Contributing Factors to Adoption of Electronic Medical Records in Otolaryngology Offices

Transcription

1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. Contributing Factors to Adoption of Electronic Medical Records in Otolaryngology Offices Hossein Mahboubi, MD, MPH; Ara A. Salibian, BS; Edward C. Wu, MD, MBA; Madhukar S. Patel, MD, MBA, ScM; William B. Armstrong, MD Objectives/Hypothesis: (1) To determine the characteristics of outpatient otolaryngology offices with an electronic medical record (EMR) system, and (2) to compare those characteristics with the trends in surgical and medical specialties. Study Design: Cross-sectional analysis of U.S. representative data from the National Ambulatory Medical Care Survey (NAMCS). Methods: The 2005 to 2010 NAMCS datasets were analyzed. Physicians specialty was recoded as otolaryngology, all surgical specialties, and all specialties combined. Physician offices with all- or partial-emr system adoption were then compared to offices without EMR systems with respect to year; geographic region; urban setting; office setting; practice type; practice ownership; employment status; and revenues from Medicare, Medicaid, private insurance, and patient payment. Results: Upon univariate analysis, EMR use was significantly higher among otolaryngology practices located in metropolitan areas and practices run or owned by larger groups of practitioners. Sources of patient revenue did not correlate with the likelihood of EMR use. Multivariate analysis revealed that EMR use by otolaryngologists was significantly associated with group practices and offices owned by institutions. Similar associations were observed with surgical specialties combined in addition to a higher EMR usage in practices with more than 25% of total revenue from private insurance. Conclusions: EMR utilization by otolaryngology practices appears similar to that of other specialties, and is more likely in metropolitan areas and larger practice settings. Despite the announcement of incentive programs under Medicare and Medicaid in 2009, EMR usage was not dependent on the percentage of physicians total revenue from these sources. Key Words: Electronic medical record (EMR), electronic health record, otolaryngology, outpatients, National Ambulatory Medical Care Survey (NAMCS), physician office, meaningful use. Level of Evidence: N/A. Laryngoscope, 123: , 2013 INTRODUCTION Electronic Medical (Health) Records (EMRs) have become the center of attention in recent years as part of health-care reform. The promising advantages of EMRs in optimizing physicians and hospitals workflow have spurred federal funding of approximately $27 billion in efforts to transition to computerized systems through incentive programs. 1 With the passing of the Health Information and Technology for Economic and Clinical Health (HITECH) Act of 2009, physicians (including otolaryngologists) enrolled in the program will not only be From the Department of Otolaryngology Head and Neck Surgery (H.M.,A.A.S., W.B.A.), University of California, Irvine, Department of Head and Neck Surgery (E.C.W.), University of California, Los Angeles Medical Center, Los Angeles, California; and the Department of Surgery (M.S.P.), Massachusetts General Hospital, Boston, Massachusetts. Editor s Note: This Manuscript was accepted for publication April 24, Presented at the 116th Triological Society Annual Meeting at COSM, Orlando, Florida, U.S.A, April 10 14, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to William B Armstrong, MD, Professor of Clinical Otolaryngology Head and Neck Surgery, Chair, Department of Otolaryngology Head and Neck Surgery, University of California, Irvine, 101 The City Dr. S., Bldg. 56, Ste. 500, Orange, CA wbarmstr@uci.edu DOI: /lary expected to adopt electronic systems, but also be expected to demonstrate meaningful use of EMR through several core objectives and clinical quality measures. 2 With the incentive payments recently started in 2011, 3 it is crucial to investigate the progress of the field of otolaryngology in the adoption of EMRs and the factors that have contributed to these trends. Office-based physicians use of EMRs has been increasing in recent years, from about 29.6% during 2005 to to 48% in 2009 and 72% in Despite this rapid growth enhanced by the start of meaningful use payments, a number of gaps remain to be filled before achievement of complete adoption and meaningful use of EMRs. One concern is that using EMRs does not guarantee meaningful use. In 2012, fewer than one-third of office-based physicians who planned to apply or already had applied for meaningful use incentives had computerized systems capable of meeting the core set objectives of stage 1 of meaningful use. 5 Another concern is that the observed increase in EMR usage may be caused by practices that are better adapted to accommodate the transition. Previous studies have demonstrated higher EMR usage in the case of practices with 11 or more physicians 6 and offices owned by health maintenance organizations (HMOs). 7,8 Obstacles such as high costs and lack of standardization across platforms 9,10 may contribute to this observed difference. 2658

2 In a previous study by the authors, the National Ambulatory Medical Care Survey (NAMCS) was utilized to examine the trends of EMR use in otolaryngology. 11 Our analysis revealed that EMR usage by office-based otolaryngologists increased from 27% to 48.5% during 2005 to 2010, consistent with trends in other specialties. However, less than one-half of otolaryngology practices were using EMRs up to 2009 to There is little information on the characteristics of otolaryngology practices that have implemented EMRs and why others continue to use paper records. In the current study, we sought to utilize the NAMCS data sets to (1) determine the characteristics of otolaryngology offices that use EMR systems, (2) compare the observed differences in office characteristics with the trends in other specialties, and (3) investigate any association between EMR adoption and office characteristics. Determining a correlation between attributes of otolaryngology practices and EMR usage may elucidate certain factors that influence EMR usage and explain recent trends. Furthermore, achieving a better understanding of paper-based practices may provide valuable clues to the future challenges and remaining progress of EMR adoption in otolaryngology as well as other specialties. MATERIALS AND METHODS Data Source The National Center for Health Statistics (NCHS) annually surveys the use of ambulatory resources and health-care patterns in the outpatient setting. Data is collected from randomly selected, nonfederally employed physicians from a variety of specialties (excluding anesthesiology, pathology, and radiology) who are primarily engaged in direct patient care. The data is then publicly released in the form of the NAMCS, which includes patient- and physician-level deidentified data. The surveys have collected data on EMR usage in physician offices since 2001, which served as the basis for this study. Information on data collection instruments and methodology is available on the website of the Centers for Disease Control and Prevention ( 12 The most recent NAMCS data sets from 2005 to 2010 were merged, and data on EMR usage; physician specialty; geographic location; urban setting; office setting; practice type and ownership; employment status; and percentages of revenue from Medicare, Medicaid, private insurance, and patient payment were extracted. Variables and Definitions The usage of EMRs was defined by using the physicians responses to the question, Does your practice use electronic medical records or health records [EMR/EHR] (not including billing records)? Those offices with completely or partly electronic workflow were recoded as EMR users. The specialty of the physicians was divided into three groups: otolaryngology, surgical specialties (otolaryngology, general surgery, obstetrics and gynecology, orthopedic surgery, urology, ophthalmology), and all medical and surgical specialties combined. The geographic location of the practices was classified into Northeast, Midwest, South, and West, corresponding to those used by the U.S. Bureau of the Census. The urban setting was divided into Metropolitan Statistical Areas (MSA) and non- MSA, as defined by the U.S. Office of Management and Budget. An individual MSA involved (1) a city or cities of a specified population that constituted the central city and identified the county in which it was located as the central county, and (2) adjacent counties with established economic and social relationships that were metropolitan in character. The office setting was recoded into private solo or group practice and other. The latter included freestanding clinic/surgicenters, community health centers, mental health centers, nonfederal government clinics, family planning clinics, HMO or other prepaid practices, and faculty practice plans. The practice type was divided into solo and group practices. The practice ownership was recoded as physicians versus institutions, which included HMOs, community health centers, academic health centers, other hospitals, and other health-care corporations. The employment status of physicians was recoded as owner versus employee/contractor. The physicians revenue from different sources (Medicare, Medicaid, private insurance, patient payment) was recorded as rough estimates provided by the physicians. These estimates were recoded into 25% or less, versus more than 25% of total revenue for each source. Statistical Analysis Each physician office had an assigned sample weight that was calculated based on the complex probabilities of a physician s office being selected. This physician-level weight was used to produce nationwide estimates for office-based practices; therefore, all reported percentages here represent national estimates. The study years were grouped into 2-year periods ( , , ) in order to increase the reliability of the estimates. Standard errors (SE) were calculated for each estimate using the Taylor series approximation method, and they were reported when the number of cases was 30 or greater or when the relative SE (SE divided by the estimate) was less than 0.3 (as recommended by the NCHS). All statistical analyses were performed using SAS 9.3 for Windows (SAS Institute Inc., Cary, NC). A P value of less than 0.05 was considered statistically significant. The surveyfreq procedure was used to evaluate the differences in EMR usage within each specialty group. A multivariate logistic regression model was fit using the surveylogistic procedure to calculate adjusted odds ratio (OR) for each office characteristic while controlling for all other characteristics. RESULTS A total of 7,449 practices were surveyed from 2005 to This extrapolated to an annual average of 321, ,418 offices in practice in the United States. Otolaryngology and all surgical specialty groups comprised 1.9% 6 0.1% and 24.5% 6 0.5% of these practices, respectively. The univariate analysis revealed that EMR usage in otolaryngology has increased nearly parallel to the trends observed across other designated specialty groups over the studied period (Table I). EMR usage in otolaryngology offices was not statistically different between geographic regions, while the West had higher usage in both surgical (46.2% 6 4.2%) and all (48.6% 6 2.9%) specialties groups. Otolaryngology and surgical specialty offices located in MSAs had a higher EMR usage (42.2% 6 3.4% and 40.5% 6 1.6%, respectively) in comparison to non-msas, although this difference was not observed when all specialties were combined. Larger practices including group and institution-owned 2659

3 TABLE I. Comparison of Electronic Medical Record Usage and Office Characteristics Between Otolaryngology and Other Specialties. %of Otolaryngology Offices % of EMR Usage in Otolaryngology Offices (SE) P Value, Within Otolaryngology % of EMR Usage in Surgical Specialty Offices (SE) P Value, Within Surgical Specialties % of EMR Usage in All Specialty Offices (SE) P Value, Within All Specialties Year <0.001 < % 27.0% (64.8%) 27.1% (62.1%) 27.7% (61.4%) % 45.1% (65.3%) 39.5% (62.4%) 40.4% (61.7%) % 48.5% (65.3%) 50.4% (62.5%) 51.8% (61.7%) Geographic Region <0.001 Northeast 19.8% 40.6% * 35.8% (62.6%) 35.7% (61.5%) Midwest 19.5% 38.3% * 36.5% (63.7%) 39.7% (62.8%) South 37.0% 33.2% (65.2%) 38.6% (62.4%) 37.8% (61.8%) West 23.7% 52.4% (66.4%) 46.2% (64.2%) 48.6% (62.9%) Urban Setting Non-MSA 10.0% 22.6% * 30.6% (64.2%) 37.2% (63.2%) MSA 90.0% 42.2% (63.4%) 40.5% (61.6%) 40.7% (61.2%) Office Setting <0.001 <0.001 <0.001 Private solo or 92.7% 36.9% (63.2%) 36.8% (61.7%) 37.6% (61.2%) group practices Other 7.3% 82.2% * 66.0% (64.1%) 59.7% (62.3%) Practice Type <0.001 <0.001 <0.001 Solo 31.4% 21.1% * 25.4% (62.0%) 27.6% (62.3%) Group 68.6% 49.0% (63.8%) 45.2% (62.0%) 46.7% (61.4%) Practice Ownership <0.001 <0.001 <0.001 Physicians 89.5% 36.7% (63.3%) 35.7% (61.2%) 36.2% (61.1%) Institutions 10.5% 70.5% * 63.8% (62.2%) 57.7% (62.2%) Employment Status <0.001 <0.001 of Physician Owner 78.9% 35.0% (63.6%) 34.8% (61.6%) 34.4% (61.1%) Employee/Contractor 21.1% 59.1% (66.3%) 53.8% (63.0%) 52.6% (61.8%) Revenue from Medicare % of total revenue 64.2% 36.0% (64.3%) 41.1% (62.2%) 40.1% (61.2%) >25% of total revenue 35.8% 39.4% (65.0%) 35.1% (62.2%) 38.7% (61.7%) Revenue from Medicaid % of revenue 88.3% 38.0% (63.6%) 38.3% (61.7%) 39.9% (61.3%) >25% of revenue 11.7% 30.1% * 38.9% (63.4%) 37.3% (62.0%) Revenue from <0.001 private insurance 25% of total revenue 10.8% 33.8% * 32.8% (62.8%) 34.9% (61.8%) >25% of total revenue 89.2% 37.7% (63.4%) 39.8% (61.8%) 41.2% (61.3%) Revenue from <0.001 patient payment 25% of total revenue 86.5% 40.7% (63.7%) 41.9% (61.8%) 43.8% (61.4%) >25% of total revenue 13.5% 38.5% * 31.7% (66.4%) 26.8% (62.9%) *Unreliable estimates due to sample size < 30. Includes: health maintenance organization (HMO), academic, other; SE 5 standard error. Includes: freestanding clinic/surgicenter, HMO, faculty practice plan, nonfederal government. EMR 5 electronic medical record; MSA 5metropolitan statistical area. practices, offices where physicians were employees/contractors, and other office settings had a significantly higher EMR usage in otolaryngology as well as surgical and all specialties groups. EMR usage was not statistically different in otolaryngology offices with respect to different sources of revenue. However, it was significantly higher in surgical specialty practices with > 25% of total revenue from private insurance (39.8% 6 1.8%) and 25% of total revenue from Medicare (41.1% 6 2.2%). With all specialties combined, physician practices with > 25% of total revenue from private insurance and 25% of total revenue from patient payment had a higher EMR usage. Table I presents the detailed findings of the univariate analysis. After adjusting for the effects of different otolaryngology office characteristics (Table II), the adjusted odds 2660

4 (95% confidence interval) of using EMR were 3.91 ( ) in 2009 to 2010, 4.95 ( ) in other office settings, and 4.41 ( ) in group practices compared to their counterparts. EMR usage in surgical specialty practices was associated with similar office characteristics in addition to practices owned by institutions (adjusted OR: 1.86 [ ]) and practices with- > 25% of total revenue from private insurance (adjusted OR: 1.57 [ ]). Similar trends were observed with all specialties combined. DISCUSSION Electronic medical records have been found to enhance the quality of health care and performance of providers, 13 yielding improved quality, cost savings, and greater data availability to both patients and physicians. The benefits of EMRs have been mostly documented by large organizations that were early adopters. 14 However, these benefits are pertinent to all types of practices, and have the potential to also influence smaller practices. 15 The pace of EMR adoption has remained relatively slow, as noted by different studies, 8,11,15 conceivably due to obstacles such as high cost, complexity, inconsistent platforms, and lack of skilled staff. 10,16,17 These obstacles may afflict certain practices more and hinder adoption rates. Inherently, practices with strong infrastructure, strong capital position, and ability to leverage the investment in an EMR are more likely to adopt computerized systems. Previous studies on office-based practices showed larger clinics, with 11 or more physicians were most likely to use an EMR system compared with smaller ones, 4,7,18,19 and physicians in solo practice were least likely to use EMRs. 6 Univariate analysis in our study similarly showed that EMR use was significantly higher in group practices compared to solo practices for otolaryngology offices, as well as surgical specialty and all specialty ambulatory offices (Table I). These patterns may be due to the ability of larger groups to spread associated costs of EMR over more physicians. High costs of EMR implementation have been cited as a major barrier to EMR adoption, especially for smaller practices that do not have the budgets to support the startup and maintenance of these systems. 21,24 Multivariate analysis also showed that EMR adoption was associated with group practices in all three specialty categories (Table II). Greater adoption of EMR by larger practices suggests that smaller practices less fit to switch to electronic systems may comprise a majority of the remaining offices using paper records. This in turn could slow down the progress of EMR adoption in upcoming years. Studies have also shown that EMR use is higher among physicians in multispecialty practices than in solo or single-specialty practices. 6 As multispecialty practices could be inherently larger than single-specialty practices, this may again reflect the barriers associated with smaller practice size. Physician employment status was also an important factor with respect to EMR use. Univariate analysis revealed that otolaryngologists who were employees or contractors were significantly more likely to use EMRs compared to those who owned their practices (Table I), supporting the importance of organizational factors in EMR adoption. 7 However, employment status was not an independent factor to influence EMR usage in the multivariate analysis. Practice ownership has also been linked to EMR use, with EMRs more prevalent in offices owned by HMOs 7,8 and in practices associated with hospitals. 22 In an analysis of the NAMCS data from 2001 to 2003, Burt et al. reported that practices owned by HMOs had more than four times greater odds of using EMR compared to physician-owned practices. 7 Univariate analysis in our study similarly showed that otolaryngologists, as well as surgical specialty and all specialty offices, which were a part of institutions such as HMOs or academic centers, were more likely to use EMR (Table I). In the multivariate analysis, however, the institution-owned practices only emerged as an independent factor for surgical and all specialty groups. EMR cost may once again be an underlying factor, as third parties would handle expenses of EMR systems in institution-owned practices, whereas individual physicians would bear this burden with private ownership. In addition, implementation of EMR by institutions instead of physicians themselves may save the time required to select, purchase, and install these systems, 22,25 27 as well as provide the necessary hardware and technical training that is currently lacking. 21,26,28,29 Practice organization may especially be relevant for receiving incentive payments as HMO-owned practices have recently been shown to be highly associated with the adoption of EMRs with the 15 required core functionalities for the first stage of meaningful use. 15 Interestingly, surgical specialty practices with > 25% of total revenue from private insurance were associated with greater EMR use by multivariate analysis. EMR use was also associated with all specialty practices that derived >25% of their total revenue from private insurance. The lack of association with particular payers that offer incentives for EMR use, such as Medicare and Medicaid, may be because these payments are still fairly recent, 1 year after the latest data set in this survey in This observation may change in the upcoming years as our previous analysis of 2010 NAMCS data showed that 39.9% of otolaryngologists had plans to apply for incentive payments. 11 In addition, a NAMCS mail survey of office-based physicians in 2012 reported that 66% of physicians intended to participate (already applied or intending to apply) in the Medicare or Medicaid Incentive Programs. 5 It should be noted that of these physicians, only 27% had an EMR system capable of supporting 13 of the stage 1 core objectives for meaningful use. 5 In a 2005 report, Burt et al. attributed the absence of association between EMR use and revenue source to the recent start of EMR promotion by payers. 7 However, the authors also showed no increase in EMR use with any type of payer, whereas we found that surgical specialty offices more likely to use EMR had lower revenue from Medicare and higher revenue from private insurance, and all specialty offices with increased EMR use had higher revenue from private 2661

5 TABLE II. Multivariate Logistic Regression Analysis of the Association Between Electronic Medical Record (EMR) Adoption and Otolaryngology Office Characteristics. Otolaryngology Adjusted Odds Ratio (95% CI) Surgical Specialties Adjusted Odds Ratio (95% CI) All Specialties Adjusted Odds Ratio (95% CI) Year Geographic Region Urban Setting Office Setting Practice Type Practice Ownership Employment Status of Physician Revenue from Medicare Revenue from Medicaid Revenue from Private Insurance Revenue from Patient Payment ( ) 1.45 ( ) 1.54 ( ) ( ) 2.39 ( ) 2.50 ( ) Northeast Midwest 0.88 ( ) 0.86 ( ) 0.99 ( ) South 0.57 ( ) 1.16 ( ) 1.04 ( ) West 0.98 ( ) 1.15 ( ) 1.38 ( ) Nonmetropolitan statistical area Metropolitan statistical area 2.70 ( ) 1.29 ( ) 0.97 ( ) Private solo or group practices Other 4.95 ( ) 1.97 ( ) 1.49 ( ) Solo Group 4.41 ( ) 1.99 ( ) 1.79 ( ) Physicians Institutions * 3.83 ( ) 1.86 ( ) 1.44 ( ) Owner Employee/contractor 0.69 ( ) 1.09 ( ) 1.18 ( ) >25% of total revenue 1.34 ( ) 0.99 ( ) 1.07 ( ) >25% of total revenue 1.67 ( ) 1.17 ( ) 0.82 ( ) >25% of total revenue 1.42 ( ) 1.57 ( ) 1.38 ( ) >25% of total revenue 1.43 ( ) 0.63 ( ) 0.60 ( ) *Includes: health maintenance organization (HMO), academic, other. Includes: freestanding clinic/surgicenter, HMO (Health Maintenance Organization), faculty practice plan, nonfederal government. CI 5 confidence interval. insurance and lower revenue from patient payment. The reasons behind why increased revenue from private insurance is associated with EMR use are still not completely understood. Examining the total amount of revenue generated by these practices may provide further explanation as the observed discrepancies may rely on differences in profit based on varying payer compensation models, eventually making the cost of EMRs more affordable to these practices. 30 Also, it is possible that the practices with higher revenue from private insurance payers are the HMO and large 2662 private institutions that are pioneering computerized systems, potentially explaining why the source of revenue did not emerge as a key influencing factor for EMR usage. Geographic variables have also been associated with patterns of EMR use in office-based practices. Several studies have reported increased EMR use in officebased practices in the West. 4,6,20 In our study, univariate analysis showed that EMR use was more likely with all specialties in the West than in other regions of the country; however, this was not observed in otolaryngology or

6 surgical specialty offices. In addition, though univariate analysis showed increased EMR usage in otolaryngology and surgical specialty practices located in MSAs, multivariate analyses revealed that urban setting was not an independent factor for EMR use. A previous study examining 2007 NAMCS data on office-based practices similarly found no association between urban setting and EMR use, 6 though a study from the previous year reported more EMR usage with office-based practices in MSAs compared to non-msas. 8 Limitations of this study included a low sample size for a number of subgroups within otolaryngology offices, which limited the reliability of the respective estimates. Although interpretations could be made using their more reliable counterparts with greater sample sizes, the observed differences are better evaluated in the context of the trends observed in surgical specialties and all specialties combined. In addition, the definition used for EMR included practices with both a completely and a partly electronic workflow. Therefore, only a portion of offices considered as EMR users may actually own a computerized system capable of meeting the requirements for the meaningful use criteria, overestimating actual progress. Finally, the accuracy of data captured by the NAMCS is dependent on the physicians and their staff, and may be subject to data-entry level errors. Despite these limitations, however, the consistent design and collection of data on EMR through the NAMCS provided a unique opportunity to investigate the trends in EMR usage. This study builds a foundation for future studies to monitor the progress of small and large otolaryngology practices as the emphasis on the need for EMR adoption persists. CONCLUSION EMR utilization by otolaryngology practices measured by data from the NAMCS is similar to other surgical and nonsurgical specialties, and is more likely in practices owned by institutions and group of physicians. Despite the announcement of incentive programs under Medicare and Medicaid in 2009, EMR usage was not dependent on the percentage of physicians total revenue from these sources. BIBLIOGRAPHY 1. Cimino JJ. Improving the electronic health record are clinicians getting what they wished for? JAMA 2013;309: Das S, Eisenberg LD, House JW, et al. Meaningful use of electronic health records in otolaryngology: recommendations from the American Academy of Otolaryngology Head and Neck Surgery Medical Informatics Committee. Otolaryngol Head Neck Surg 2011;144: Sun GH, Eisenberg LD, Ermini EB, et al update on meaningful use of electronic health records: recommendations from the AAO-HNS Medical Informatics Committee. Otolaryngol Head Neck Surg 2012;146: Romano MJ, Stafford RS. 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