Clinics: Adoption and Use of EHRs and Exchange of Health Information, 2015

Transcription

1 Minnesota e-health Report Clinics: Adoption and Use of EHRs and Exchange of Health Information, 2015 August 2015 Prepared by: Minnesota Department of Health Office of Health Information Technology

2 Table of Contents page Executive Summary... 2 List of Exhibits... 4 Introduction... 5 Findings: EHR Adoption... 6 Findings: Utilization of EHR Systems... 9 Findings: Electronic Prescribing Findings: Health Information Exchange Findings: Privacy & Security Findings: Consumer Access to Health Information Findings: Telemedicine Conclusion Appendix A: Methods Appendix B: Glossary Appendix C: Resources to Promote e-health in Minnesota Minnesota HIT Clinic Survey, 2015 page 1

3 Executive Summary This report presents results from the 2015 Minnesota Health Information Technology (HIT) Ambulatory Clinics Survey, the annual survey of clinics in the state regarding implementation of e-health. E-health is adoption and effective use of electronic health record (EHR) systems and other health information technology (HIT), including health information exchange, to improve health care quality, increase patient safety, reduce health care costs, and enable individuals and communities to make the best possible health decisions. Adoption Adoption refers to the clinics that have gone live with an EHR system, meaning that the system is implemented and in use in some or most areas of the clinic. Nearly all (97%) ambulatory clinics in Minnesota have adopted EHRs, representing 1,146 clinics in Of the 35 clinics that have not adopted EHRs, 21 were currently or planning to implement in the next several years. Epic is the dominant EHR vendor system and is in use by 49% of Minnesota s clinics. Seventy-six percent of clinics with EHRs indicated they were entirely paperless and 22% maintained paper charts but relied on the EHR for the most accurate information. Ninety-nine percent of primary care clinics and 100% of rural clinics have adopted EHRs. Effective Use of EHR Systems Effective use of EHRs refers to the use of electronic clinical support tools, such as computerized provider or entry (CPOE) and clinical decision support (CDS) tools. Use of these tools indicates that clinics are optimizing the technology to enhance health care delivery. Ninety-six percent of clinics with EHRs used CPOE for some or all provider orders, and 89% of clinics complete 80% or more of orders using CPOE. Ninety-three percent of clinics with EHRs used medication guides/alerts routinely and another 3% used occasionally. Utilization of CDS tools has increased over time. Ninety-three percent of clinics with EHRs agreed that the EHRs have alerted their providers to potential medication errors, and 93% agreed that the EHR enhanced patient care in their clinic. Primary care clinics indicate higher impact of EHRs on clinical practice than specialty clinics. Clinics using CPOE for most orders Clinics routinely using medication guides/alerts Clinics e- prescribing Snapshot: Effective Use of EHRs Ninety-one percent of all Minnesota clinics electronically prescribed for most non-controlled substance prescriptions, either using their EHR or another electronic method. Clinics continue to face technical obstacles for e-prescribing controlled substances; they use the EHR to order the prescription but most clinics rely on a manual process to transfer the script to a dispenser. Most clinics with EHRs use strong privacy controls. Ninety-three percent limited the EHR user s access to information based on staff function or other criteria, and 98% conducted or reviewed security risk analysis information and updates as necessary as part the their risk management processes. 93% 91% 96% Percent of Clinics with EHRs (N=1,146) Minnesota HIT Clinic Survey, 2015 page 2

4 Eighty-eight percent of clinics with EHRs provided patients with the option to view their patient health information online; 65% offered the option to download, and 42% offered the option to electronically transmit their patient health information. Nine in ten clinics with EHRs (91%) offered an online patient portal, up from 77% in Exchange of Health Information Health information exchange is the secure electronic exchange of clinical information between organizations using nationally recognized standards. Three in four clinics with EHRs (73%) electronically exchanged health information with unaffiliated hospitals or clinics. Primary care clinics exchanged health information with unaffiliated hospitals and clinics (80%) at a higher rate than specialty care clinics (65%). Four in five clinics with EHRs (82%) are able to generate an electronic summary of care record, but just 33% of these clinics provide an electronic care records for 50% or more of patients who require transfer or referral. Snapshot: Health Information Exchange Clinics electronically exchanging with unaffiliated hospitals/clinics Clinics providing electronic care record for 50%+ patient transfers Clinics exchanging using a statecertified HIE service provider Clinics recieving automated alerts from hospitals The most common mechanism for health information exchange is through capabilities built into the EHR (61%). Forty-two percent of clinics exchange health information using a state-certified HIE service provider. Just under half of clinics with EHRs (47%) received automated alerts from hospitals when a patient is admitted, discharged, or transferred. In Summary Since Minnesota began measuring e-health implementation in 2010, the state s clinics have made great strides toward implementation and effective use of EHRs. Effective use of EHRs has improved over time and fewer indicate barriers to using decision support and patient management tools in the EHR. Electronic exchange of health information has improved dramatically for clinics that have this capability built within their EHR. However, clinics that rely on other mechanisms struggle to exchange data with unaffiliated providers. Even among clinics that exchange information, most are not completely interoperable in that their EHR does not consume the exchanged information as discrete, standardized data. Progress to date can be attributed to state grant and loan programs to support e- health, federal meaningful use incentives to promote implementation of EHRs, as well as Minnesota law requiring all providers to utilize interoperable EHR systems by Furthermore, there has been strong collaboration within Minnesota s health community to work together to advance e-health across the state. Providers will advance health information exchange by continuing to work together to overcome the organizational, workflow and technological barriers, and advocate for the improvement of tools and systems. 33% 42% 47% 73% Percent of Clinics with EHRs (N=1,146) Minnesota HIT Clinic Survey, 2015 page 3

5 List of Exhibits Exhibit 1: EHR Adoption among Minnesota Clinics, Exhibit 2: EHR Adoption by Practice Type and Geography, Exhibit 3: EHR Systems Used by Adopting Clinics, Exhibit 4: Non-EHR Adopter Plans to Acquire and Implement an EHR, Exhibit 5: Barriers to Adopting an EHR among Non-Adopting Clinics, Exhibit 6: Use of Computerized Provider Order Entry (CPOE), Exhibit 7: Use of Clinical Decision Support (CDS) Tools, Exhibit 8: Trends in Use of Key Clinical Decision Support (CDS) Tools, Exhibit 9: EHR Documentation of Advance Directive in the EHR, Exhibit 10: Capture of Patient s Demographic Information in the EHR, Exhibit 11: Impact of EHRs on Clinical Practice All Clinics with EHRs, Exhibit 12: Impact of EHRs on Clinical Practice Primary Care versus Specialty Care Clinics, Exhibit 13: E-Prescribing by Practice Type and Geography, 2015*...15 Exhibit 14: Electronic Prescribing Alerts, Exhibit 15: Health Information Exchange with Unaffiliated Hospitals and/or Clinics, Exhibit 16: Clinics Need and Actual Electronic Health Information Exchange by Type of Organization, Exhibit 17: Use of Electronic Summary of Care Records for Transitions or Referrals, Exhibit 18: EHR Integration of Electronic Information from Outside Sources, Exhibit 19: Exchange Mechanisms Used by Minnesota s Clinics, Exhibit 20: Receipt of Automated Alerts from Hospitals, Exhibit 21: Challenges to Secure Health Information Exchange, Exhibit 22: Patients Control of Privacy Settings, Exhibit 23: Methods for Tracking Patient Consents, Exhibit 24: Electronic Functions offered to Patients, Exhibit 25: Percent of Clinics Offering Online Patient Portal, Exhibit 26: Online Services Offered Through Patient Portal, Exhibit 27: Additional Electronic Functionalities Offered, Exhibit 28: Use of any Telemedicine Service by Practice Type and Geography, Exhibit 29: Telemedicine Activities Conducted at Clinic, page Minnesota HIT Clinic Survey, 2015 page 4

6 Introduction E-health is adoption and effective use of electronic health record (EHR) systems and other health information technology (HIT), including health information exchange, to improve health care quality, increase patient safety, reduce health care costs, and enable individuals and communities to make the best possible health decisions. In 2008, the Minnesota e-health Initiative, a public-private collaborative to accelerate the adoption and use of health information technology, developed the Minnesota Model for Adopting Interoperable EHRs that is applied to all aspects of the Initiative s work and policy development. The model has seven steps which are grouped into three major categories: Adopt: assessment of needs and readiness, planning, and selecting an EHR system. Utilize: implementing an EHR system to go live and learning how to use it effectively. Exchange: determining readiness to exchange information electronically with other partners, and implementing regular, ongoing exchange between interoperable EHR systems. To help inform progress toward these goals and identify guidance needed by providers to meet this mandate, the Minnesota Department of Health (MDH) established a framework the Minnesota e- Health Profile for assessment and evaluation of EHR adoption and use across multiple health settings that is based on the Minnesota Model. The Minnesota e-health Profile is a series of online surveys of health care settings designed to uniformly collect and share the progress of Minnesota s providers in adopting and implementing EHR systems, and exchanging electronic health information. The assessment information is used to: Measure Minnesota s status on achieving state and national goals to accelerate adoption and use of EHRs and other HIT and to achieve interoperability of health information; Identify gaps and barriers to enable effective strategies and efficient use of resources; Help develop programs and inform decisions at the local, state and federal levels of government; and Support community collaborative efforts. Data presented in this report are from the HIT Ambulatory Clinic Survey (clinic survey) conducted by the MDH Office of Health Information Technology. The clinic survey has been conducted annually since The 2015 survey includes responses from 1,181 of 1,473 clinics that have registered with the Statewide Quality Reporting and Measurement System (SQRMS), for a response rate of 80%. Complete methodology information is presented in Appendix A. Minnesota HIT Clinic Survey, 2015 page 5

7 Findings: EHR Adoption This section presents information on EHR adoption status, the systems used, and barriers to implementation among clinics that have not yet adopted. Adoption of EHR systems involves a process of assessment, planning, and selection, followed by a series of steps leading to a go live date. As such, this assessment recognizes that clinics may be in part of that process toward going live. Most Clinics Have Implemented EHR Systems Ninety-seven percent of ambulatory clinics in Minnesota have implemented EHRs, representing 1,146 clinics in 2015 (Exhibit 1). Just 35 clinics did not have an EHR. Among clinics with EHRs, 76% indicated they were entirely paperless and 22% maintained paper charts but relied on the EHR for the most accurate information. EHR adoption rates among Minnesota s clinics have increased over time, from 67% when the annual clinic survey began in 2010 to 97% in Earlier data on EHR adoption is limited, with a 2005 survey among a subset of adult primary care clinics estimating the EHR adoption rate at 17% (data not shown). Exhibit 1: EHR Adoption among Minnesota Clinics, (N=1,181) 2014 (N=1,206) 2013 (N=1,286) 2012 (N=1,180) 2011 (N=1,246) 2010 (N=1,121) 67% 72% 79% 87% 93% 97% Percent of Clinics in Minnesota* * The number of clinics is based on registrations for the Statewide Quality Reporting and Measurement System, and varies by year based on outreach efforts for clinics to register, and business changes to the clinic such as mergers, closings, and openings. Exhibit 2 presents adoption rates by type of practice and geography. There is a significant difference in rates of adoption between practice type, with 99% of primary care and 94% of specialty care clinics having implemented EHR systems. There is no significant difference in adoption rates between urban (97%) and rural clinics (100%). Minnesota HIT Clinic Survey, 2015 page 6

8 Exhibit 2: EHR Adoption by Practice Type and Geography, 2015 Type of Practice Primary Care (N=637) Specialty Care (N=509) 94% 99% Geography Urban (N= 945) Rural (N=202) 97% 100% Percent of Clinics with EHRs Few EHR Vendors Share the Market Minnesota s EHR market is dominated by the Epic system, which was used by 49% of clinics (Exhibit 3), an increase from 40% in Other systems with strong market penetration include NextGen (6%), Allscripts (6%), eclinicalworks (6%), Cerner (4%), Centricity (4%), and Greenway (4%). Epic s market share was higher among primary care clinics (57%) compared to specialty care clinics (38%), and also among urban clinics (50%) compared to rural clinics (44%). Most of the clinics (94%) were using an EHR system that is certified by the Office of the National Coordinator. 1 Exhibit 3: EHR Systems Used by Adopting Clinics, 2015 EHR Vendor Percent Count Epic 49% 559 NextGen 6% 71 Allscripts 6% 70 eclinicalworks 6% 67 Cerner 4% 50 Centricity 4% 45 Greenway 3% 40 Meditech 2% 24 Other 19% 220 Total 1,146 1 A complete list of certified HIT products is available at: Minnesota HIT Clinic Survey, 2015 page 7

9 Most Non-Adopting Clinics Plan to Implement Of the 35 clinics that have not yet implemented or begun installing their EHR system, 21 planned to implement within five years (Exhibit 4). Just 14 clinics in this year s survey indicated that do not plan to implement an EHR. Exhibit 4: Non-EHR Adopter Plans to Acquire and Implement an EHR, 2015 Planning to implement 21 (2%) Not planning to implement 14 (1%) (N = 1,181 Clinics) Implemented 1,146 (97%) Non-adopting clinics indicated several barriers to adopting an EHR system. Exhibit 5 shows that the most significant barriers were annual cost of maintaining an EHR system (66%), finding an EHR system to meet their needs (57%), and ability to secure financing for an EHR system (54%). Other major barriers were reliability of the system, lost productivity during the transition, effort needed to select a system, and adequacy of training for staff. Exhibit 5: Barriers to Adopting an EHR among Non-Adopting Clinics, 2015 Significant barrier Somewhat of a barrier Annual cost of maintaining an EHR system 66% 23% Finding an EHR system that meets your practice s needs Ability to secure financing for an EHR system 57% 54% 17% 29% Reliability of the system Loss of productivity during transition to an EHR 34% 29% 40% 51% Effort needed to select an EHR system Adequacy of training for you and your staff Resistance of your practice to change work habits Reaching consensus within the practice to select an EHR 26% 20% 11% 11% 34% 63% 46% 54% Percent of Non-Adopting Clinics (N=35) Minnesota HIT Clinic Survey, 2015 page 8

10 Findings: Utilization of EHR Systems The real value from investing in and implementing an EHR system comes from using it to support efficient workflows and effective clinical decisions. Effective use means that the EHR has tools such as computerized provider order entry (CPOE), clinical decision support (CDS) tools, and electronic prescribing, and that there are processes in place to use these tools for improving health care. This section presents utilization of EHRs for CPOE, CDS, electronic prescribing, and quality measure reporting. See Appendix B for definitions of these tools. Use of Computerized Provider Order Entry is Common Use of CPOE has achieved near universal application among Minnesota clinics that have adopted EHRs. Ninety-six percent of clinics with EHRs used CPOE for some or all provider orders and another 3% have the functionality but it s not in use. Exhibit 6 shows that CPOE utilization increased from 74% of clinics with EHRs in 2010 to 96% in There is a statistically significant difference in the use of CPOE among primary care clinics (100%) versus specialty care clinics (93%), but no difference between urban and rural clinics. Looking at volume of orders, 89% of clinics using CPOE do so for most orders (80-100% of orders). Ninety-eight percent of primary care clinics used CPOE for most orders, which is significantly more than specialty care clinics (76%). Eight-eight percent of urban clinics used CPOE for most orders compared to 92% of rural clinics; this rural clinic use is up from 80% in Exhibit 6: Use of Computerized Provider Order Entry (CPOE), (N=1,146) 2014 (N=1,118) 2013 (N=1,114) 96% 97% 95% 2012 (N=935) 89% 2011 (N=900) 82% 2010 (N=750) 74% Percent of Clinics with EHRs Responding clinics did not indicate many barriers to using CPOE. Most common challenges included required time to build orders into the EHR system (35%), limited time during patient encounters (28%), required redesign of workflow processes (23%), required system maintenance (22%), provider preference to use paper orders (21%), and lack of staff training (20%). Minnesota HIT Clinic Survey, 2015 page 9

11 Use of Clinical Decision Support Tools is Increasing The clinic survey measured several CDS tools and functionalities. Exhibit 7 shows that 95% of primary care and 90% of specialty care clinics with EHRs used medication guides/alerts. All seven of the measured CDS tools were routinely used by half or more of primary clinics with EHRs, but most of these tools are routinely used by less than half of specialty care clinics. Furthermore, there was evidence that providers in clinics used multiple tools, with 82% of primary care and 47% of specialty clinics reporting that their providers used three or more of the seven CDS tools measured. Exhibit 7: Use of Clinical Decision Support (CDS) Tools, 2015 Primary Care (N = 637) Specialty Care (N = 509) Medication guides/alerts 95% 90% Preventive care services due 43% 83% Automated reminders for missing labs and tests 40% 76% Patient specific or condition specific reminders 42% 70% Clinical guidelines based on patient problem list, gender, and age 44% 59% Chronic disease care plans and flow sheets 31% 55% High tech diagnostic imaging decision support tools 23% 52% Percent of Clinics with EHRs Using Tools Routinely Common barriers to effective use of CDS tools included too many false alarms/too disruptive 50%), required redesign of workflow processes (45%), lack of resources to build/implement (41%), and lack of staff and/or provider training (32%). Utilization of CDS tools has increased over time. Exhibit 8 presents the percent of clinics that utilized three key CDS tools over time: medication guides/alerts, preventive care reminders, and clinical guidelines. Routine use of medication guides/alerts increased from 76% clinics in 2010 to 93% clinics in Routine use of preventive care services reminders increased from 52% to 65% of clinics, and routine use of clinical guidelines increased from 29% to 52% of clinics in that time frame. Minnesota HIT Clinic Survey, 2015 page 10

12 Exhibit 8: Trends in Use of Key Clinical Decision Support (CDS) Tools, Percent of clinics using routinely 100% 80% 60% 40% 20% 0% 76% 81% 78% 80% 52% 54% 55% 57% 29% 2010 (N=750) 43% 2011 (N=900) 53% 2012 (N=935) 50% 48% Medication guides/alerts 2013 (N=1,114) 90% 93% 64% 65% Preventive care services reminders Clinical guidelines 2014 (N=1,118) 52% 2015 (N=1,146) Documentation of Advance Directives is Incomplete An advance directive is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions. These documents serve to convey a patient s wishes for care to the care team; therefore, they should be available in the patient s electronic medical record. As shown in Exhibit 9, over three-fourths of Minnesota s clinics document the existence of a patient s advance directive in their EHR, including 95% of primary care and 64% of specialty care clinics. Despite these capabilities of the EHR to document advance directives, just 14% of clinics have an advance directive for % of their patients age 65 and older, 44% have an advance directive for less than half of patients in this age group, and 23% document the advance directive but for an unknown percent of patients. Three-fourths of clinics that document advance directives in the EHR (76%) have the directive electronically accessible in the EHR, and 22% incorporate it in the EHR but not in a consistent location. Exhibit 9: EHR Documentation of Advance Directive in the EHR, 2015 Does not know, 3% Does not document advance directives in EHR, 16% Documented for % of patients 14% Documented for unknown percent of patients, 23% (N = 1,146 Clinics) Documented for <50% of patients 44% Minnesota HIT Clinic Survey, 2015 page 11

13 Most Clinics Document Demographic Information in the EHR Minnesota s clinics effectively capture patient demographic information in their EHRs. Exhibit 10 shows that nearly all clinics report they capture race, Hispanic ethnicity, and preferred language in the EHR. Clinics are slightly less effective in capturing country of origin, with 90% of primary care and 76% of specialty care capturing this information. Eighty percent of clinics can capture more than one race per patient in the EHR, including 92% of primary care and 65% of specialty care clinics. Two in three clinics (65%) can capture granular ethnicity information in the EHR, and of these clinics 73% capture granular ethnicity for 80% or more of their patients. Exhibit 10: Capture of Patient s Demographic Information in the EHR, 2015 Primary Care (N = 637) Specialty Care (N = 509) Race Hispanic ethnicity Country of origin Preferred language Insurance status 76% 98% 97% 98% 94% 90% 98% 94% 99% 99% Percent of Clinics Capturing Data for 80% or More of Patients Most Clinics Maintain Disease Registries, Use EHRs for Quality Measurement Nearly all clinics (96%) are able to generate at least one report that lists patients by a specific conditions. Among primary care clinics the most common disease reports they generate from the EHR include diabetes (91%), asthma (91%), depression (87%), vascular disease (83%), hypertension (78%), and obesity (62%). Most clinics utilized data from the EHR for internal quality improvement efforts. Ninety percent of clinics with EHRs shared data with providers, 84% used EHR data to set goals around clinical guidelines, 82% created benchmarks or develop priorities, and 55% supported professional development activities. Furthermore, 90% of clinics with EHRs used only their EHR (no paper) to collect and submit quality measures to outside organizations. Minnesota HIT Clinic Survey, 2015 page 12

14 EHRs Have Positive Impact on Clinical Practice Exhibit 11 provides opinion measures related to the impact EHRs have had on clinical practice. There was strong agreement on the positive impact of EHRs, particularly on two important measures: 93% of clinics agreed that the EHRs have alerted their providers to potential medication errors, and 93% agreed that the EHR has enhanced patient care in their clinic. Exhibit 11: Impact of EHRs on Clinical Practice All Clinics with EHRs, 2015 Agree Agree Somewhat Be alerted to potential medication errors 70% 23% Agree + Agree Somewhat* 93% Be alerted to critical lab values 65% 23% 87% Be reminded to provide preventive care 60% 21% 81% Enhance patient care in your clinic 58% 35% 93% Identify needed lab tests 54% 23% 78% Provide care that meets clinical guidelines for patients with chronic disease 52% 27% 79% Order more on-formulary drugs 51% 30% 81% Order fewer tests due to better availability of other lab results 41% 37% 78% * Totals may not match sum of chart percentages due to rounding. Percent of Clinics with EHRs (N= 1,146) Minnesota HIT Clinic Survey, 2015 page 13

15 Primary care clinics indicated higher ratings for impact of the EHR on clinical practice. Exhibit 12 shows Agree responses for primary and specialty clinics. Primary care clinics expressed more value compared to specialty clinics on all measures, most notably being alerted to critical lab values (78% among primary care versus 48% among specialty clinics), reminders to provide preventive care (73% and 43%, respectively), identifying needed lab tests (65% and 41%, respectively), and providing care that meets clinical guidelines for patients with chronic disease (65% and 37%, respectively). Exhibit 12: Impact of EHRs on Clinical Practice Primary Care versus Specialty Care Clinics, 2015 Primary Care (N = 637) Specialty Care (N = 509) Be alerted to critical lab values Be alerted to potential medication errors Be reminded to provide preventive care Enhance patient care in your clinic Identify needed lab tests Provide care that meets clinical guidelines for patients with chronic disease 48% 43% 49% 41% 37% 78% 73% 66% 73% 65% 65% 65% Order more on-formulary drugs 42% 58% Order fewer tests due to better availability of other lab results 33% 47% Percent of Clinics that Agree Minnesota HIT Clinic Survey, 2015 page 14

16 Findings: Electronic Prescribing Electronic prescribing, or e-prescribing, means secure bi-directional electronic information exchange between prescribing providers (prescribers), pharmacists and pharmacies, and payers or pharmacy benefit managers. E-prescribing improves the quality of patient care because it enables a provider to electronically send an accurate and understandable prescription directly from the point-of-care to a pharmacy. E-prescribing is a way to: Improve the quality, safety and cost-effectiveness of the entire prescribing and medication management process. Reduce potential adverse drug events and related costs. Reduce burden of callbacks and rework needed to address possible errors and clarify prescriptions. Increase efficiency of the prescription process and convenience for the patient/consumer. Exhibit 13 shows that 91% of all Minnesota clinics e-prescribed for most non-controlled substance prescriptions, either using their EHR or another electronic method. Primary care EHR clinics used e- prescribing at a significantly higher rate (96%) than specialty care EHR clinics (85%). There was no difference in e-prescribing between urban (91%) and rural (93%) clinics. Exhibit 13: E-Prescribing by Practice Type and Geography, 2015* Geography Type of Practice Total All Clinics (N=1,181) Primary Care (N=642) Specialty Care (N=539) Urban (N=979) Rural (N=202) 85% 91% 96% 91% 93% * Prescribing for non-controlled substance prescriptions. Percent of Clinics E-prescribing rates for controlled substances were much lower, with just 8% of clinics e-prescribing. Another 74% of clinics created these prescriptions electronically and then faxed or otherwise manually delivered to the pharmacy or patient. Minnesota now allows electronic prescribing of controlled substances, but not all pharmacy and EHR systems currently support the security and technology requirements to do so. The greatest barrier to e-prescribing was the inability to send prescriptions for controlled substances (47%). Other barriers included capabilities of the pharmacy to send and receive data are not known (10%), the pharmacy does not receive e-prescriptions (10%), and provider preference for prescribing by hand (8%). Minnesota HIT Clinic Survey, 2015 page 15

17 Nine in ten clinics were electronically alerted to drug interactions at the point of prescribing, including 91% for potential drug-drug interactions and 91% for potential drug-allergy interactions (Exhibit 14). More than two-thirds of clinics were alerted to patient-specific formulary information (71%), 62% alerted to generic alternatives, and just 25% were alerted to cost comparison of medications. Exhibit 14: Electronic Prescribing Alerts, 2015 Potential drug-drug interactions Potential drug-allergy interactions 91% 91% Patient-specific formulary information 71% Generic alternatives 62% Cost comparison of medications 25% Percent of Clinics (N=1,181) Minnesota HIT Clinic Survey, 2015 page 16

18 Findings: Health Information Exchange Health information exchange (HIE) is the secure electronic exchange of clinical information between organizations using nationally recognized standards (Minn. Stat. 62J.498 sub. 1(f)). The goal of health information exchange is to help make health information available, when and where it is needed, to improve the quality and safety of health and health care. In Minnesota, many efforts are underway to help achieve the secure electronic exchange of clinical information between organizations using nationally recognized standards. Other than electronic prescribing, most of the health information exchange happening in Minnesota is primarily between hospitals and clinics in the same system or with affiliated partners. Health Information Exchange by Clinics has increased but Faces Challenges Minnesota s clinics have indicated a tremendous increase in health information exchange since 2014, with 73% indicating they exchanged with unaffiliated hospitals or clinics, compared to 40% in Exhibit 15 shows that primary care clinics exchanged health information with unaffiliated hospitals and/or clinics at a significantly higher rate (80%) than specialty care clinics (65%). There was no significant difference in exchange activity between urban (74%) and rural (71%) clinics. Exhibit 15: Health Information Exchange with Unaffiliated Hospitals and/or Clinics, 2015 Type of Practice Total All Clinics (N=1,146) Primary Care (N=637) Specialty Care (N=509) 65% 73% 80% Geography Urban (N=945) Rural (N=202) 71% 74% Percent of Clinics with EHRs Exhibit 16 shows the types of health information exchange partners that clinics may have, comparing their need to exchange with each type of partner to their actual electronic exchange, as well as the gap between actual and need. In general, there is high need among clinics to exchange with providers across the continuum of care. The greatest need for health information exchange was with unaffiliated clinics (86%) and unaffiliated hospitals (79%). At least three in five clinics indicated a need to exchange with nursing homes (60%), long-term care providers other than nursing homes (60%), behavioral health providers (56%), and home health agencies (55%). Half of clinics (51%) indicated a need to exchange with the Minnesota Department of Health, 44% with local public health, and 28% with social services. Despite the identified needs, actual electronic exchange with most of the unaffiliated partners lags the need by a large margin. About two-thirds of clinics actually exchanged with unaffiliated clinics (71%) and/or unaffiliated hospitals (66%). Similar large gaps between needed and actual electronic exchange exist for all types of providers except with MDH, although these gaps are much smaller than in Minnesota HIT Clinic Survey, 2015 page 17

19 Exhibit 16: Clinics Need and Actual Electronic Health Information Exchange by Type of Organization, 2015 Need to Exchange Currently Exchange Clinical/ambulatory providers outside of your health system 71% 86% Hospitals outside of your health system 66% 79% Long-term care and post-acute care facilities other than nursing homes 39% 60% Nursing homes 44% 60% Behavioral health providers 36% 56% Home health agencies 28% 55% Minnesota Department of Health 51% 50% Local public health departments 24% 44% Social service agencies/organizations 12% 28% Percent of Clinics with EHRs (N=1,146) Minnesota HIT Clinic Survey, 2015 page 18

20 Exchange of Electronic Summary of Care Records is Not Common A summary of care record is a standardized data packet that includes patient information that is relevant to care providers, such as procedures, diagnoses, history, etc. Four in five (82%) of clinics with EHRs were able to generate an electronic summary of care record from their EHR for patients who require a referral to another provider, or transition from one setting of care to another. Another 12% have the capability in their EHR but don t use it. Just 33% of clinics provided an electronic summary care record to that facility for 50% or more of patients who transitioned (Exhibit 17). Exhibit 17: Use of Electronic Summary of Care Records for Transitions or Referrals, 2015 EHR has function but not in use, 12% Provided for unknown percent of patients, 4% EHR does not have function, 5% Provided for % of patients, 33% Provided for <25% of patients, 27% (N = 1,146 clinics) Provided for 25-49% of patients, 19% Clinics EHRs Do Not Typically Consume Data An important component of interoperability is that the receiving EHR is able to incorporate standardized data without the need for manual entry. Most clinics do not incorporate electronic information from other providers into their EHRs as standardized data. Exhibit 18 shows that about one in five clinics typically consume standardized data from outside sources for immunizations (22%), medication history (21%), and lab results (20%), but just 11% do so with summary of care records. A small percent of clinics, integrate these data in non-standardized format, but most incorporate a scanned or PDF file. Exhibit 18: EHR Integration of Electronic Information from Outside Sources, 2015 Standardized data Non-standardized data Fax/scan/PDF Not sure Immunizations (N = 922) 22% 13% 60% 4% Medication history (N = 1,054) 21% 5% 72% 2% Lab results (N = 1,062) 20% 6% 73% 1% Summary of care record (N = 1,058) 11% 8% 79% 2% Percent of Clinics with EHRs that Use These Types of Data Minnesota HIT Clinic Survey, 2015 page 19

21 The EHR Exchange Mechanism is Dominant The most common mechanism for health information exchange is through capability built into the EHR, with 59% of clinics using this exchange mechanism (Exhibit 19). Forty-two percent of clinics are using a State-Certified HIE Service Provider. 2 About one in four clinics (28%) used Direct secure messaging, 18% used Interstate HIE and HealtheWay/eHealth Exchange, 3 8% used peer-to-peer exchange, and 6% used Connect query-based exchange. Seventeen percent of clinics did not electronically exchange information, down from 32% in Exhibit 19: Exchange Mechanisms Used by Minnesota s Clinics, 2015 Exchange capability built into your EHR 61% Exchange using a State-Certified HIE Service Provider 42% Direct secure messaging 28% Interstate HIE and HealtheWay/eHealth Exchange 18% Peer-to-peer exchange 8% Connect query-based exchange 6% Do not electronically exchange health information 17% Percent of Clinics with EHRs (N=1,146) 2 A complete list of state-certified HIE service providers is at 3 The ehealth Exchange is a group of federal agencies and non-federal organizations that came together under a common mission and purpose to promote interoperable health information exchange. Now rebranded as the Sequoia project; information is at Minnesota HIT Clinic Survey, 2015 page 20

22 Receipt of Automated Notifications from Hospitals Automated electronic notifications can be used by hospitals to notify another provider when their patient has been admitted, discharged, and or transferred to another facility. These notifications are commonly referred to as ADT alerts, and are designed to improve the timely flow of information in situations where care coordination is a critical need. 4 About half of Minnesota s clinics received automated electronic alerts from hospitals (Exhibit 20). This is almost all from hospitals within the same health system as the clinic (47%), but includes 2% receiving from hospitals outside of their system. There is little variation between urban and rural clinics. Exhibit 20: Receipt of Automated Alerts from Hospitals, 2015 Don't know, 3% Do not receive, 51% From affiliated hospitals, 47% (N = 1,146 Clinics) 4 Office of the National Coordinator for Health IT Improving Hospital Transitions and Care Coordination Using Automated Admission, Discharge and Transfer Alerts; A Learning Guide. Available at Minnesota HIT Clinic Survey, 2015 page 21

23 As shown in Exhibit 21, the top challenges to secure HIE include capabilities of outside organizations to send/receive were not known (67%), limited or no capacity among outside organizations to send and receive (63%), and/or competing priorities (60%). Other challenges included high subscription rates for exchange services (31%), exchange partners not connected to a State-Certified HIE Service Provider (29%), HIPAA, privacy or legal concerns (28%), unclear value of return on investment (22%), inability of system to generate, send or receive electronic messages or transactions in standardized format (20%), insufficient information on exchange options available (19%), and lack of access to technical support or expertise (14%). Exhibit 21: Challenges to Secure Health Information Exchange, 2015 Capabilities of outside organizations to receive and send electronic data unknown Capacity of outside organizations to send and receive is limited or does not exist Competing priorities 63% 60% 67% Subscription rates for exchange services are too high 31% Partners not connected to our state-certified HIE vendor 29% HIPAA, privacy or legal concerns 28% Unclear value of investment or return on investment Inability of system to generate, send or receive electronic messages or transactions in standardized format Insufficient information on exchange options available 22% 20% 19% Lack of access to technical support or expertise 14% Percent of Clinics with EHRs (N=1,146) Minnesota HIT Clinic Survey, 2015 page 22

24 Findings: Privacy & Security An important component of health information exchange is that patients must have confidence in the integrity of the data being shared, and trust that providers using the data have procedures in place to keep their information safe and secure. Health care providers must implement standards for securing electronic health information to ensure that appropriate safeguards are in place to protect that data from unauthorized access. Four in five clinics with EHRs (81%) allowed patients to set privacy settings to authorize release of health information to another party (Exhibit 22). Three-fourths of clinics with EHRs allowed patients to define permissions for who should have access to their health record and under what circumstances (75%), and 73% allowed patients to set preferences regarding how and under what circumstances health information may be shared with others. Exhibit 22: Patients Control of Privacy Settings, 2015 Authorize the release of health information to another provider or third party Define permissions for who should have access to their health record and under what circumstances Express preferences regarding how and under what circumstances health information may be shared with others 75% 73% 81% Percent Clinics with EHRs (N = 1,146) Most clinics with EHRs (93%) limited the EHR user s access to information based on staff function or other criteria, and 98% conducted or reviewed security risk analysis information and updates as necessary as part the their risk management processes. Clinics most often used a manual process to integrate patient consents into the EHR. Exhibit 23 shows that 35% of clinics with EHRs tracked consents electronically. Almost twice as many (61%) scanned signed paper consents into the EHR. Just two percent of these clinics were handling consents only by paper. Exhibit 23: Methods for Tracking Patient Consents, 2015 Scanned paper consents - signed papers scanned into the EHR 61% Consents are tracked electronically 35% Paper consents only - signed consents filed as paper 2% Percent of Clinics with EHRs (N = 1,146) Minnesota HIT Clinic Survey, 2015 page 23

25 Findings: Consumer Access to Health Information With the implementation of EHRs, health care providers have the opportunity to provide patients with their health information in an electronic format. These tools can help patients take responsibility for their own health and aid in keeping the health records updated with current information. The clinic survey assessed two aspects of consumer engagement: ability of patients to electronically view, download and/or transmit their personal health information, and use of patient portals. Portability of Personal Health Information is Limited Eight-eight percent of clinics with EHRs provided patients with the option to view their patient health information online (Exhibit 24). Fewer clinics (65%) offered the option to download that information to a physical electronic media, and 42% offered the option to electronically transmit their patient health information. These results have increased since 2013 (60% view, 44% download and 8% transmit), but continue to reflect interoperability challenges for patients to share data between providers. More primary care clinics offer view options (92%) and download (69), compared to 83% and 60% of specialty clinics, respectively. There is no difference in transmit options between primary and specialty clinics. Exhibit 24: Electronic Functions offered to Patients, 2015 View online 88% Download 65% Transmit 42% Percent of Clinics with EHRs (N=1,146) A Growing Number of Clinics Offer Patient Portals Patient portals are an internet application maintained by the clinic or provider organization that allow patients to access their electronic health records and permit two-way communication between patients and their health care providers. Exhibit 25 shows that 91% of clinics with EHRs offered an online patient portal in 2015, including 96% of primary care and 84% of specialty clinics. There has been a steady increase in the offer of patient portals since 2011, when just 35% of clinics offered this service. Exhibit 25: Percent of Clinics Offering Online Patient Portal, % 77% 80% 66% 60% 50% 35% 40% 20% 0% 2011 (N=900) 2012 (N=935) 2013 (N=1,114) 2014 (N=1,118) 91% 2015 (N=1,146) Minnesota HIT Clinic Survey, 2015 page 24

26 Among the 1,042 clinics with EHRs and online patient portals, most offered several access options. Exhibit 26 shows that nine in ten of these clinics provided access to clinical visit summaries (90%) and test results (89%). Eight in ten of these clinics offered medication lists (82%), diagnosis/problem list (79%), allergies lists (77%), and immunization records (77%). Forty-four percent of these clinics offered patients access to their care plans through their portal, and just 24% offered providers progress notes. Exhibit 26: Online Services Offered Through Patient Portal, 2015 Clinic visit summary Test results Medication lists Diagnosis/problem list Allergies list Immunization records Care plans Providers' progress notes 24% 44% 90% 89% 82% 79% 77% 77% Percent of Clinics with EHRs and Patient Portals (N=1,042) Most clinics with EHRS that offer patient portals provided additional electronic services through the portal or other methods. Exhibit 27 shows that administrative services offered included secure message or (92%), online appointment scheduling (81%), online bill pay (80%), patient education materials (70%), electronic reminders for visits or follow-up care (64%), and electronic reminders for recommended care (63%). Less common functionalities included e-visits (40%), and blogs or online support groups (19%). Some other emerging functionalities mentioned by clinics include prescription refill requests, depression assessments, and requests for a patient s personal health record. Exhibit 27: Additional Electronic Functionalities Offered, 2015 Secure messaging/ 92% Online appointment request or scheduling Online bill pay 81% 80% Patient education materials Reminders for visits or follow-up care Reminders for recommended care 64% 63% 70% E-visits 40% Blogs or online support groups 19% Percent of Clinics with EHRS and Patient Portals (N=1,042) Minnesota HIT Clinic Survey, 2015 page 25

27 Findings: Telemedicine Telemedicine (also called telehealth) is the use of telecommunications technologies to provide health care services to a patient who is physically not with the provider. Telemedicine can include diagnosis, treatment, education and other health care activities. Less than Half of Clinics Use Telemedicine Services Forty-one percent of clinics in Minnesota used telemedicine services. Exhibit 28 shows that there was significant variation in use by geography and practice type, with 58% of rural clinics using telemedicine compared to 38% of urban clinics. Over half of primary care clinics (55%) used telemedicine compared to 24% of specialty care clinics. Exhibit 28: Use of any Telemedicine Service by Practice Type and Geography, 2015 All Clinics (N=1,181) 41% Practice Type Primary Care (N=539) Specialty Care (N=642) 24% 55% Geography Urban (N=979) Rural (N=202) 38% 58% Percent of Clinics The types of telemedicine activities used by Minnesota clinics are shown in Exhibit 29. The most common were real-time teleconsultations (30%), being the originating or patient site (28%), primary care and specialist referral services (23%), and remote patient monitoring (19%). Store-and-forward teleconsultations are used by just 7% of clinics. Among rural clinics, 62% were host sites compared to 20% among urban clinics. Thirty-eight percent of primary care clinics were host sites compared to 12% of specialty care clinics. Exhibit 29: Telemedicine Activities Conducted at Clinic, 2015 Real-time teleconsultations 30% Originating or patient site 28% Primary care and specialist referral services 23% Remote patient monitoring 19% Store-and-forward teleconsultations 7% 0% 10% 20% 30% 40% 50% Percent of Clinics (N=1,181) Among the 475 clinics that use telemedicine services, the most common services used included chronic disease management (69%), provider and staff medical education (37%), after-hours pharmacy (36%), remote patient monitoring (28%), correctional health triage (26%), and consumer medical/health information (25%), and behavioral health (18%). The most commonly identified barriers to using telemedicine included cost to provide the services (51%) cost of equipment (48%), and insufficient reimbursement (41%). Urban clinics noted additional barriers including lack of staff enterprise, lack of staff support, availability of providers, and lack of demand. Minnesota HIT Clinic Survey, 2015 page 26

28 Conclusion Minnesota began measuring EHR implementation among the state s clinics in Since then these clinics have made great strides toward implementation and effective use of EHRs. This has been driven in part by federal incentive payments and in part by state policy actions. As of July 2015, organizations in Minnesota have received more than $650 million in federal incentive payments to implement EHRs. 5 Prior to this funding, policymakers in Minnesota recognized that more effective use of health information technology was needed to improve the quality and safety of care and to help control costs, and enacted legislation that requires all health care providers in the state to implement an interoperable EHR system by January 1, 2015 (Minn. Stat. 62J.495). The Minnesota Department of Health provides guidance that describes Minnesota s law, the types of providers impacted, what kind of information should be exchanged, privacy and security requirements, and how organizations can go about exchanging information. 6 Effective use of EHRs has improved over time, and Minnesota has had great success with e-prescribing following the state s 2011 e-prescribing Mandate (Minn. Stat. 62J.497). There is still room for improvement, however, and barriers to interoperability need to be addressed. EHRs have usability issues that may inhibit optimal utilization, such as excessive alerts, poor functionality for providers using the tools, and tools that don t apply for a clinic s practice; as technology evolves these issues are diminishing, but many providers have not learned to optimize their EHR systems. Ongoing training will be needed both for the existing workforce and for new hires. While health care providers are increasingly embracing EHRs and related technologies to improve population health, more work is needed to achieve interoperability. Results from this study demonstrate that clinics still face gaps between their need to electronically exchange health information and their ability to do so with complete interoperability. These gaps are particularly large for exchange among providers that do not share a common EHR vendor. Despite these successes with clinics, adoption of EHRs lags among providers not eligible for meaningful use incentives. As Minnesota embraces more coordinated models of health care delivery, it will be important to exchange health information with all relevant providers in their community so these providers have the right information at the right time, and that this information is available for all patients. Providers will benefit by continuing to work together to overcome technological barriers and advocate for the improvement of tools and systems and share best practices for effective use of health information technology. 5 Centers for Medicare & Medicaid Services. EHR Incentive Programs, Data and Program Reports web page; 6 This guide can be found at: Minnesota HIT Clinic Survey, 2015 page 27