Physician Capability to Electronically Exchange Clinical Information, 2011 | Page 3
Published Online: October 23, 2013
Vaishali Patel, PhD, MPH; Matthew J. Swain, MPH; Jennifer King, PhD; and Michael F. Furukawa, PhD
However, our findings indicate that EHR systems do not all offer equivalent exchange capability. Although most physicians with EHRs reported capability to e-prescribe and view laboratory results, we found wide variation across EHR vendors in capabilities for lab ordering and exchange of clinical summaries. This variation may be due to how recently the physician implemented the EHR and whether the product met certification criteria requiring it to support clinical summary exchange. Some EHR vendors have designed products using outdated technology that does not enable interoperability with other systems.24 Variation in HIE capability across vendors may diminish over time as physicians upgrade their systems or purchase newer systems that meet more rigorousstage 2 meaningful use certification criteria related to HIE. The requirement to demonstrate the capability to exchange clinical summaries across different vendor platforms may increase the number of vendors offering products featuring this functionality, paving the way for an increase in the proportion of physicians using EHRs to exchange clinical care summaries with other providers. Evidence suggests that after the implementation of stage 1 meaningful use requiring physicians to e-prescribe, the proportion of providers e-prescribing on the Surescripts network using an EHR increased almost 7-fold from 7% in 2008 to 48% in 2012.25
Another potential driver of HIE is healthcare payment and delivery reform. As payment and organization continues to evolve, rewarding providers who better manage patient populations and penalizing those that do not will likely spur demand for HIE and the ability to facilitate transitions in care electronically.26 Specifically, accountable care organizations, which allow entities to share cost savings, may create a business case for HIE by giving providers greater financial incentives to exchange information regarding their patients with each other. Additionally, financial penalties for high hospital readmission rates, for example, may spur greater care coordination between hospitals and ambulatory care providers to better manage transitions of care through the use of care summaries.27,28
Physician exchange capability also varied widely across states. Prior state health information technology investment, state legislation and regulations, and existing local/regional health information organizations may help explain some of this variation.29 Furthermore, variation in EHR adoption rates may also explain these differences. Except for Vermont, all the states with above-average (relative to national) exchange capability (across multiple measures) also have significantly higher levels of EHR adoption.30 Understanding how states such as Minnesota have facilitated higher rates of physician exchange capability across a number of measures may provide other states with best practices in promoting greater exchange activity. These findings suggest that ONC's State HIE program has an important role in ensuring that physicians, regardless of their geographic location, have the capability to exchange clinical information with patients and other providers. The measures examined as part of this baseline study of exchange capability are being used by the State HIE program to monitor the performance of states and set national goals.15
In addition to EHR use, other physician and practice characteristics were associated with greater exchange capability. However, these were not as strong predictors as EHR adoption, nor were the patterns necessarily consistent across the different types of clinical data. Smaller practices have previously reported experiencing barriers to HIE, and our findings suggest that smaller practices do have less capability to exchange with pharmacies and laboratories compared with larger practices; however, we did not find differences with regard to clinical summary exchange.31 Primary care physicians’ higher rates of exchange capability compared with specialists—which persisted after controlling for EHR use—may be driven in part by primary care physicians’ greater need to exchange information with other providers to coordinate and manage their patients care.28
This study has some important limitations. These findings are based on self-reported survey data, which could not be independently verified. The survey did not capture detail on all mechanisms or tools by which physicians may exchange clinical information, including stand-alone systems or proprietary portals. Our measure of pharmacy exchange was limited; the survey did not capture potential exchange from the pharmacy or pharmacy benefit manager such as prescription renewals, eligibility/formulary verification, and medication histories.32 Nor did the survey report on whether physicians exchanged information with providers outside their practice or organization. We were also not able to measure physicians’ capability to exchange data across different EHR vendor platforms, which is required for stage 2 meaningful use. In addition to examining trends in exchange capability, future research should examine physicians’ actual use of exchange functionality.33
This baseline study of physician capability to exchange key types of clinical information found room for improvement but also a foundation on which to build and expand physician exchange capability. Our findings suggest that while most physicians possess the capability to meet certain HIE-related meaningful use requirements such as e-prescribing, physicians are less prepared to meet other upcoming stage 2 core HIE requirements such as clinical care summary exchange. It will be important to monitor these key measures of exchange capability as ambulatory providers implement EHRs meeting meaningful use stage 2 requirements and as shifts in healthcare delivery require robust exchange of health information.
Author Affiliations: From Office of the National Coordinator for Health Information Technology (VP, MJS, JK, MFF), US Department of Health and Human Services, Washington, DC.
Funding Source: None.
Author Disclosures: The authors (VP, MJS, JK, MFF) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (VP, MJS, JK, MFF); acquisition of data (VP); analysis and interpretation of data (VP, MJS, JK, MFF); drafting of the manuscript (VP, MJS, MFF); critical revision of the manuscript for important intellectual content (VP, MJS, JK, MFF); statistical analysis (JK, MFF); and supervision (MFF).
Address correspondence to: Vaishali Patel, PhD, MPH, Senior Advisor, Office of Economic Analysis Evaluation and Modeling Office of the National Coordinator for Health Information Technology, 200 Independence Ave SW, Washington, DC 20201. E-mail: firstname.lastname@example.org.
1. Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5-10-W5-18.
2. Fontaine P, Ross SE, Zink T, Schilling LM. Systematic review of health information exchange in primary care practices. J Am Board Fam Med. 2010;23(5):655-670.
3. Adler-Milstein J, Bates DW, Jha AK. A survey of health information exchange organizations in the United States: implications for meaningful use. Ann Intern Med. 2011;154(10):666-671.
4. Dullabh P, Nye C, Moiduddin A, et al. Provider experiences and perceptions of health information exchange. Poster presented at: Academy Health Annual Research Meeting; June 26, 2012; Orlando, FL.
5. Grossman JM, Kushner KL, November EA. Creating sustainable local health information exchanges: can barriers to stakeholder participation be overcome? Res Briefs. 2008;(2):1-12.
6. Desroches CM, Agarwal R, Angst CM, Fischer MA. Differences between integrated and stand-alone E-prescribing systems have implications for future use. Health Aff (Millwood). 2010;29(12):2268-2277.
7. Grossman JM, Bodenheimer TS, McKenzie K. Hospital-physician portals: the role of competition in driving clinical data exchange. Health Aff (Millwood). 2006;25(6):1629-1636.
8. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood). 2010;29(6):1214-1219.
9. Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. Health information technology: initial set of standards, implementation, specifications, and certification criteria for electronic health record technology: final rule. Fed Regist. 2010;75(144):44590-44654.
10. Williams C, Mostashari F, Mertz K, Hogin E, Atwal P. From the Office of the National Coordinator: the strategy for advancing the exchange of health information [published correction appears in Health Aff (Millwood). 2012;31(3):886]. Health Aff (Millwood). 2012;31(3):527-536.
11. Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. Standard and Interoperability Framework Wiki. http://wiki.siframework.org/. Accessed January 31, 2013.
12. Marcotte L, Seidman J, Trudel K, et al. Achieving meaningful use of health information technology. Arch Intern Med. 2012;172(9):731-736.
13. Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare and Medicaid programs: electronic health record incentive program: final rule. Fed Regist. 2010. 2010; 75(144):44313-44588.
14. Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare and Medicaid programs: electronic health record incentive program—stage 2: final rule. Fed Regist. 2012;77(171):53967-534162.
15. The Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. Program Information Notice: Requirements and Recommendations for the State Health Information Exchange Cooperative Agreement Program [ONCHIE- PIN-002]. http://statehieresources.org/wp-content/uploads/2010/12/ONC-PIN-February-2012.pdf. Published February 8, 2012. Accessed January 31, 2013.
16. Hsiao CJ, Decker SL, Hing E, Sisk JE. Most physicians were eligible for federal incentives in 2011, but few had EHR systems that met meaningful use criteria. Health Aff (Millwood). 2012;31(5):1100-1107.
17. Gold MR, McLaughlin CG, Devers KJ, Berenson RA, Bovbjerg RR. Obtaining providers’ ‘buy-in’ and establishing effective means of information exchange will be critical to HITECH’s success. Health Aff (Millwood). 2012;31(3):514-526.
18. Surescripts. The National Progress Report on ePrescribing and Interoperable Health Care. Year 2011. http://www.surescripts.com/downloads/nprNational%20Progress%20Report%20on%20E%20Prescribing%20Year%202011.pdf. Published 2011. Accessed August 28, 2012.
19. Hufstader M, Furukawa M, Vaidya V. Emerging and encouraging trends in e-prescribing. Am J Manag Care. In press.
20. The Lewin Group, for the California Healthcare Foundation. Under the Microscope: Trends in Laboratory Medicine. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/L/PDF%20LabDataTrends.pdf. Published April 2009. Accessed June 7, 2012.
21. Kern LM, Barrón Y, Blair AJ 3rd, et al. Electronic result viewing and quality of care in small group practices. J Gen Intern Med. 2008;23(4): 405-410.
22. Kern LM, Barrón Y, Dhopeshwarkar RV, Kaushal R. Health information exchange and ambulatory quality of care. Appl Clin Inform. 2012; 3(2):197-209.
23. Kellerman AL, Jones SS. What it will take to achieve the as-yetunfulfilled promises of health information technology. Health Aff (Millwood). 2013;32(1):63-68.
24. Mandl KD, Kohane IS. Escaping the EHR trap—the future of health IT. N Engl J Med. 2012;366(24):2240-2242.
25. Hufstader M, Swain M, Furukawa MF. State variation in e-prescribing trends in the United States. ONC Data Brief, no. 4. Office of the National Coordinator for Health Information Technology. http://www.healthit.gov/sites/default/files/us_e-prescribingtrends_onc_brief_4_nov2012.pdf. Published November 2012. Accessed January 31, 2013.
26. Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306(16): 1794-1795.
27. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care in practice. Health Aff (Millwood). 2010;29(5):982-990.
28. Bates D, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood). 2010;29(4):614-621.
29. National Conference of State Legislatures. Health Information Technology and States: A Project Report From NCSL’s Health Information Technology Champions. http://www.ncsl.org/print/health/forum/HITCH_report.pdf. Published February 2009. Accessed June 7, 2012.
30. Hsiao CJ, Hing E, Socey TC, Cai B. Electronic health record systems and intent to apply for meaningful use incentives among office-based physician practices: United States, 2001-2011. NCHS Data Brief. 2011;(79):1-8.
31. Fontaine P, Zink T, Boyle RG, Kralewski J. Health information exchange: participation by Minnesota primary care practices. Arch Intern Med. 2010;170(7):622-629.
32. Grossman JM, Cross DA, Boukus ER, Cohen GR. Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies. J Am Med Inform Assoc. 2012;19(3):353-359.
33. Vest JR, Jasperson J. What should we measure? conceptualizing usage in health information exchange. J Am Med Inform Assoc. 2010; 17(3):302-307