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The Role of Health IT and Delivery System Reform in Facilitating Advanced Care Delivery
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The Role of Health IT and Delivery System Reform in Facilitating Advanced Care Delivery

Jennifer King, PhD; Vaishali Patel, PhD; Eric Jamoom, PhD; and Catherine DesRoches, DrPH
In 2012, electronic health record use and participation in accountable care organization or patient-centered medical home initiatives were associated with performing care processes expected to improve healthcare outcomes.
ABSTRACT

Objectives: To examine whether physicians using health information technology and participating in new models of payment and delivery were more likely to perform care processes associated with improved care delivery.

Study Design: Nationally representative, cross-sectional data on US office-based physicians from the 2012 National Ambulatory Medical Care Survey Physician Workflow Survey.

Methods: Multivariate regression analysis of whether physicians routinely performed 14 specific care processes in 4 categories: population management, quality measurement, patient communication, and care coordination. Key independent measures were electronic health record (EHR) use and accountable care organization (ACO) or patient-centered medical home (PCMH) participation.

Results: A majority of physicians reported routinely conduct at least 1 care process related to care coordination (89%), patient communication (69%), and population management (67%); less than half reported performing at least 1 quality measurement process routinely (44%). EHR use and ACO or PCMH participation were independently associated with a higher likelihood of performing care processes. Physicians who were using EHRs in combination with participation in ACO or PCMH initiatives had the highest likelihood of routinely performing the care processes: physicians who used an EHR and participated in ACO or PCMH initiatives were between 6 and 22 percentage points more likely to routinely perform the care processes than physicians with EHRs alone.

Conclusions: In 2012, physicians using EHRs and participating in ACO or PCMH initiatives were more likely than other physicians to be routinely engaging in care processes expected to improve healthcare outcomes. Yet, many US physicians were not performing these processes routinely. This analysis highlights several specific areas where more work is necessary to facilitate wider adoption of these activities.

Am J Manag Care. 2016;22(4):258-265
Take-Away Points

National policies are supporting the use of health information technology (IT) and testing new models of payment and delivery, such as accountable care organizations (ACO) and patient-centered medical homes (PCMH). This study examined whether use of health IT and participation in new models of care are associated with improved care delivery.
  • In 2012, physicians using electronic health records (EHRs) and participating in ACO or PCMH initiatives were more likely to routinely perform population management, quality measurement, patient communication, and care coordination processes; yet, many physicians were not performing these processes routinely.
  • There are several areas where EHRs may be important to facilitate wider adoption of these activities.
There is wide consensus that changes are necessary in the way healthcare is delivered in the United States in order to realize reductions in healthcare spending and improvements in population health outcomes.1,2 National policies currently support 2 programs that may substantially change the way care is delivered; one related to health information technology (IT) adoption and the other related to payment reform and the use of new care delivery models.3

The Health Information Technology Act (HITECH) Act of 2009 was designed to provide the infrastructure necessary for improvements in care delivery by supporting greater adoption of IT tools, including electronic health records (EHRs), which can facilitate high-quality care.4 The HITECH Act authorized the Medicare and Medicaid EHR Incentive Programs, which provide financial assistance to eligible professionals for the “meaningful use” (MU) of certified EHRs with functionalities associated with enhanced quality of care, such as electronic prescribing and medication alerts.5

Concurrently, the 2010 Affordable Care Act (ACA) is supporting the development and implementation of new delivery and payment models, such as patient-centered medical homes (PCMHs) and shared savings arrangements like accountable care organizations (ACOs). Although EHRs are not required for participation in all types of PCMH or ACO programs, it is widely believed that providers need a robust health IT infrastructure to be fully successful in these payment and delivery arrangements.6-7

Early indicators suggest strong physician participation in initiatives to support health IT adoption and to reform healthcare payment and delivery.8-12 However, evidence on whether provider participation in these initiatives has translated to better care delivery is just beginning to emerge.13-15 Areas identified as priorities for improvement include care processes, such as population management and prevention, quality measurement and reporting, care coordination, and patient engagement.2 Although studies prior to HITECH and the ACA found health IT and external reporting or payment incentives to be associated with a higher likelihood of performing these care processes, they are performed at low rates even when these factors are in place.16-20 At least 1 study of primary care physicians found evidence that those in PCMH practices using EHRs had greater quality improvements and changes in utilization over time on some measures than those in non-PCMH practices with or without EHRs.21,22

We examined 4 main questions about the relationship between EHR use, participation in new payment and delivery models, and the extent to which physicians perform care processes that may lead to improved outcomes. First, how routinely did US physicians perform population management, quality measurement, patient communication, and care coordination processes? Second, were physicians using EHRs and participating in ACO or PCMH initiatives more likely than other physicians to perform these 4 types of care processes? Third, given that health IT and new payment models often are envisioned to work symbiotically to improve care,23,24 were physicians using EHRs and participating in ACO or PCMH initiatives more likely to routinely perform these types of care processes than those using EHRs alone? Finally, since previous studies have shown room for improvement in the extent to which EHR adopters use their EHRs to engage in these care processes,25 were certain EHR-related factors associated with use of computerized tools to routinely perform these processes? The results of this study may be useful to policy makers and researchers concerned with the level of adoption of these advanced care processes and the potential policies and tools to support their greater diffusion.

METHODS 
Data Source and Analysis Sample 

We used data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Workflow Survey, the second wave of a panel survey conducted by the National Center for Health Statistics to collect nationally representative information on physicians’ attitudes toward and experiences with EHRs.26 The first wave of the Physician Workflow Survey was conducted in 2011 as a follow-up to the 2011 NAMCS Electronic Health Records Survey.27 

The sample for the 2012 NAMCS Physician Workflow Survey came from the 2011 NAMCS Electronic Health Records Survey (ie, nonfederal office-based physicians, excluding radiologists, anesthesiologists, and pathologists). Eligibility status was determined for 8198 of the 10,302 physicians sampled, and those deemed eligible were mailed the Physician Workflow questionnaire. In 2012, 2567 physicians responded for an unweighted response rate of 45%. There were no significant differences in characteristics between responders and nonresponders.

Measuring Care Processes

The 2012 NAMCS survey included 14 separate items that queried physicians on 14 specific care processes in 4 categories: population management, quality measurement, patient communication, and care coordination. For each care process, the survey asked “Is this done routinely?” (yes/no) and then “Is this process computerized?” (yes, usually/yes, sometimes/no).

Dependent Variables

Use of care processes. In the multivariate analyses described below, we used 2 sets of dependent variables. First, to examine factors associated with routinely performing the care processes overall, we assigned the dependent variables a value of 1 if the physician reported routinely performing each process, and 0 otherwise. Second, to examine EHR-related factors associated with routinely performing the care processes using computerized tools, we assigned the dependent variables a value of 1 if the physician reported the process was performed routinely and the process was computerized (either usually or sometimes), and 0 otherwise. Missing responses, which ranged from 2% to 11% across the items, were assigned the value of 0.

For ease of communicating results across the 14 processes queried in the survey, we also created 1 measure for each of the 4 categories indicating whether at least 1 of the processes in the category was performed routinely. We reported multivariate results for these category-level measures in the main text and reported multivariate results for all 14 individual processes in the eAppendix [eAppendices available at www.ajmc.com]). The results for the category-level measures were substantively similar to the results for the individual process measures.

Independent Variables

EHR use and characteristics. We measured EHR use based on the question, “Which of the following best describes [your primary practice] location’s current EHR adoption status?” with response options: 1) “We do not have an EHR system,” 2) “We are not actively using an EHR system but have one installed,” and 3) “We are actively using an EHR system.” Our main measure of EHR use assessed whether or not the physician reported their primary practice location was actively using an EHR. We also reported the percent of physicians who responded, “We are not actively using an EHR system but have one installed” or answered yes to another question, “At the reporting location, are there plans for installing a new EHR system within the next 12 months?”

We examined 3 EHR-related characteristics among physicians using EHRs: whether the EHR met MU criteria, the length of EHR experience, and the receipt of technical assistance for initial EHR implementation. Physicians who answered “yes” to the question, “Does your current system meet meaningful use criteria as defined by the Centers for Medicare & Medicaid Services (CMS)?” were considered to have EHRs that met MU criteria. Length of EHR experience was calculated based on the difference between year of the survey (ie, 2012) and year reported in response to the item: “In which year did you install your EHR system?” Receipt of technical assistance was based on questions about whether the physician’s primary practice location received assistance “in implementing an EHR system” (yes/no/uncertain) and “with training staff in using your EHR system” (yes/no/uncertain).

ACO or PCMH participation. We measured participation in ACO or PCMH arrangements based on responses to 2 questions: 1) “Does [your primary practice location] participate in an Accountable Care Organization or similar arrangement by which you may share savings with insurers (including private insurance, Medicare, Medicaid, and other public options)?” and 2) “Does [your primary practice location] receive any additional compensation beyond routine visit fees for offering Patient-Centered Medical Home (PCMH)-type services or does [the location] participate in a certified PCMH arrangement?”

In multivariate analyses (described below), we used a measure of whether or not the physician reported participating in either an ACO or PCMH arrangement. Results of sensitivity analyses examining ACO and PCMH participation as separate variables were similar to results from the combined variable (results not shown but are available on request). 

Analyses

We first conducted univariate and bivariate descriptive statistics of the key independent and dependent variables. We then performed multivariate logistic regression to examine the relationship between EHR use, ACO or PCMH participation, and routinely performing the care processes while controlling for other physician and office characteristics. We estimated 18 logistic regression models (1 for each of the 14 individual process measures and the 4 category-level measures), regressing the dependent variable (whether or not the physician routinely performed the process of interest) on whether the physician used any EHR, whether the physician participated in an ACO or PCMH, and an interaction between the EHR use and ACO/PCMH participation variables. The models also included physician and practice characteristics as control variables: physician age, physician specialty, practice size, practice ownership, practice specialty, county metropolitan status, and region (eAppendix Table 1).

To assess whether EHR use and ACO or PCMH participation were independently associated with routinely performing the care processes, we used the logistic regression results to calculate the average incremental effects of EHR use and ACO or PCMH participation. To assess whether physicians using EHRs and participating in ACO or PCMH initiatives are more likely to routinely perform these care processes than those using EHRs alone, we used the regression results to calculate predicted probabilities for combinations of the interaction. 

 
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