Currently Viewing:
The American Journal of Managed Care Special Issue: Health Information Technology
Improving Adherence to Cardiovascular Disease Medications With Information Technology
William M. Vollmer, PhD; Ashli A. Owen-Smith, PhD; Jeffrey O. Tom, MD, MS; Reesa Laws, BS; Diane G. Ditmer, PharmD; David H. Smith, PhD; Amy C. Waterbury, MPH; Jennifer L. Schneider, MPH; Cyndee H. Yo
Information Retrieval Pathways for Health Information Exchange in Multiple Care Settings
Patrick Kierkegaard, PhD; Rainu Kaushal, MD, MPH; and Joshua R. Vest, PhD, MPH
The 3 Key Themes in Health Information Technology
Julia Adler-Milstein, PhD
Leveraging EHRs to Improve Hospital Performance: The Role of Management
Julia Adler-Milstein, PhD; Kirstin Woody Scott, MPhil; and Ashish K. Jha, MD, MPH
Electronic Alerts and Clinician Turnover: The Influence of User Acceptance
Sylvia J. Hysong, PhD; Christiane Spitzmuller, PhD; Donna Espadas, BS; Dean F. Sittig, PhD; and Hardeep Singh, MD, MPH
Cost Implications of Human and Automated Follow-up in Ambulatory Care
Eta S. Berner, EdD; Jeffrey H. Burkhardt, PhD; Anantachai Panjamapirom, PhD; and Midge N. Ray, MSN, RN
Primary Care Capacity as Insurance Coverage Expands: Examining the Role of Health Information Technology
Renuka Tipirneni, MD, MSc; Ezinne G. Ndukwe, MPH; Melissa Riba, MS; HwaJung Choi, PhD; Regina Royan, MPH; Danielle Young, MPH; Marianne Udow-Phillips, MHSA; and Matthew M. Davis, MD, MAPP
Adoption of Electronic Prescribing for Controlled Substances Among Providers and Pharmacies
Meghan Hufstader Gabriel, PhD; Yi Yang, MD, PhD; Varun Vaidya, PhD; and Tricia Lee Wilkins, PharmD, PhD
Health Information Exchange and the Frequency of Repeat Medical Imaging
Joshua R. Vest, PhD, MPH; Rainu Kaushal, MD, MPH; Michael D. Silver, MS; Keith Hentel, MD, MS; and Lisa M. Kern, MD
Information Technology and Hospital Patient Safety: A Cross-Sectional Study of US Acute Care Hospitals
Ajit Appari, PhD; M. Eric Johnson, PhD; and Denise L. Anthony, PhD
Automated Detection of Retinal Disease
Lorens A. Helmchen, PhD; Harold P. Lehmann, MD, PhD; and Michael D. Abràmoff, MD, PhD
Trending Health Information Technology Adoption Among New York Nursing Homes
Erika L. Abramson, MD, MS; Alison Edwards, MS; Michael Silver, MS; Rainu Kaushal, MD, MPH; and the HITEC investigators
Currently Reading
Electronic Health Record Availability Among Advanced Practice Registered Nurses and Physicians
Janet M. Coffman, PhD, MPP, MA; Joanne Spetz, PhD; Kevin Grumbach, MD; Margaret Fix, MPH; and Andrew B. Bindman, MD
Overcoming Barriers to a Research-Ready National Commercial Claims Database
David Newman, JD, PhD; Carolina-Nicole Herrera, MA; and Stephen T. Parente, PhD
The Effects of Health Information Technology Adoption and Hospital-Physician Integration on Hospital Efficiency
Na-Eun Cho, PhD; Jongwha Chang, PhD; and Bebonchu Atems, PhD

Electronic Health Record Availability Among Advanced Practice Registered Nurses and Physicians

Janet M. Coffman, PhD, MPP, MA; Joanne Spetz, PhD; Kevin Grumbach, MD; Margaret Fix, MPH; and Andrew B. Bindman, MD
Availability of electronic health records among advanced practice nurses and physicians in California is concentrated among large practices with fewer Medicaid patients.
ABSTRACT
Objectives
To characterize availability of electronic health records (EHRs) at the primary practice locations of certified nurse midwives (CNMs), nurse practitioners (NPs), and physicians in California prior to the implementation of the state’s Medicaid EHR incentive program.

Study Design and Methods
Cross-sectional mail surveys of samples of CNMs, NPs, and physicians who have active California licenses and reside in California.

Descriptive statistics were calculated and multivariate regression analyses were estimated to identify characteristics associated with having an EHR. The following practice characteristics were included in the multivariate model: payer mix (% Medicaid), practice setting (hospital vs outpatient), and practice size. Variables for practitioner’s age, sex, and practice location were also included.

Results
For both CNMs/NPs and physicians, practice size was the strongest predictor of EHR availability. Practicing in a large or mid-sized group was associated with higher odds of having a basic EHR or an advanced EHR. Having a high percentage of Medicaid patients was associated with lower odds of having an advanced EHR. Among physicians, but not CNMs/NPs, hospital-based practice was associated with higher odds of having an advanced EHR; being over age 45 years was associated with lower odds of having any EHR.

Conclusions
The results suggest that prior to the launch of California’s Medicaid EHR incentive program, similar characteristics predicted EHR availability among both CNMs/NPs and physicians, and that availability was concentrated among large practices with fewer Medicaid patients. Future studies should assess whether Medicaid and Medicare incentive payments attenuate these relationships.

Am J Manag Care. 2014;20(11 Spec No. 17):eSP31-eSP38
We conducted surveys of the availability of electronic health records (EHRs) among certified nurse midwives (CNMs), nurse practitioners (NPs), and physicians in California prior to the launch of its Medicaid EHR incentive program.
  • CNMs and NPs were less likely than physicians to have an EHR with advanced functions.
  • For CNMs, NPs, and physicians, availability of advanced EHRs was concentrated among large practices with fewer Medicaid patients.
  • Data from this baseline survey can be combined with data from future surveys to assess whether Medicaid and Medicare incentive payments attenuate the relationship between EHR availability and practice size and payer mix.
A growing number of studies suggest that electronic health records (EHRs) can improve processes of care and outcomes for patients.1-4 The rate of EHR availability among physicians has increased substantially over the past decade. Findings from the National Ambulatory Medical Care Survey (NAMCS) suggest that the percentage of physicians with any sort of EHR increased from 18% to 72% between 2002 and 2012.5 Seeking to accelerate EHR use, the president signed the Federal Health Information Technology for Economic and Clinical Health Act into law in 2009. This legislation provides $27 billion for Medicare and Medicaid incentive payments to hospitals and certain health professionals who adopt and demonstrate “meaningful use” of EHRs.6

Surveys of physicians have found that availability of EHRs is associated with multiple factors, including practice size,7-10 practice type,10 specialty,7,8,11 and age.7,11,12 Little is known about the availability of EHRs in settings in which certified nurse midwives (CNMs) and nurse practitioners (NPs) practice. The few studies of CNMs’ or NPs’ use of EHRs that have been published have been limited to CNMs and NPs working in a single healthcare organization.13 Assessing use of EHRs by CNMs and NPs is important because their numbers have grown substantially in recent decades.14 CNMs and NPs are also among the health professionals that have been posited as potential solutions for the shortage of primary care physicians.15

This paper seeks to fill an important gap in the literature by presenting findings from a survey of California CNMs and NPs regarding their experiences with EHRs and comparing them with findings from a similar survey of California physicians. Findings from California are of nationwide importance because it is a large state representing a large share of the nation’s healthcare workforce and because health professionals in California practice in a wide range of settings, from solo practices to large multi-site, multi-specialty groups. In addition, California’s laws governing educational requirements, supervision, and prescribing for CNMs and NPs are similar to those of many other states.16

METHODS

Data Sources

The primary sources of data for this analysis are surveys of samples of CNMs, NPs, and physicians with California licenses conducted in 2011. The physician survey was fielded before California began registering providers for the Medicaid EHR incentive program and the survey of CNMs and NPs was fielded during the program’s early stages.

The sample frame for the survey of CNMs and NPs came from license and address information from the California Board of Registered Nursing. Nurses were identified as having a CNM or NP certificate, and some had dual certification. CNMs and NPs in some regions of California were oversampled to ensure adequate numbers of each type of respondent in each region. We mailed the questionnaire on October 21, 2011, accompanied by a letter indicating that completion was voluntary. The letter also included a link to an online version of the survey with login and password information. We subsequently mailed 3 reminder postcards and a second copy of the survey. Data collection closed on January 18, 2012.

We used similar methods to administer a survey to a probability sample of physicians (medical doctors; MDs) in partnership with the Medical Board of California. MDs in California must renew their licenses every 2 years. The renewal process includes completing a mandatory survey that includes questions regarding their professional activities, primary practice location, training, and demographic characteristics. For this study, we developed a 1-page, double-sided, voluntary supplemental questionnaire on EHR availability and included it in the materials sent to MDs whose license renewals were due between June 1 and July 31, 2011. Because the timing of the relicensing process is based on the applicant’s birth month, the sample was essentially random.

Study Samples

The analysis of data from the survey of CNMs and NPs was limited to respondents who were potentially eligible for Medicaid EHR incentive payments.17 We included respondents in the analysis if they lived in California, worked in a position for which certification as a CNM or NP is required, and spent at least 1% of their time providing direct patient care. A total of 4862 CNMs and NPs were eligible for inclusion in the analysis. Responses were received from 2644, resulting in a response rate of 54% among those eligible.

We mailed the physician survey to 10,353 physicians. To limit the analysis to physicians who were potentially eligible for Medicaid incentive payments, we analyzed only responses from physicians who practiced in California and who reported that they provide at least 1 hour of patient care per week. Among the 7931 eligible physicians, the response rate was 68%, yielding a final sample size of 5384 physicians.

Statistical Analysis

We calculated descriptive statistics for demographic and practice characteristics of CNMs/NPs and physicians that prior research suggests are associated with EHR availability. Frequency distributions were calculated to compare the availability of any EHR, a basic EHR, and an advanced EHR at the main practice locations of CNMs/NPs and physicians. We estimated multivariate logistic regressions to assess the association between EHR availability and characteristics of the 2 groups of health professionals. For both survey populations, we used weights to ensure that the estimates would reflect the characteristics of the populations from which the samples were drawn.

Measures of Availability of EHRs

Estimates of the percentage of practitioners who had any EHR at their main practice location were based on responses to the following question: “Does your main practice location have any type of computerized medical records system (also known as an electronic health record or an electronic medical record)?” Respondents who answered “yes” to this question were considered to have an EHR. Those who did not answer this question or who answered “no” or “don’t know” and then went on to affirmatively answer questions about availability and use of specific EHR functions were also considered to have an EHR. In most cases, the respondent skipped the question, suggesting the respondent did not notice it; those who answered “no” may have misread the question. The recoding of this question affected less than 10% of the respondents to each survey. We used definitions developed for the NAMCS EHR Supplement to classify respondents as having a “basic” or an “advanced” EHR.18,19 The specific functions of basic and advanced EHRs are listed in Table 1.

Measures of Characteristics Hypothesized to Be Associated with EHR Availability

We estimated with multivariate logistic regressions to assess the relationship between having any, a basic, or an advanced EHR and 4 practice characteristics that previous research suggests are associated with EHR availability. The regressions also controlled for age and sex.

Practice Location. We hypothesized that rural respondents would have a lower likelihood of having an EHR because rural practices often have limited financial resources relative to urban practices. A crosswalk of zip codes with the California Office of Statewide Health Planning and Development’s Medical Services Study Areas, which are based on census tracts, was used to classify zip codes for providers’ main practice locations as urban or rural.

Practice Setting. Findings from previous research suggest that EHR availability is associated with practice size and type.7-10 CNMs’, NPs’, and physicians’ practices were grouped into 5 categories derived from the survey’s response options: small practices (<10 CNMs, NPs, or physicians), mid-sized group practices (10-49 providers), large group practices (50 or more providers), community/ public clinics, and other settings. Among CNMs and NPs, “other settings” included hospitals (both inpatient and outpatient units), military medical facilities, Department of Veterans Affairs (VA) medical facilities, and other unspecified settings. Among physicians, “other settings” included military facilities, VA facilities, and other unspecified settings. Providers practicing in community/public clinics, whose patients are primarily uninsured or enrolled in Medicaid, were analyzed separately, because they may have had fewer resources available to purchase an EHR prior to the establishment of California’s Medicaid EHR incentive program.

Practice Type. We hypothesized that hospital-based CNMs, NPs, and physicians would be more likely to have EHRs at their main practice locations because hospitals have greater financial resources than physician practices and can amortize the cost of EHRs across larger numbers of providers. Consistent with the eligibility criteria for the Medicaid and Medicare EHR incentive payments,17,20 we classified CNMs, NPs, and physicians as hospital based if they reported spending 90% or more of their patient care hours in inpatient or emergency department settings.

Percentage of Medicaid Patients. We hypothesized that prior to the launching of California’s Medicaid EHR incentive program, respondents who had high percentages of Medicaid patients in their practices would be less likely to have an EHR because Medicaid typically pays lower reimbursement rates than Medicare and commercial insurers.21 Respondents were classified as having a high percentage of Medicaid patients if 50% or more of their patients were enrolled in Medicaid.

RESULTS

Demographic and Practice Characteristics of CNMs/ NPs and Physicians

Table 2 describes the demographic and practice characteristics of the CNMs, NPs, and physicians who responded to the 2 surveys. Compared with physicians, CNMs and NPs were younger, and more likely to be female, practice in a rural area, and have a high percentage of Medicaid patients in their practices. Respondents and nonrespondents were similar (results not shown).

EHR Availability

The Figure displays the percentages of CNMs/NPs and physicians who have any EHR, a basic EHR, or an advanced EHR at their main practice location. The findings indicate that access to EHRs was widespread in California in 2011 but that many of the EHRs in use did not meet the NAMCS EHR Supplement definitions of basic and advanced EHRs. CNMs and NPs were more likely to have any sort of EHR at their main practice location than physicians (78% vs 71%) and were also more likely to have a basic EHR (54% vs 49%). However, they were less likely than physicians to have an advanced EHR (24% vs 45%) that incorporated both basic features used in individual patient encounters and advanced features used to manage population health and exchange information among providers and patients.

 
Copyright AJMC 2006-2017 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up
×

Sign In

Not a member? Sign up now!