The American Journal of Managed Care April 2011
Electronic Medical Records and Efficiency and Productivity During Office Visits
Objective: To estimate the relationship between electronic medical record (EMR) use and efficiency of utilization and provider productivity during visits to US office-based physicians.
Study Design: Cross-sectional analysis of the 2006-2007 National Ambulatory Medical Care Survey.
Methods: The sample included 62,710 patient visits to 2625 physicians. EMR systems included demographics, clinical notes, prescription orders, and laboratory and imaging results. Efficiency was measured as utilization of examinations, laboratory tests, radiology procedures, health education, nonmedication treatments, and medications. Productivity was measured as total services provided per 20-minute period. Survey-weighted regressions estimated association of EMR use with services provided, visit intensity/duration, and productivity. Marginal effects were estimated by averaging across all visits and by major reason for visit.
Results: EMR use was associated with higher probability of any examination (7.7%, 95% confidence interval [CI] = 2.4%, 13.1%); any laboratory test (5.7%, 95% CI = 2.6%, 8.8%); any health education (4.9%, 95% CI = 0.2%, 9.6%); and fewer laboratory tests (−7.1%, 95% CI = −14.2%, −0.1%). During pre/post surgery visits, EMR use was associated with 7.3% (95% CI= −12.9%, −1.8%) fewer radiology procedures. EMR use was not associated with utilization of nonmedication treatments and medications, or visit duration. During routine visits for a chronic problem, EMR use was associated with 11.2% (95% CI = 5.7%, 16.8%) more diagnostic/screening services provided per 20-minute period.
Conclusions: EMR use had a mixed association with efficiency and productivity during office visits. EMRs may improve provider productivity, especially during visits for a new problem and routine chronic care.
(Am J Manag Care. 2011;17(4):296-303)
Electronic medical record (EMR) use had a mixed association with efficiency and productivity during office visits, and the relationships varied by type of service and by the major reason for the visit.
- EMR users had higher intensity and productivity of diagnostic/screening services, especially during visits for a new problem and routine visits for a chronic problem.
- Use of EMRs may alter the content of office visits and improve a provider’s productivity, which might lead to cost savings and quality improvements.
- Contrary to expectation, EMR use had no association with efficiency or productivity during visits for preventive care.
Empirical studies demonstrating the impact of EMR systems on the efficiency and quality of care in ambulatory settings have been limited.6,7 Most prior work has focused on the relationships between specific EMR functions and medication safety8 and quality of care.9,10 In contrast, relatively few studies have examined the association of EMR with efficiency of utilization and provider productivity.2,6,7 The economic benefits of integrated EMR functionality from commercial systems used in community settings remains uncertain.11
This study examined the association between EMR use and efficiency and productivity during office visits using a large-scale, nationally representative data set. The findings from this study provide important evidence of the value of health information technology in ambulatory care.
Electronic Medical Record Use and Efficiency of Utilization
In theory, EMR use has the potential to improve efficiency of utilization. An EMR system may include clinical notes, problem/medication lists, and test results. These functions can provide information about chronic conditions and prior utilization, which might reduce redundant and inappropriate diagnostic/screening services and medications. Computer-generated care suggestions and automated reminders could improve adherence to evidence-based guidelines and might increase provision of some services. Thus, in theory, EMR might increase or decrease utilization of services depending on the EMR functionality and the reason for visit.1
Prior studies of the association of EMR use with the efficiency of utilization have been limited.6,7,12,13 Some evidence suggests that EMR use can improve care for chronic illness and preventive care.14-19 However, 3 large-scale studies found little relationship between EMR use and quality of care in ambulatory settings.20-22 Whether and to what extent that EMR use is associated with the level of utilization during visits remains uncertain.
Electronic Medical Record Use and Provider Productivity
An EMR system can automate manual tasks, streamline documentation, and improve access to information. These EMR functions can support clinical decision making and might reduce physician time, at least in theory.1 Improvements in productivity could allow physicians to see more patients per day or to provide more services to the same patient during each visit.
Evidence of the impact of EMR use on provider time efficiency is mixed,23 and few studies have examined the relationship between EMR use and visit duration in ambulatory settings.24,25 Prior studies of the association of EMR use with provider productivity have also been limited, and study designs have varied in their unit of analysis.26-35 Whether and to what extent that EMR use is associated with visit intensity, duration, and productivity per visit remains an open question.
The study used data from the public use version of the National Ambulatory Medical Care Survey (NAMCS) from 2006 and 2007. Conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention, the NAMCS is a survey of visits to US nonfederal office–based physicians. The multistage probability design is based on a random sample of physicians stratified by geographic area and specialty. Patient visits during a randomly selected week were sampled for each participating physician. Patient characteristics, reason for visit, and utilization of medical services were reported on individual patient record forms. Information about the physician and their practice, including EMR use, were captured during a separate intake survey. The NAMCS included weights for visits and physicians that allowed for the generation of nationally representative estimates. The 2006 and 2007 surveys collected information on 62,170 visits to 2625 physician respondents, and the full sample was included in the analysis.
Electronic Medical Record Use
The main variable of interest is whether the physician’s practice used an EMR system. The NAMCS asked “Does this practice use electronic medical records (not including billing records)?” The survey also asked whether the practice’s EMR system or another computerized system included any of 13 specific EMR functions (Table 1). Nonresponse and survey responses of “turned off” and “unknown” were included as not having the EMR system or function. Based on definitions developed by a consensus panel,4,36 EMR use in this study was defined as a Basic or Fully Functional EMR system with at least the minimum set of functions.
Efficiency of Utilization and Provider Productivity
The NAMCS collected details on the number and type of medical services ordered or provided during each visit. The NAMCS allowed physicians to report 2 additional diagnostic/screening services, which were classified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code. These services were included in laboratory tests if the ICD-9-CM code started with 90 or 91 and in radiology procedures if the ICD-9-CM code started with 87, 88, or 92. Measures of efficiency of utilization and provider productivity during office visits were specified based on prior literature11,37,38 and are reported in Table 2.
Major Reason for Visit
The NAMCS captured information about the patient’s major reason for visit, and each visit was classified into 1 of 5 visit types. “New problem” included visits for conditions that occurred within 3 months of the visit. “Routine visit for a chronic problem” included visits to receive care or examination for a preexisting chronic condition, illness, or injury that occurred more than 3 months prior to the visit. “Preventive care” included visits for general medical examinations and routine periodic examinations. “Flare-up of a chronic problem” included visits primarily due to sudden exacerbation of a preexisting chronic condition. “Pre/post surgery” included visits scheduled primarily for care required prior to or following surgery.
A cross-sectional analysis of pooled survey data was conducted. Two-part models of medical care utilization were specified to analyze the association of EMR use with efficiency of utilization.39 This allowed separate analyses of the relationship of EMR use with the probability of any use and the number of services provided, conditional on some utilization. All productivity measures had a highly skewed distribution and were log-transformed to approximate a normal distribution. Analyses were conducted by averaging across all visits and by major reason for visit.
Estimation was performed using Stata 10.1 software that accounted for the complex survey design. Survey-weighted probit, Poisson, and ordinary least squares regressions included patient, physician, and practice characteristics reported in eAppendix A at www.ajmc.com. Marginal effects from probit/ordinary least squares regressions and semielasticities from Poisson regressions were calculated, and results can be interpreted as the percent change in the dependent variable associated with EMR use.
Descriptive statistics for patient, physician, and practice characteristics are reported in eAppendix A. Descriptive statistics for efficiency of utilization and provider productivity during office visits are presented in eAppendix B at www.ajmc.com.
Electronic Medical Record Use in Physician Offices
Table 1 presents nationally representative estimates of physician use of EMR systems and specific EMR functions. In 2006-2007, 32.5% of US office-based physicians reported the use of any EMR system in their practice. On average, EMR systems included 7.25 out of 13 functions. Conditional on some EMR use, patient demographic information (90.2%) and clinical notes (78.4%) were the most commonly used EMR functions. Test orders sent electronically (33.7%) and electronic images returned (28.5%) were the least commonly used.
Although one-third of physicians used any EMR, only 10.9% of US office-based physicians reported the use of a Basic or Fully Functional EMR system, which included the minimum set of functions. On average, Basic/Fully Functional EMR systems included 11.11 out of 13 functions, with 94.2% having medical history and follow-up notes and 85.2% having computerized orders for tests.
Table 3 presents regression results of physician and practice characteristics associated with EMR use. Specialty, geographic region, practice size, ownership, and electronic billing/claims submission were significant predictors of EMR use. Relative to general/family practice, physicians in psychiatry (−7.7%) and pediatrics (−4.2%) had a lower probability of EMR use. Relative to the Midwest region, practices in the Northeast region were 4.7% less likely to use an EMR system. Solo practitioners had a 5.6% lower probability of EMR use than physicians in partnerships/group practices. Relative to practices owned by a physician/physician group, practices owned by an HMO and practices owned by a corporation/other were 43.8% and 12.2% more likely, respectively, to use EMRs. Practices with electronic billing/claims submission had a 5.4% higher probability of EMR use. Metropolitan status, the number of managed care contracts, and percentage of revenue from managed care had no significant association with EMR use.
Patients of EMR users differed from nonusers in some characteristics (eAppendix A). Patient age, race, chronic conditions, and insurance status were different for physicians with EMR use. Patients of EMR users were less likely to be children (aged 17 years and under) and to have Medicaid or self-pay insurance, but were more likely to be aged 18 to 44 years, to be other race, and to have hyperlipidemia, diabetes, and private insurance.
Electronic Medical Record Use and Efficiency of Utilization