Published Online: October 23, 2013
Vaishali Patel, PhD, MPH; Matthew J. Swain, MPH; Jennifer King, PhD; and Michael F. Furukawa, PhD
Objectives: To provide national estimates of physician capability to electronically share clinical information with other providers and to describe variation in exchange capability across states and electronic health record (EHR) vendors using the 2011 National Ambulatory Medical Care Survey Electronic Medical Record Supplement.
Study Design: Survey of a nationally representative sample of nonfederal office–based physicians who provide direct patient care.
Methods: The survey was administered by mail with telephone follow-up and had a 61% weighted response rate. The overall sample consisted of 4326 respondents. We calculated estimates of electronic exchange capability at the national and state levels, and applied multivariate analyses to examine the association between the capability to exchange different types of clinical information and physician and practice characteristics.
Results: In 2011, 55% of physicians had computerized capability to send prescriptions electronically; 67% had the capability to view lab results electronically; 42% were able to incorporate lab results into their EHR; 35% were able to send lab orders electronically; and, 31% exchanged patient clinical summaries with other providers. The strongest predictor of exchange capability is adoption of an EHR. However, substantial variation exists across geography and EHR vendors in exchange capability, especially electronic exchange of clinical summaries.
Conclusions: In 2011, a majority of office-based physicians could exchange lab and medication data, and approximately one-third could exchange clinical summaries with patients or other providers. EHRs serve as a key mechanism by which physicians can exchange clinical data, though physicians’ capability to exchange varies by vendor and by state.
Am J Manag Care. 2013;19(10):835-843
Physicians’ ability to access key clinical information electronically in a timely manner can potentially improve the safety, quality, and efficiency of patient care.
Our findings indicate that the majority of US physicians have the capability to exchange laboratory and pharmacy data electronically.
One-third of physicians are capable of exchanging clinical summaries with patients or other providers.
Electronic health records (EHRs) could serve as a primary means for exchange of clinical information, but there is variation in exchange capability among EHR products.
The capability to electronically share and view clinical data has the potential to enable clinical information to follow patients wherever they go to seek care and thereby improve the safety, quality, and efficiency of healthcare.1 Despite promising benefits, historically physicians have not exchanged clinical information electronically due to the high costs associated with implementation and limited incentives for data sharing.2 Exchange activity has largely been confined to regions of the country where there are operational health information organizations that support clinical data exchange within their community.3 Furthermore, physicians have typically had to use stand-alone e-prescribing systems or proprietary portals that support the exchange of specific types of clinical data (eg, viewing lab data), which can be costly, difficult to incorporate into their clinical work flow, and possess limited capability to support integrated data as with an electronic health record (EHR).4-7
A number of federal programs and other initiatives are under way to help address some of these barriers. The Health Information echnology for Economic and Clinical Health (HITECH) Act of 2009 includes up to $22.5 billion in financial incentives for eligible professionals who demonstrate “meaningful use” of interoperable EHRs capable of electronic exchange. HITECH also awarded more than $540 million to the Office of the National Coordinator for Health Information Technology (ONC) State Health Information Exchange (HIE) Program, which provides support for state-designated entities to ensure mechanisms are in place to enable providers to exchange clinical information.8 Furthermore, ONC’s Health Information Technology Certification Program seeks to ensure that EHR products include functionality that enables electronic exchange.9 In addition to the HITECH incentives and programs, a public-private initiative provides relatively simple technical solutions to enable directed exchange between 2 known providers.10 A community of participants from the public and private sector focus on providing tools, services, and guidance to promote functional interoperability.11
In the first stage of meaningful use, it was sufficient for providers to perform a test to demonstrate their EHR’s capacity to electronically exchange information.12,13 Stage 2 meaningful use requirements related to HIE have evolved to become more advanced. Physicians must go beyond demonstrating capability to exchange; they must actually electronically exchange key clinical data among providers and patient-authorized entities. Additionally, physicians must demonstrate the capability to send summary-of-care documents electronically to recipients with a different EHR vendor.14
Yet little is known about current physician capability to electronically exchange clinical information at a national or state level, both of which are relevant in implementing ONC’s strategy and in assessing its potential for success. We used a nationally representative survey of office-based physicians conducted in 2011 to provide a snapshot of physicians’ capability to electronically exchange clinical information associated with key national priorities: pharmacy exchange(e-prescribing), laboratory exchange (including receipt of results and lab orders), and clinical summary exchange with patients and providers.15 This assessment provides both a portrait of exchange capability as of stage 1 meaningful use and a baseline for monitoring progress going forward as new policies and initiatives to accelerate HIE are implemented—in particular, stage 2 meaningful use. Future trends in physicians’ HIE capability could help assess the effectiveness of these policies. We describe physician exchange capability geographically across states and by EHR vendor. Finally, we examined the association between physician and practice characteristics, including adoption of EHRs, with physician capability to exchange different types of clinical information.
Data Source and Collection
We analyzed the 2011 National Ambulatory Medical Care Survey Electronic Medical Record Supplement (NAMCS EMR supplement), a cross-sectional nationally representative survey of nonfederal office–based physicians who provide direct patient care.16 The overall sample consisted of 4326 hysician respondents, with a 61% weighted response rate. The sample size is sufficient to generate state-level estimates.
Measures of Electronic Exchange of Clinical Information
The NAMCS EMR supplement asks physicians to report on their practices’ capability to electronically exchange key types of clinical information, including pharmacy data, laboratory data, and patient clinical summaries (eAppendix A, available at www.ajmc.com).
To assess the capability of physicians to send pharmacy data and to send and receive laboratory data, we examined the percentage of physicians with the ability to send prescriptions electronically, send lab orders electronically, view lab results electronically, and incorporate lab results into the EHR. The latter item provides an indication of whether physicians receive results in a structured format that enables them to view and track individual test results.
To assess the capability of physicians to exchange patient clinical summaries, we examined the percentage of physicians who indicated that they “exchange patient clinical summaries electronically with any other providers” by either receiving and/or sending patient clinical summaries. This measure goes beyond capability to exchange, capturing actual exchange activity.
We calculated estimates of the electronic exchange measures at the national and state levels, and examined whether physicians’ capability to exchange these types of clinical information at the state level differed from the national average. We used t tests to test for significant differences at the P <.05 level.
We used multivariate analyses to examine the association between the capability to exchange different types of clinical information and physician and practice characteristics, including EHR adoption and state fixed effects to control for confounding within each state. Given the dichotomous nature of the dependent variables, we estimated probit regression models and used the regression results to calculate the incremental effects associated with each independent variable (all were categorical variables). These incremental effects represent the percentage point change in the outcome that is associated with a given characteristic (compared with a reference category). Analyses were conducted using Stata 12.0 (StataCorp, College Station, Texas). We used weights to account for nonresponse and standard errors, which were adjusted to account for the complex sample design.
We assessed the extent to which exchange capability varied by vendor. We only included vendors that had at least 1% of the market share (representing a total of 55% of physicians with EHRs). Vendors with at least 1% of the market share included the following: Allscripts, Cerner, eClinicalWorks, Epic, eMDs, GE/Centricity, Greenway Medical, NextGen, and Sage.
Physicians’ capability to electronically exchange clinical data varied by type of information (Figure 1). More than half of all physicians (55%) reported that their practices have computerized capability to e-prescribe. A majority of physicians (67%) reported that they are able to view lab results electronically, but fewer physicians (42%) were able to incorporate lab results into their EHR. More than one-third (35%) reported they are able to send lab orders electronically. The computerized capability to provide clinical summaries to patients was reported by 38% of physicians.
Among those physicians who reported exchanging clinical summaries with other providers (31%), approximately three-fourths (76%) reported both sending and receiving clinical summaries (eAppendix B, available at www.ajmc.com). About one-fifth (19%) of physicians reported that they send clinical summaries only to other providers. Of all physicians who exchange clinical summaries with other providers (eAppendix C, available at www.ajmc.com), the most common method of access was through an EHR vendor (64%), followed by a hospital-based system (28%).
Physicians’ capability to exchange varies by EHR adoption status (Figure 1). A large majority of physicians with an EHR have the capability to send prescriptions electronically (78%) and view lab results electronically (87%). Substantial minorities of physicians with no EHR also have these capabilities (23% and 42%, respectively), highlighting the role that stand-alone e-prescribing products and proprietary portals continue to play in facilitating physician access to pharmacy and lab result data. However, very few physicians without an EHR have the capability to electronically exchange clinical summaries and lab orders.
Physician Exchange Capability by State
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