in 2007, we used logistic regression, accounting for all available covariates, to identify the factors correlated with being a “high user.”
Among the panel of eligible 2005 survey participants (n = 1,146), 910 completed surveys were returned in 2007, resulting in a response rate of 79.4%. Respondents and nonrespondents were similar with respect to specialty, practice size, hospital-based practice, and location (urban vs. nonurban). Among the eligible sample of 537 physicians licensed in the state since 2005, 386 responded (71.9%); these respondents were similar to nonrespondents with respect to specialty, but nonrespondents were more likely to be urban-based (90.6 versus 75.0%, p < 0.001) and more likely to be hospital-based (40.9 versus 23.7%, p < 0.001).
In 2007, in Massachusetts, 35% of practices had EHRs. Among practices with 7 or more physicians, 71.4% had EHRs, compared with 54.6% among practices with 4–6 physicians, 45.7% among practices with 2–3 physicians, and 22.5% among solo practitioners. Among the cohort who responded both in 2005 and 2007, the proportion of practices with EHR increased from 23 to 36%. Among physicians newly licensed since 2005, 46% reported having EHRs in their practice.
Table 1, which is limited to respondents to both the 2005 and 2007 surveys, shows the characteristics of the 373 respondents who indicated that their practice had an EHR in 2007, stratified by whether EHR was present in 2005 (“early adopters”, n = 234) or adopted since then (“recent adopters”, n = 139). Early adopters and recent adopters differed on several key characteristics. Early adopters had graduated from medical school more recently (mean years since medical school 21.3 vs. 24.3, p = 0.007) and were less likely to have an ownership stake in their practice (40.2 vs. 51.8%, p = 0.03). Early adopters were also more likely to be at larger practices (mean number of physicians 6.0 vs. 4.0, p < 0.001). Early adopters had fewer outpatient visits per week (median 60 vs. 80, p < 0.001) and were more likely to teach students or residents in their practice (70.5 vs. 48.9%, p < 0.001). In addition, early adopters were less likely to indicate that their practice was subject to financial incentives for using HIT (27.8 vs. 41.0%, p = 0.008).
Availability of Key EHR Features
Table 2 shows the availability of ten key EHR functions in 2005 and in 2007 among all physicians whose practices had EHRs in each time period. There was little change in the availability of nine of the ten features considered. In 2007, as in 2005, approximately half of physicians with EHRs reported that their systems enabled laboratory order entry (50% in 2007) or radiology order entry (54% in 2007). There was no increase in the proportion of physicians who indicated that their EHR systems provided clinical decision support. In contrast, availability of electronic prescribing, defined as “can transmit prescriptions to pharmacy electronically or via electronic faxing,” increased from 45% in 2005, to 71% in 2007 (p < 0.001).
With the notable exception of electronic prescribing, early adopters had greater functionality in 2007 when compared with recent adopters, indicating that any apparent increases in functionality between 2005 and 2007 were attributable to increased availability of functions among the early adopters.
Use of Key EHR Functions
In both 2005 and 2007, more than one out of five physicians reported not using each available function most or all of the time (See online appendix Fig 1). Although there were no declines in the proportion of physicians using any of the functions most or all of the time when comparing physicians who had EHRs in 2005 with those who had them in 2007, for nine of ten functions assessed, there was less than a 10% increase in the absolute percentage of physicians using the function most or all of the time.
The greatest increase in usage between 2005 and 2007 for physicians with EHRs was seen for electronic prescribing, with the percentage of using electronic prescribing most or all of the time increasing from 20% in 2005 to 43% in 2007 (p < 0.001). Similarly, among early adopters who had EHRs in 2005 and continued their use in 2007, the greatest absolute increase in the usage of EHR functions was observed for electronic prescribing (Table 3). In 2005, 25% of physicians with electronic prescribing available used this function most or all the time compared to 39% in 2007 (p = 0.001). Similar increases in usage were seen for radiology order entry (29 vs. 41%, p = 0.008), electronic medication lists (55 vs. 66%, p = 0.02), and electronic problem list (47 vs. 57%, p = 0.04).
Predictors of Usage
In 2005, 78% of EHR users were classified as high users and 22% as low users, while in 2007, 77% were high users and 23% were low users. Table 4 shows the bivariate and multivariate relationships between physician and practice variables and EHR usage (dichotomized as high users vs. low users). None of the physician or practice variables measured in this study was associated with higher EHR usage.
Although much attention has been focused on the adoption of electronic health records,9 12 simply having an EHR may not lead to improved quality and safety of health care. In this statewide survey of a cohort of physicians in Massachusetts in 2005 and 2007, we found that many physicians have EHRs but their systems do not have key functions, such as order entry and decision support, that many argue are necessary for improved safety and quality of ambulatory care. Furthermore, even when these functions are available, more than 1 in 5 physicians report that they do not use each of them regularly. With the notable exception of electronic prescribing, which has been embraced with increased intensity among physicians in ambulatory care, and some subtle usage increases among early EHR adopters who had EHRs in 2005, there was little change in the availability and use of key EHR functions from 2005 to 2007. These findings underscore the fact that simply assessing EHR adoption is not sufficient for understanding the potential impact of EHRs on medical practice.
The relative stagnancy in the availability and use of key EHR functions from 2005 to 2007 is surprising, given the increasing competition in the marketplace among EHR vendors,13 the publication of the Certification Commission for Healthcare Information Technology (CCHIT) standards for EHR functionality,14 and the previously reported increase in the proportion of practices that have EHRs.12 While some may argue that little progress can be detected in the time span of two years, others will point out that both EHR adoption and usage will need to advance rapidly if the nation is to achieve the goal of universal EHR implementation by 2014.15 Given that the rate of EHR adoption in Massachusetts already exceeds the average rate of adoption across the United States,9 it is notable that there was little change in how physicians used these systems in the few years before this study. This may indicate that even if substantial increases in adoption are achieved, the desired quality gains may not be realized in the near term.
While fewer than half (45%) of physicians with EHRs in 2005 had electronic prescribing, 7 in 10 physicians with EHRs (71%) had this function available in 2007, with similar increases in the use of this feature. A variety of factors may have contributed to these increases, including the fact that this functionality is now relatively well developed in many EHRs; in addition, there is improved availability of electronic prescribing hubs in Massachusetts that can route electronic prescriptions to pharmacies after checking for insurance coverage and compliance with formularies.16 Much of the increased usage of electronic prescribing in Massachusetts may be attributable to pilot initiatives sponsored by health plans.17 In addition, large commercial pharmacies in Massachusetts, as in the rest of the nation, are now increasingly accustomed to accepting electronic prescriptions. Despite the increased availability and use of electronic prescribing, it is important to note that more than one half of physicians who have this function available in their EHR do not use it regularly. Attention needs to be directed to identifying the barriers to and facilitators of using electronic prescribing and other key functions, and interventions should attempt to assist physicians in using this technology effectively.
Strengths of this study include its high response rate and its ability to report longitudinally on a cohort of physicians randomly sampled from across Massachusetts. While prior studies have examined trends and correlates of EHR adoption,11 12 and some have begun to examine the availability and use of key functions,9 10 previous reports have not been able to examine how these measures change over time within a cohort of physicians.
One limitation of this study is that it was restricted to Massachusetts. The rate of EHR adoption in Massachusetts—35% of practices in this study—is higher than adoption rates nationally.9 Furthermore, Massachusetts has been on the leading edge of HIT adoption, including the ongoing efforts of the Massachusetts e-Health Collaborative to spearhead EHR adoption and healthcare information exchange across the Commonwealth.18 These observations suggest that the gaps in EHR usage observed in this study are likely to be at least as wide as in many other states, a hypothesis that should be tested.
Another limitation is that our estimates of the availability and use of EHR functions were based on the self-report of responding physicians. This statewide survey was not designed to verify the reported availability and usage of EHR functions. It is possible that physicians did not report the availability of functions that they do not routinely use; if this underreporting of availability occurred, then our findings would tend to overestimate actual usage of available functions further highlighting the observed gaps. Similarly, if social desirability bias led physicians to overestimate their actual usage of key EHR functions, then the true usage gaps would be even greater than observed.
The findings of this study have important implications for physicians, practices, and health policy makers. This study suggests that physicians need support, training, or other interventions to increase their use of key EHR functions that are likely to improve quality and safety of health care. Practices undertaking the purchase of a new EHR or upgrading an existing system should examine carefully the functions available in the EHRs they are considering. At a minimum, systems should be certified by CCHIT as having minimum functionality for ambulatory EHRs.14 In addition, we hypothesize that physicians would benefit from training to optimize their use of functions offered in their EHRs. Moreover, adopting an EHR may be a necessary foundation for quality improvement, but physicians and staff likely need considerable additional support in workflow redesign and change management to harness the benefits of these systems.
For policy makers, this study raises important questions for the expansion of HIT to improve quality and safety. Given the wide gaps in the availability and use of key functions that are essential to clinical quality, such as alerts, reminders and order entry, incentives could target adoption initially, but should quickly move to targeting quality performance, as has been done in the United Kingdom.19 Incentives for using EHRs and, in particular, electronic prescribing, are becoming more prevalent in the United States, as well.20 21
In summary, physicians' reported adoption rates of EHRs increased over the period of study, as did use of e-prescribing, but the use of other functions generally did not. Moreover, there was essentially no change reported by providers in the availability of functions. These findings suggest that while EHRs may be necessary for broad quality improvement in the outpatient setting, they are unlikely to be sufficient. Policymakers should consider financial incentives not only for EHR adoption but also for use of key EHR functions likely to improve quality and safety. Ultimately, physicians and practices may need support and guidance to transform the way they are delivering care.
The authors thank Christina Kara for administrative support and assistance with manuscript preparation and Elizabeth McGlinchey for data collection and data management. The authors also thank the physicians who participated in the survey.
This study was funded in part by Agency for Healthcare Research and Quality cooperative agreement #1UC1HS015397 and the Massachusetts e-Health Collaborative.
The Agency for Healthcare Research and Quality and the Massachusetts eHealth Collaborative had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Massachusetts e-Health Collaborative.