The Adoption of Electronic Health Records and Associated Information Systems by Medical Group Practices

Transcription

1 The Adoption of Electronic Health Records and Associated Information Systems by Medical Group Practices Terry Hammons* and John Kralewski** Principal Investigators David Gans* and Bryan Dowd** Investigators Final Report AHRQ Task Order #5 March 31, 2005 revised July 15, 2005 Corresponding Authors: John Kralewski University of Minnesota David Gans Medical Group Management Association *The Medical Group Management Association, Englewood, CO **The University of Minnesota, Minneapolis, MN

2 TABLE OF CONTENTS INTRODUCTION... 2 FINDINGS... 6 A. Adoption and Implementation of Electronic Health Records... 6 B. EHR Capabilities...11 C. Do EHRs Improve the Performance of Group Practices...12 D. EHR Implementation Costs...13 E. Other Electronic Information Systems Capabilities...14 F. What Could Be Done to Make It Easier to Adopt and Implement EHRs...36 WHAT HAVE WE LEARNED FROM THIS RESEARCH...40 APPENDIX (REPRODUCTION OF SURVEY QUESTIONNAIRE)

3 INTRODUCTION This is the final report for the first phase of AHRQ Task Order Number 5 Assessing the Adoption of Information Technology by Medical Group Practices. This report focuses on the degree to which group practices are adopting and implementing EHRs and associated information systems. A second report provided in-depth information about the adoption and implementation process obtained from site visits and phone interviews with the medical directors of 30 practices. Data for this first phase report were obtained from a national random sample of medical group practices. The population of the group practices was obtained from data collected for a separate AHRQ task order (establishing a network of nationally representative medical groups). That project identified 36,943 medical groups and classified them into ownership, size, location and specialty type categories. About 25 percent of these practices are members of MGMA. We placed these practices into 16 sampling cells for our EHR study; four regions and four practice sizes. Past experience has indicated that this framework would provide a representative mix of practices when random samples are drawn from within each cell. The following table shows the distribution of the practices in the 16 cells. Table 1 Group Practice Population in the U.S. Size (FTE Physicians) 5 and 21 or Regions Fewer Greater Percent Practices Eastern 18.9% 7.2% 2.6% 1.9% 30.0% 11,323 Midwest 11.6% 5.0% 2.0% 1.8% 20.4% 7,536 Southern 19.0% 6.9% 2.6% 2.1% 30.5% 11,265 Western 11.1% 4.3% 1.8% 1.3% 18.5% 6,819 % 60.6% 23.4% 9.0% 7.0% 100.0% 36,943 Practices 22,396 8,613 3,313 2, % 36,943 2

4 Four regions are used because this configuration enables us to perform cross checks of the data with other MGMA databases. The states included in each region are shown in Table 2. Table 2 - Geographic Regions Use in This Study 1. Eastern Region: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Vermont, Virginia and West Virginia 2. Midwest Region: Illinois, Indiana, Iowa, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota and Wisconsin 3. Southern Region: Alabama, Arkansas, Florida, Georgia, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee and Texas 4. Western Region: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington and Wyoming We drew 50 percent random samples of the group practices in each of the 16 cells. These practices were then surveyed using a three stage process. First, all of those with addresses were surveyed using a web-based survey instrument. Next, a hard copy survey instrument was mailed to those with no address and to those that didn t open their surveys (we have found that the main reason why surveys are not opened is because they are blocked as SPAM). Finally, after reviewing the non-respondents in each cell we conducted phone surveys of 750 non-respondent practices selected randomly from each cell to obtain at least 100 total responses in each of the four size cell and to obtain at least 50 phone survey responses in each of those cells to identify any bias in the responses to the two previous surveys. This resulted in 3,354 total responses. The phone survey obtained a 94 percent response rate after three call backs and, consequently, provides excellent data to use to detect biases in the other surveys. The final count of the responses is shown in the following table. 3

5 Geographic Section Table 3 Responses by Region and Practice Size Number of FTE Physicians 5 and Fewer and Greater N Percent N Percent N Percent N Percent N Percent Eastern Section Midwest Section Southern Section Western Section , , It should be noted that only practices that responded to all of the questions in the survey were included in Table 3. Consequently, the total responses for specific questions will vary somewhat from this figure. To assess the potential bias introduced by the non respondents, we compared the data from the phone survey with the and mailed survey responses in each of the size-ofpractice categories for the key questions (Table 4) asked in all three survey modes related to EHRs. The 94% response rate from the randomly selected sample for the phone survey was considered to provide unbiased data. We assumed that lack of bias in the responses for these key questions would indicate probable degree of nonresponse bias to the other questions in the surveys. Table 4 EHR Responses by Type of Survey Type of Questionnaire Type of Health Record Electronic Paper Telephone Questionnaire Questionnaire Interview N Percent N Percent N Percent N Percent Paper medical records filed in record cabinet , , A scanned image filed electronically using DIMS A dictation and transcription system combined with a DIMS ERH storing information in a relational database Other , , ,

6 As shown in Table 4, the respondents to the mailed paper survey reported lower rates of EHR adoption than those in either of the other surveys. Taken alone, the e-survey data would bias the response rate upward and the paper survey would bias it downward. The practices that were reached successfully by and completed the web survey are probably more likely to adopt computer systems than the others since they are familiar with that technology. Thus, the degree to which electronic information technology has been incorporated into their practices is likely to be higher than for the average practice. Similarly, the degree to which electronic information technology has been incorporated into practices that had to be contacted by paper questionnaire is likely to be lower than average. The telephone interview should provide a good estimate of the true mean, especially in light of the high response rate, but the sample size is smaller. The phone survey point estimate for EHR storing information in a relational database of 13.3 percent falls between the electronic-friendly estimate of 20.6 percent and the mail survey response rate of 12.0 percent, indicating that the data should be adjusted to account for these apparent differences. We explored this issue two ways. First, since practice size was found to be an important causal variable we analyzed differences in adoption rates from the three surveys within each of the size categories using a stepwise regression. We found that when size was controlled the differences in responses were not statistically significant. However, since there was a higher rate of response by larger practices and since more of them have EHRs we performed a second analysis to account for these differences. This was accomplished by weighting the data to give the smaller practices in our sample representation equal to their proportion of the overall sample. This reduced the overall adoption rate estimate from 15.3% to 14.1%. These adjusted data are used throughout this report. 5

7 FINDINGS A. Adoption and Implementation of Electronic Health Records 1. Type of Health Record Now in Use Our first analysis focuses on the current use of EHRs in these group practices. The relevant survey questions are as follows: 11. Describe the health/medical records system used by your medical practice for current patients. If your organization uses multiple technologies choose the system used for the majority of your patients medical records. (Check only one box) 1 Paper medical records/charts filed in record cabinet 2 A scanned image of a paper medical record/chart filed electronically using a document imaging management system (DIMS) 3 A dictation and transcription system for physician visit notes, combined with a DIMS for information received on paper, all stored electronically 4 EHR accessible through a computer terminal that stores patient medical and demographic information in a relational data base 5 Other As noted, 14% of our respondents report having an electronic medical record. However, this rate varies by practice size, type, ownership and region. Smaller practices have lower EHR adoption rates, especially those with five or fewer physicians (12-13%) while practices with more than ten physicians have higher rates (19%), Table 5. Number of FTE Physicians Paper Medical Records Filed in Record Cabinet Table 5 Type of Health Record by Practice Size A Scanned Image Filed Electronically Using DIMS Type of Health Record A Dictation and Transcription System Combined with a DIMS EHR Storing Information in a Regional Database Other 5 and Fewer 1, , and Greater * 2, , * weighted to reflect the response by size of group 6

8 It is interesting to note that having at least 11 physicians appears to provide some type of trigger point for adoption of EHRs. At this point in size, these rates increase rather dramatically. Whether this results from more available financial resources at this level or more administrative capacity is unknown although more will be said about that later in this report. The regional location of the practice (Table 6) does not appear to influence adoption rates although these rates are influenced by practice type and ownership. As shown in Table 7, practices that are owned by some type of larger organization such as a health plan or university are more likely to have EHRs than physician-owned groups (Table 7). This effect likely reflects both the availability of resource to cover the costs of EHRs and the availability of skilled administrative capability. Even smaller practices owned by hospitals have higher rates than physician-owned practices (data not shown). Geographical Section Paper Medical Records Filed in Record Cabinet Table 6 Type of Health Record by Region A Scanned Image Filed Electronically Using DIMS Type of Health Record A Dictation and Transcription System Combined with a DIMS EHR Storing Information in a Regional Database Other Eastern Section Midwest Section Southern Section , Western Section Majority Owner Paper Medical Records Filed in Record Cabinet Table 7 Type of Health Record by Majority Owner A Scanned Image Filed Electronically Using DIMS Type of Health Record A Dictation and Transcription System Combined with a DIMS EHR Storing Information in a Regional Database Other Government Hospital/Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * MSO or PPMC Physicians 1, ,

9 Majority Owner University or Medical School Part of Academic Medical Institution Paper Medical Records Filed in Record Cabinet A Scanned Image Filed Electronically Using DIMS Type of Health Record A Dictation and Transcription System Combined with a DIMS EHR Storing Information in a Regional Database Other Other *Insufficient responses to support analysis. A caveat about effect of type of ownership: as is clear from Table 7, the majority owners for most responding practices were physicians, hospitals and integrated systems, and those that were part of academic medical centers. We also provide data in the tables analyzing results by majority ownership for practices owned by government and management service organizations (MSOs) or physician practice management companies (PPMCs). However, the numbers of responses for these practices are quite small, and we do not have confidence in their meaning. We will generally present these results throughout this report, but will not comment on them. The most notable finding in Table 8 is that single specialty primary care practices have higher HER adoption rates than single specialty practices. Practice Specialty Type Paper Medical Records Filed in Record Cabinet Table 8 Type of Health Record by Specialty Type A Scanned Image Filed Electronically Using DIMS Type of Health Record A Dictation and Transcription System Combined with a DIMS EHR Storing Information in a Regional Database Other Primary Care Single Specialty Group Specialist Single Specialty Group 1, , Multispecialty Group Degree of EHR Implementation and Plans to Implement Our next analysis explores this issue in more depth by examining the degree of EHR implementation in the practices and plans for the future. This analysis captures another level of 8

10 EHR adoption by including those that are in the process of implementing these technologies but do not report them as fully operational for the majority of their patients. 12. As of today, what is your degree of electronic health record implementation? (Check only one box) 1 Fully implemented for all physicians and all practice locations 2 Implementation in process or EHR is fully implemented for a portion of practice physicians or locations 3 Implementation planned in next 12 months 4 Implementation planned in next 13 to 24 months 5 Not implemented As shown in Table 9, combining the rates for fully implemented and implementation-inprocess rates increases the adoption rate to about 25 percent of the practices. However, most of these gains appear to be in the larger practices and multispecialty groups rather than in the mainstream smaller primary care practices (Tables 9 and 11). It is important to note that the physician-owned practices show important gains when these categories are combined and that this does not vary much regionally (Tables 10 and 12). In terms of future plans, it appears that important gains will be made in the smaller physician-owned practices (Tables 9 and 12). If the respondents projections are accurate, it appears that nearly 40 percent of the practices will have adopted EHR technologies by spring 2006 and that another 20 percent will have these technologies by spring Even about 50 percent of the small practices with five or fewer physicians are projected to have EHRs in some stage of development by that time and 70 percent of the multispecialty groups would have these information systems. However, we have no data to validate these projections and, therefore, they must be considered with caution. We anticipate a follow-up survey in 12 to 24 months to determine whether these plans are realized. 9

11 Number of FTE Physicians Fully Implemented for All Physicians and Locations Table 9 Degree of Implementation by Practice Size Implementation in Process Degree of Implementation Implementation Planned in Next 12 Months Implementation Planned in Next 13 to 24 Months Not Implemented and No Planned Implementation in 24 Months 5 and Fewer , and Greater * , , *Weighted to reflect the response by size of group. Table 10 Degree of Implementation by Region Degree of Implementation Fully Not Implemented Geographic Implemented for Implementation Implementation and No Planned Region All Physicians Implementation Planned in Next Planned in Next Implementation in and Locations in Process 12 Months 13 to 24 Months 24 Months Eastern Section Midwest Section Southern Section , Western Section Table 11 Degree of Implementation by Specialty Type Degree of Implementation Fully Not Implemented Practice Implemented for Implementation Implementation and No Planned Specialty Type All Physicians Implementation Planned in Next Planned in Next Implementation and Locations in Process 12 Months 13 to 24 Months in 24 Months Primary Care Single Specialty Group Specialist Single Specialty Group , Multispecialty Group Table 12 Degree of Implementation by Majority Owner Degree of Implementation Fully Not Implemented Majority Implemented for Implementation Implementation and No Planned Owner All Physicians Implementation Planned in Next Planned in Next Implementation in and Locations in Process 12 Months 13 to 24 Months 24 Months Government Hospital/ Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * MSO or PPMC

12 Degree of Implementation Fully Not Implemented Majority Implemented for Implementation Implementation and No Planned Owner All Physicians Implementation Planned in Next Planned in Next Implementation in and Locations in Process 12 Months 13 to 24 Months 24 Months Physicians , University or Medical School Part of Academic Medical Institution Other *Insufficient response to support analysis. B. EHR Capabilities To further evaluate what an EHR means, we asked the practices that reported having an EHR to indicate whether they have each of a number of capabilities that one would expect in a fully functional and complete computer based system. Table 13 EHR Capabilities by Size of Medical Group (Percent of EHRs with Each Feature for Practices with an EHR Storing Information in a Relational Database) 5 and Fewer FTE 21 and Greater FTE Features the EHR has: FTE FTE Patient Demographics 99% 99% 99% 100% 99% Visit/Encounter Notes 98% 96% 99% 98% 98% Patient Medications/Prescriptions 96% 97% 98% 98% 97% Presenting Complaint 96% 97% 99% 95% 96% Physical Exam/Review of Systems 97% 96% 97% 96% 97% Past Medical History 95% 95% 99% 95% 95% Problem Lists 94% 93% 94% 96% 94% Procedure/Operative Notes 92% 93% 97% 96% 93% Laboratory Results 89% 87% 94% 97% 89% Drug Interaction Warnings 79% 75% 81% 84% 79% Radiology/Imaging Results 75% 72% 87% 89% 76% Consult/Reports From Specialists 78% 81% 86% 84% 80% Referrals to Specialists 84% 79% 78% 77% 82% Drug Reference Information 76% 80% 78% 79% 77% Immunization Tracking 80% 72% 64% 75% 76% Drug Formularies 62% 64% 67% 68% 63% Clinical Guidelines and Protocols 64% 62% 71% 64% 64% Integration with Practice Billing System 84% 83% 83% 75% 83% 11

13 These data suggest that smaller practices tend to have EHRs with about the same capabilities as larger practices. Overall the EHRs have extensive capabilities in all areas. The notable exceptions are clinical guideline protocols and prescription drug controls. From a quality of care perspective this indicates that prevention reminders are less prominent than expected and that many practices with EHRs still do not have prescription drug warning system or clinical guideline support mechanisms. C. Do EHRs Improve the Performance of Group Practices? To address this issue, we asked the respondents to provide a subjective evaluation of the contribution of the EHRs to their practices. Only those practices with EHRs were included in this analysis. We asked the respondents to address the following areas, using a five point scale where 1 = no value, 2 = marginal value, 3 = some value, 4 = important value and 5 = very important value. The following table provides the mean value for all practices with EHRs for each area of potential contribution. We examined the differences in EHR features by size of practice and found that the differences were small and not consistently related to size (data not shown). Table 14 - Perceived Benefits of an EHR to the Practice Benefit to the Practice of: Mean Rating Improved Access to Medical Record Information 4.60 Improved Work Flow 4.49 Improved Patient Communications 4.28 Improved Accuracy for Coding Evaluation and Management Procedures 4.28 Improved Drug Refill Capabilities 4.21 Reduced Medication Errors 4.19 Improved Charge Capture 4.16 Improved Clinical Decision Making 4.15 Improved Claim Submission Process 4.13 Reduced Medical Records Staff Expenses 3.96 Reduced Medical Records Storage Costs 3.92 Reduced Transcription Costs 3.92 Reduced Medical Records Transportation Costs 3.64 Improved Physician Recruitment

14 There are three important findings from these data. First, the scores are very high. The administrators clearly believe that the EHRs make significant contributions to their group practices. Second, one would expect improved access to medical record information to be one of the most important functions of EHRs, and this benefit received the highest score from the respondents. The second highest rated benefit is improved workflow in the practice. It has been pointed out that redesigning and improving workflow is a critical partner of implementing information technology if benefits of the latter are to be realized. Finally, contrary to anecdotal information, the areas related to cost savings received generally lower scores. Whether this results from a lag in achieving savings or the possibility that there are few savings is unknown. D. EHR Implementation Costs The cost of buying and implementing an EHR is noted in several studies as a major factor limiting adoption of these technologies. We asked the practices with EHRs to provide cost data and to estimate any cost overruns. As shown in the following tables, the mean cost of a fully implemented EHR for all practices is about $30,000 per physician. These costs are slightly higher for smaller practices and lower for larger practices. Median initial cost is lower than the mean, reflecting particularly high costs reported by some respondents. The maintenance fees are around $1,000 per physician per year. Smaller practices have lower maintenance costs per physician. An important finding is that overrun costs are quite high averaging greater than 20 percent. This probably reflects the uncertainty in the EHR field and the lack of group practice administrators and physicians with extensive experience in this area. It certainly raises a flag for future EHR adoption strategies. 13

15 Table 15 EHR Purchase and Implementation Cost per FTE Physician by Practice Size for Practices with an EHR Storing Information in a Relational Database Number of FTE Physicians N Mean Standard Deviation Median Under and Greater $37,204 $29,846 $32,700 $24,988 $32,606 $32,579 $29,445 $31,940 $17,971 $30,080 $28,750 $21,738 $25,000 $25,000 $25,000 Table 16 EHR per Month Maintenance Cost per FTE Physician for Practices with an EHR Storing Information in a Relational Database Number of FTE Standard Physicians N Mean Deviation Median Under $896 $1,664 $ $1,267 $1,922 $ $1,496 $2,143 $ and Greater 38 $1,371 $3,787 $ $1,177 $2,240 $500 Table 17 Percent EHR Implementation Costs Were Greater Than the Initial Vendor Estimate by Practice Size for Practices with an EHR Storing Information in a Regional Database Number of FTE Standard Physicians N Mean Deviation Median Under % 22.3% 15.0% % 33.8% 15.0% % 47.9% 12.0% 21 and Greater % 38.7% 20.0% % 33.7% 15.0% E. Other Electronic Information Systems Capabilities 1. Prescription Drug Ordering and Control Systems The relevant survey questions are as follows: 8. What best describes the prescription writing system currently used in your practice? (Check only one box) 1 Manual system using paper documents, fax and telephone requests 2 system where practice staff use computer terminals, PDAs or other electronic means to write a prescription 3 system where practice physicians use computer terminals, PDAs or other electronic means to write a prescription 4 Combination of the responses above 5 Other 14

16 9. What best describes the prescription refill system currently used in your practice? (Check only one box) 1 Manual system using paper documents, fax and telephone communications 2 system where practice staff use computer terminals, PDAs or other electronic means to communicate with a pharmacy to refill a prescription 3 system where practice physicians use computer terminals, PDAs or other electronic means to communicate with a pharmacy to refill a prescription 4 Combination of the responses above 5 Other As shown in the following tables, most of the prescription drug transactions are still being done manually. This is true of writing new prescriptions and for refills. Larger practices have higher levels of computer-based systems but overall less than 25 percent of the practices write and reorder prescriptions using some computer based information systems, and this doesn t vary by more than two or three percent regionally, although multispecialty groups and medical school practices have higher rates. However, this is slightly higher than the number of practices that report having an EHR. Consequently, it appears that these two information systems are not dependent on each other. To explore this further, we examined the prescription drug data by those with and without an EHR. As shown in Table 26, computerization of the prescription drug and EHR systems are related but not tightly coupled (practices with EHRs are more likely to use computerized mechanisms for prescriptions) and it appears that the drug ordering systems quite often are in place before the EHR is adopted because the practices with plans to implement EHRs at a future date have higher rates of drug ordering systems compared to those with no EHR plans. 15

17 Table 18 Type of Prescription Writing System by Practice Size Type of Prescription Writing System Manual System Number of of Paper FTE Documents, Fax Staff Using Physicians Physicians and Telephone Terminals or Using Terminals Combination of Requests PDAs or PDAs Responses Other 5 and Fewer 1, , and Greater * 2, , *Weighted to reflect the response by size of group. Geographic Section Table 19 Type of Prescription Writing System by Region Manual System of Paper Documents, Fax and Telephone Requests Staff Using Terminals or PDAs Type of Prescription Writing System Physicians Using Terminals or PDAs Combination of Responses Other Eastern Section Midwest Section Southern Section , Western Section Practice Specialty Type Table 20 Type of Prescription Writing System by Specialty Type Manual System of Paper Documents, Fax and Telephone Requests Staff Using Terminals or PDAs Type of Prescription Writing System Physicians Using Terminals or PDAs Combination of Responses Other Primary Care Single Specialty Group Specialist Single Specialty Group 1, , Multispecialty Group

18 Majority Owner Table 21 Type of Prescription Writing System by Majority Owner Manual System of Paper Documents, Fax and Telephone Requests Staff Using Terminals or PDAs Type of Prescription Writing System Physicians Using Terminals or PDAs Combination of Responses Other Government Hospital/ Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * MSO or PPMC Physicians 1, , University or Medical School Part of Academic Medical Institution Other *Insufficient response to support analysis. Table 22 Type of Prescription Refill System by Practice Size Type of Prescription Refill System Manual System Number of of Paper FTE Documents, Fax Staff Using Physicians Physicians and Telephone Terminals or Using Terminals Combination of Requests PDAs or PDAs Responses Other 5 and Fewer 1, , and Greater * 2, , *Weighted to reflect the response by size of group. Geographic Section Manual System of Paper Documents, Fax and Telephone Requests Table 23 Type of Prescription Refill System by Region Staff Using Terminals or PDAs Type of Prescription Refill System Physicians Using Terminals or PDAs Combination of Responses Other Eastern Section Midwest Section Southern Section , Western Section

19 Practice Specialty Type Table 24 Type of Prescription Refill System by Specialty Type Manual System of Paper Documents, Fax and Telephone Requests Staff Using Terminals or PDAs Type of Prescription Refill System Physicians Using Terminals or PDAs Combination of Responses Other Primary Care Single Specialty Group Specialist Single Specialty Group 1, , Multispecialty Group Majority Owner Table 25 Type of Prescription Refill System by Majority Owner Manual System of Paper Documents, Fax and Telephone Requests Staff Using Terminals or PDAs Type of Prescription Refill System Physicians Using Terminals or PDAs Combination of Responses Other Government Hospital/ Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * MSO or PPMC Physicians 1, , University or Medical School Part of Academic Medical Institution Other *Insufficient response to support analysis. 18

20 Table 26 Type of Prescription Writing System by Degree of EHR Implementation Degree of Implementatio n Manual System of Paper Documents, Fax and Telephone Requests Staff Using Terminals or PDAs Type of Prescription Writing System Physicians Using Terminals or PDAs Combination of Responses Other Fully Implemented for all Physicians and Locations Implementation in Process Implementation Planned in Next 12 Months Implementation Planned in Next 13 to 24 Months Not Implemented and No Planned Implementation in 24 Months 1, , Drug Interaction Warning Systems The type of information systems used in these practices to prevent drug errors doesn t follow either the drug ordering or EHR patterns. Fewer than 15 percent of the practices have computer-based drug interaction warning systems although another percent reports some combination of computer plus manual systems to prevent these errors. There are two important findings from this analysis. First, it appears that practices invest in drug ordering information technologies more often than in the patient safety components of these technologies. Second, about one-sixth of the practices that have adopted EHRs and report them to be fully implemented do not report having electronic drug interaction warning systems in place (data not shown). Whether they never added this feature to their EHR or locked it out because of dissatisfaction with the performance is unknown. As with most aspects of computerization, smaller practices 19

21 have lower use of computerized drug interaction warning systems than larger practices (Table 27). Number of FTE Physicians Table 27 Type of Drug Interaction Warning System by Practice Size Manual System Using Publications Type of Drug Interaction Warning System System Combination of Responses Practice Does Not Routinely Screen for Drug Interactions Other 5 and Fewer , and Greater * 1, , *Weighted to reflect the response by size of group. Table 28 Type of Drug Interaction Warning System by Region Type of Drug Interaction Warning System Practice Does Geographic Manual System Not Routinely Section Using Combination of Screen for Drug Publications System Responses Interactions Other Eastern Section Midwest Section Southern Section Western Section Table 29 Type of Drug Interaction Warning System by Specialty Type Type of Drug Interaction Warning System Practice Does Practice Manual System Not Routinely Specialty Type Using Combination of Screen for Drug Publications System Responses Interactions Other Primary Care Single Specialty Group Specialist Single Specialty Group , Multispecialty Group

22 Table 30 Type of Drug Interaction Warning System by Majority Owner Type of Drug Interaction Warning System Practice Does Majority Manual System Not Routinely Owner Using Combination of Screen for Drug Publications System Responses Interactions Other Government Hospital/ Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * MSO or PPMC Physicians 1, , University or Medical School Part of Academic Medical Institution Other *Insufficient response to support analysis. 3. Type of Referral Authorization and Tracking System The relevant survey questions are as follows: 2. What best describes the referral authorization system currently used in your practice? (Check only one box) 1 Manual system utilizing telephone or fax contacts with payers and paper documentation 2 Hybrid system with telephone or fax contacts with payers and computerized electronic tracking 3 system directly linked to HMO/PPO and other payer authorization systems and computerized electronic tracking 4 Combination of the responses above 5 Other 3. What best describes the referral tracking system currently used in your practice? (Check only one box) 1 Manual system that tracks if a consult was requested and if a consulting physician's report was received 2 system that tracks if a consult was requested and if a consulting physician's report was received 3 system that tracks if a consult was requested and if a consulting physician's report was received and can receive an electronic version of the consulting report for inclusion into the patient medical record 4 Combination of the responses above 21

23 5 Practice does not track referrals 6 Other Our data indicate that computer based systems are used more extensively to manage patient referrals than to order or monitor prescription drugs. About two-thirds of the practices use some type of computer-based information system to obtain authorization to refer a patient for specialist consults or hospital care. While smaller practices still rely heavily on telephone and paper authorization systems, over half use some computer-assisted process to obtain approval. In part, this might reflect the pressures from health insurance plans to encourage electronic communication with the practices serving their enrollees. It is interesting to note that the Midwest appears to lag behind the other regions in this regard with the eastern region the most advanced. The referral tracking systems follow the same pattern as the authorization systems indicating that they probably share some of the same computer technology. However, it does not appear that very many practices have the capability to automatically include the consult report in the patient s medical record. The fact that about 30 percent of the responding practices track referrals or consult reports electronically is higher than expected given the relatively low rates of EHR adoption. About one-quarter of practices don t track referrals at all (Table 35). Table 31 Type of Referral Authorization System by Practice Size Type of Referral Authorization System Manual System Hybrid System Number of of Telephone of Telephone System Directly FTE Contacts and Contacts and Linked to HMO Physicians Paper Computer and PPO Combination of Documentation Tracking Systems Responses Other 5 and Fewer , and Greater * , *Weighted to reflect the response by size of group. 22

24 Geographic Section Table 32 Type of Referral Authorization System by Region Manual System of Telephone Contacts and Paper Documentation Hybrid System of Telephone Contacts and Computer Tracking Type of Referral Authorization System System Directly Linked to HMO and PPO Systems Combination of Responses Other Eastern Section Midwest Section Southern Section Western Section Practice Specialty Type Table 33 Type of Referral Authorization System by Specialty Type Manual System of Telephone Contacts and Paper Documentation Hybrid System of Telephone Contacts and Computer Tracking Type of Referral Authorization System System Directly Linked to HMO and PPO Systems Combination of Responses Other Primary Care Single Specialty Group Specialist Single Specialty Group , Multispecialty Group Majority Owner Table 34 Type of Referral Authorization System by Majority Owner Manual System of Telephone Contacts and Paper Documentation Hybrid System of Telephone Contacts and Computer Tracking Type of Referral Authorization System System Directly Linked to HMO and PPO Systems Combination of Responses Other Government Hospital/ Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * MSO or PPMC Physicians , University or Medical School Part of Academic Medical Institution Other *Insufficient response to support analysis 23

25 Table 35 Type of Referral Tracking System by Practice Size Type of Referral Tracking System Manual System Number of FTE System Tracking System Tracking Capable of Receiving Practice Does Physicians Consults and Consults and Electronic Combination Not Track Reports Reports Reports of Responses Referrals Other N % N % N % N % N % N % N % 5 and Fewer , and Greater * 1, , Geographic Section Table 36 Type of Referral Tracking System by Region Manual System Tracking System Tracking Type of Referral Tracking System System Capable of Receiving Practice Does Consults and Consults and Electronic Combination Not Track Reports Reports Reports of Responses Referrals Other N % N % N % N % N % N % N % Eastern Section Midwest Section Southern Section Western Section Table 37 Type of Referral Tracking System by Specialty Type Type of Referral Tracking System Manual System Practice System System Capable of Specialty Tracking Tracking Receiving Practice Does Type Consults and Consults and Electronic Combination Not Track Reports Reports Reports of Responses Referrals Other N % N % N % N % N % N % N % Primary Care Single Specialty Group Specialist Single Specialty Group , Multispecialty Group

26 Table 38 Type of Referral Tracking System by Majority Owner Majority Manual System Tracking System Tracking Type of Referral Tracking System System Capable of Receiving Practice Does Owner Consults and Consults and Electronic Combination Not Track Reports Reports Reports of Responses Referrals Other N % N % N % N % N % N % N % Government Hospital/ Integrated Delivery System (IDS) Insurance Company or HMO * * * * * * * * * * * * MSO or PPMC Physicians , University or Medical School Part of Academic Medical Institution Other *Insufficient response to support analysis. 4. Managing Clinical Laboratory Testing and Radiology/Imaging Studies In physician practices, as in hospitals, information technology support for ordering and receiving the results of laboratory tests has been implemented more rapidly than for many other clinical and clinical support functions. With the development of document imaging management systems (DIMS) and the digitization of radiological and other imaging studies, electronic management of ordering and reporting results of these tests is also proceeding. Some practices view the implementation of these aspects of information technology as steps toward an EHR, with lower risk at this time than implementing the complete EHR system. Our survey included four questions about management of these two clinical support functions, and we present analyses of the responses to those questions by size of practice and region of the country. Since we expect that most EHRs will include management of these functions, we also provide an analysis by the type of medical record the practice has and by the degree of actual or planned implementation of EHR. 25

27 The analyses presented in this section were based on the answers to the following four survey questions, along with demographic characteristics of the responding practices: 4. What best describes the clinical laboratory order entry system currently used in your practice? (Check only one box) 1 Manual system using paper documents, fax and telephone requests 2 system where practice staff use computer terminals, PDAs or other electronic means to order laboratory tests 3 system where practice physicians use computer terminals, PDAs or other electronic means to order laboratory tests 4 Combination of the responses above 5 Other 5. What best describes the clinical laboratory results system currently used in your practice? (Check only one box) 1 Manual system using paper documents, fax and telephone responses 2 system where practice staff use computer terminals, PDAs or other electronic means to receive laboratory test results 3 system where practice physicians use computer terminals, PDAs or other electronic means to receive laboratory test results 4 Combination of the responses above 5 Other 6. What best describes the radiology/imaging order entry system currently used in your practice? (Check only one box) 1 Manual system using paper documents, fax and telephone requests 2 system where practice staff use computer terminals, PDAs or other electronic means to order radiology/imaging procedures 3 system where practice physicians use computer terminals, PDAs or other electronic means to order radiology/imaging procedures 4 Combination of the responses above 5 Other 7. What best describes the radiology/imaging results system currently used in your practice? (Check only one box) 1 Manual system using images on film or paper 2 system where practice staff use computer terminals, PDAs or other electronic means to receive radiology/imaging procedures 3 system where practice physicians use computer terminals, PDAs or other electronic means to receive radiology/imaging procedures 26

28 4 Combination of the responses above 5 Other Size of Physician Practice The following four tables (39-42) show how practices of various sizes manage clinical laboratory and radiology/imaging ordering and results. Examination of these tables suggests: For most of these information management functions, a majority of practices rely on a manual system using paper documents, fax, and telephone. Smaller practices are more likely than larger practices to rely on a manual system. A significant fraction (about 20%) of practices of all sizes have computerized systems for managing laboratory order entry and test results, and a smaller fraction (about 10 15%) have computerized systems for ordering radiology/imaging studies and managing the results. A substantial fraction of practices of all sizes use a combination of methods to manage these functions. It is not surprising that computerization of laboratory test management is more prevalent than for imaging studies, and that computerization is greater in larger practices. We would also expect practices to use a combination of methods to manage these functions. It is likely that most practices, regardless of their commitment to becoming fully computerized or paperless, will for some time have to interact by non-electronic means with some diagnostic testing sources. For example, some radiology groups may be able neither to receive requests for studies nor to report the results by electronic means. Table 39 Percent of Practices Using Each Type of Clinical Laboratory Order Entry System by Size of Practice Type of Clinical Laboratory Order Entry System Manual System Number of of Paper FTE Documents, Fax Staff Using Physicians Physicians and Telephone Terminals or Using Terminals Combination of Requests PDAs or PDAs Responses Other 5 and Fewer , and Greater * 1, , *Weighted to reflect the response by size of group. 27