Vaishali Patel, PhD

 To assess US hospital engagement in the 4 core domains of interoperability (find, send, receive, integrate) and whether engaging in these domains is associated with electronic availability of clinical data from outside providers.

 Analysis of the American Hospital Association (AHA) Annual Survey of Hospitals and the American Hospital Association (AHA) Annual Survey of Hospitals - IT Supplement datasets for 2014. Respondents included 3307 US hospitals to the AHA Annual Survey — IT Supplement. We created measures of hospital engagement in 4 core domains of interoperability, as well as access to electronic clinical data from outside providers. Regression analysis was to identify hospital characteristics associated with each measure.

 Twenty-one percent of US hospitals engaged in all 4 interoperability domains, and 25% engaged in none. Hospitals engaged in all 4 domains were more likely to have a “basic” (odds ratio [OR], 3.53; 

 <.01) or “comprehensive” (OR, 5.04; 

<.01) electronic health record (EHR) in comparison to a less than “basic” EHR, participate in a Regional Health Information Organization (OR, 4.29; 

<.01), use a single EHR vendor (OR, 2.15; 

<.01), and have a third-party health information exchange vendor (OR, 2.32; 

 <.01). They also differed by non-IT characteristics, such as medical home participation (OR, 1.77; 

<.01) information were more likely to report routine clinical information availability from outside providers.

 The one-fifth of US hospitals engaged in key domains of interoperability were more likely to have certain information technology infrastructure and participate in delivery reform. Encouragingly, interoperability engagement was associated with routine clinical information availability. Our results point to the need for ongoing efforts to expand interoperability, with the potential benefit of better information availability for clinicians and better care.

	The Office of the National Coordinator for Health Information Technology (IT) has defined 4 domains of interoperability: find, send, receive, and integrate patient health information from outside sources. We evaluated the current state of US hospitals’ engagement in interoperability:

		Only 21% of all US hospitals engage in all 4 domains of interoperability.

		Health IT infrastructure, such as robust electronic health record systems and health information organization participation, and delivery reform engagement are positively associated with engagement in all 4 domains.

		Three of the 4 domains—finding, receiving, and integrating&mdash;are significantly associated with provider access to patient information from outside providers.

		Hospitals that have invested in interoperability capabilities appear to have better access to patient information. However, given that less than 1 in 4 hospitals have these capabilities, additional policy interventions to encourage interoperability are needed.

Following the large increase in electronic health record (EHR) adoption in US hospitals over the past 6 years,

 attention is increasingly focused on ensuring that EHRs can exchange and integrate patient data. Interoperability is expected to generate substantial gains in quality and efficiency by reducing redundant care

 and improving care coordination through better frontline clinician access to information.

 It is also expected to be a key enabler of population-based payment and care delivery reform models through data aggregation

 and information technology (IT)—enabled performance measurement.

 are devoting substantial resources to increase interoperability by enhancing technical capabilities, as well as by addressing governance, financial, and policy issues.

In order to track progress and inform policy efforts, it is critical to assess where we stand today.

 Prior research has tracked EHR adoption over time and found that hospital characteristics, such as size, location, and ownership, are associated with adoption.

 A related set of studies have examined hospital characteristics associated with engaging in specific forms of electronic health information sharing; for example, private nonprofit hospitals and hospitals that were part of a healthcare system were more likely to participate in a community or Regional Health Information Organization (RHIO).

 A key difference between the 2 literatures is that the former uses a functionality-based, technology-agnostic definition of EHRs to assess adoption patterns,

 whereas the latter has lacked such a definition. We therefore took advantage of the recent effort by the Office of the National Coordinator for Health IT (ONC) to create a similar functionality-based, technology-agnostic definition of interoperability

 in order to begin to measure and track interoperability in a consistent and comparable way over time.

The definition includes 4 key domains: find, send, receive, and integrate,

 reflecting the fact that interoperability is comprised of multiple processes. Finding information involves the ability to query for patient data from outside institutions, and is a critical capability for unplanned care, such as emergency department visits. Sending and receiving can enable providers to exchange patient information during planned care transitions, such as referrals or following hospital discharge. Integrating patient information is the key capability that distinguishes interoperability from health information exchange (HIE); interoperability requires both that information is shared electronically and that no special effort on behalf of the user is needed to integrate that information into the provider’s EHR.

 Taken together, these 4 domains capture the core components of interoperability required for varied use cases in which provider organizations need to share information electronically.

Using these 4 domains as a framework, we sought to capture a current picture of interoperability in US hospitals, assess how interoperability varies by hospital characteristics—including health IT infrastructure, payment reform participation, and other demographics&mdash; and examine whether interoperability is associated with electronic availability of information from outside organizations at the point of care. We used data from the 2014 American Hospital Association (AHA) Annual Survey of Hospitals — IT Supplement  that included new questions on these capabilities. Our study is therefore the first to our knowledge to use this new functionality-based definition of interoperability, and offers a set of benchmark measures against which future progress can be assessed. This is critical to inform the wide array of efforts currently underway to ensure that disparate EHRs can provide clinicians access to complete patient information.

Our study relied on data from 3 sources. We used data from the 2014 AHA IT Supplement to capture hospital engagement in the 4 domains of interoperability along with other measures of hospital characteristics.

 This survey is sent annually to the CEO of every hospital in the United States, and he or she is asked to complete it or delegate completion to a knowledgeable person in the organization. The 2014 AHA IT Supplement was fielded between November 2014 and February 2015, was sent to 6377 hospitals, and received 3307 responses.

Our second source of data was the 2014 AHA Annual Survey, fielded in the same manner as the 2014 AHA IT Supplement Survey, which we used to create additional measures of hospital characteristics.

 Finally, we used Stage 2 Meaningful Use attestation data from CMS’ 2015 Medicare Electronic Health Record Incentive Program Eligible Professionals Public Use File, which allowed us to measure the density of potential ambulatory partners with electronic exchange capabilities in each hospital’s market.

 Our primary analytic sample included all hospitals that responded to the 2014 AHA IT Supplement, for a total of 3307 hospitals. Although previous studies examining national health IT adoption and Meaningful Use engagement have typically limited the sample to nonfederal, general acute care hospitals, we decided to include federal and specialty hospitals as these hospitals deliver care that would benefit from engagement in interoperability.

We created 4 dichotomous measures to capture whether or not each hospital was engaged in each of the 4 interoperability domains. We also created variables to capture all the possible combinations of engagement in the 4 domains (eg, send only, send and receive only).

 We defined finding data using the question, “Do providers at your hospital query electronically for patients’ health information (eg, medications, outside encounters) from sources outside your organization or hospital system?” We considered hospitals that responded “yes” as finding (querying) data.

 We defined sending and receiving data using questions that asked, “When a patient transitions to another care setting or organization outside your hospital system, how does your hospital routinely send and/or receive a summary of care record?” For sending, providers who responded “yes” to 1 or more of the following options—“secure messaging using EHR (via direct or other secure protocol),” “provider portal,” or “via health information exchange organization or other third party”&mdash;were considered to be electronically sending data. The question offered the same options for “receive” and so we created an equivalent variable (eAppendix Table A [

 We measured integrating data using responses to the question, “Does your EHR integrate any type of clinical information received electronically (not eFax) from providers or sources outside your hospital system/organization without the need for manual entry? This could be done using software to convert scanned documents into indexed, discrete data that can be integrated into EHR.” We considered respondents who answered “yes, routinely” or “yes, but not routinely” as integrating data.

Availability of Information From Outside Organizations

We used a new question on the 2014 AHA IT Supplement to create a dichotomous measure of whether providers in the hospital routinely had clinical information electronically available from outside providers or sources when needed. The question asked, “Do providers at your hospital routinely have necessary clinical information available electronically from outside providers or sources when treating a patient who was seen by another healthcare provider/setting?” We classified “yes” responses as providers had the clinical information they needed for patients who had been seen at outside providers.

We selected hospital characteristics, which fall into 3 categories—IT, organizational, and exchange partners&mdash;that we expected would be associated with engagement in interoperability domains. Our selection was based on prior studies examining characteristics associated with EHR adoption and participation in health information exchange (HIE) (eAppendix Table B).

Our IT characteristics included EHR adoption status,

 having a third-party HIE vendor, having their EHR vendor serve as their HIE vendor, and having primarily 1 EHR vendor. For organizational characteristics, we examined hospital size, teaching status, geographic location type, system membership, hospital ownership, specialty type, and payment reform participation.

 Finally, in order to evaluate the impact of available exchange partner density, we created 2 measures to capture potential exchange partners (eAppendix Table C).

We first calculated the proportion of hospitals engaged in every combination of the 4 interoperability domains. All measures used weights generated by an inverse probability model predicting response to the 2014 AHA IT Supplement, based on size, teaching status, system membership, region, urban/rural location, ownership, and critical access status (defined as a subset of rural hospitals identified by CMS as those that provide care services in certain rural areas, from the 2014 AHA Annual Survey). These weights both account for nonresponse bias and create nationally representative estimates.

Next, to assess the relationship between interoperability engagement and hospital characteristics, we identified the characteristics associated with hospitals that engage in all 4 domains compared with 3 or fewer. We ran a logistic regression model using engagement in all 4 interoperability domains as our dependent variable, and our hospital characteristics as explanatory variables, using the probability weights described above and clustering standard errors by Hospital Referral Region (HRR). We ran the model twice: once with IT, organizational, and exchange partner measures, and once with only IT and organizational measures; we did this because the exchange partner measures reduced our sample size from 3307 to 2279 respondents.

Finally, we examined the predictors of information availability from outside organizations. Our explanatory variables in the logistic regression model were the 4 interoperability domain variables: find, send, receive, and integrate. We included send as a logic check, and did not expect that sending data would be significantly associated with clinical information availability. Additional explanatory variables included the hospital characteristics from the previous model. We removed the variables that we did not expect would be related to information availability: having a third-party HIE vendor, having their EHR vendor as their HIE vendor, and using primarily 1 EHR vendor; these measures are key enablers of interoperability engagement, but not likely related to clinical information availability. The model included the same weights, and was run twice, with and without exchange partner measures. Finally, to assess the potential for synergistic effects from engaging in multiple interoperability domains, we re-ran the model with all possible interaction terms between find, send, receive, and integrate.

Over half of the hospitals had at least a “basic” (defined as an EHR with a set of 10 functionalities implemented in at least 1 unit of the hospital) EHR system (60%), while “comprehensive” (defined as an EHR with a larger set of functionalities implemented across all units of the hospital) EHR systems were less common (29%). Nearly half of the hospitals were participating in a RHIO (49%), and many hospitals had a third-party HIE vendor (80%). The majority of hospitals in our sample were small (53%) or medium-sized (40%); most hospitals were located in an urban setting (64%) and nearly half were privately owned, nonprofit (49%) (eAppendix Table D). Almost one-fifth of sample hospitals participated in an ACO (17%) and a medical home (17%), with only 8% participating in both. In HRR-level markets with at least 10 respondents, 68% of hospitals in the market, on average, engaged in sending information electronically. Similarly, the mean number of “eligible provider” exchange partners per hospital by HRR was 1.45 across all hospitals in the sample (eAppendix Table C). 

Twenty-one percent of US hospitals engaged in all 4 interoperability domains (

 and eAppendix Figure). An additional 17% of hospitals engaged in some combination of the 3 domains—the most common of which was send, receive, and integrate data (8% of total respondents). Another 20% of hospitals engaged in 2 domains of interoperability, with the most common combination being send and receive (10% of total respondents). Seventeen percent of hospitals engaged in 1 of the domains of interoperability, and the most common single domain was send (8% of total respondents). The remaining one-fourth of hospitals did not engage in any of the 4 domains.

Hospital Characteristics Associated With Engagement in All 4 Interoperability Domains

Several characteristics were significantly associated with hospital engagement in all 4 domains of interoperability (

). Hospitals with a basic or comprehensive EHR (odds ratio [OR], 3.53 and 5.04, respectively; 

 <.01) were more likely to be engaged in all 4 domains, as were hospitals participating in an RHIO (OR, 4.29; 

 <.01). Hospitals with a third-party HIE vendor (OR, 2.32; 

 <.01), hospitals using their EHR vendor as their HIE vendor (OR, 2.15; 

 <.01), and hospitals using only 1 EHR vendor (OR, 2.04; 

 <.01) were also more likely to be engaged in all 4 domains.

Among the organizational characteristics, medium-sized hospitals (OR, 1.51; 

 <.01) and hospitals that are part of a system (OR, 1.88; 

 <.01) were more likely to engage in all 4 interoperability domains, as were hospitals participating in a medical home model

 <.01) or both an accountable care organization (ACO) and a medical home model (OR, 1.78; 

When we examined the exchange partner density variables, neither the proportion of hospitals in the HRR that electronically send information nor the number of eligible professionals in the HRR that had attested to Stage 2 Meaningful Use, were related to engagement in all 4 interoperability domains (eAppendix Table E).

Characteristics Associated With Clinical Data Availability

 Just over one-third of sample hospitals reported having clinical information available from outside providers when necessary (36%) (eAppendix Table D). Find (OR, 5.51; 

 <.01) information were associated with the availability of information from outside providers. As expected, send was not associated with clinical information availability (OR, 0.98; 

Other statistically significant characteristics associated with electronic availability of information from outside providers included hospitals with a basic or comprehensive EHR system (OR, 1.47 and 2.02, respectively; 

 <.01), and hospitals owned by the federal government compared with privately owned nonprofit hospitals (OR, 2.29; 

 = .03). Neither exchange partner variable was related (eAppendix Table F). In our fully interacted model, hospitals that engaged in all 4 interoperability domains had significantly greater odds of electronic clinical information availability from outside sources (OR, 38.32; 

There is widespread agreement that interoperability across EHR systems is needed to ensure that providers have ready access to health information about their patients. Our results offer a baseline measure for the state of interoperability in US hospitals and suggest that continued efforts are needed both to increase interoperability and for data from outside providers to be routinely available. Key enablers of interoperability appear to center on certain health IT infrastructure and HIE services. Having a basic or comprehensive EHR ensures that there is a core set of patient information captured electronically, such as problem and medication lists, which are valuable both to share with outside providers during care transitions and update with information received from outside providers.

 Encouragingly, all forms of technology solutions were positively associated—ranging from RHIO to third-party HIE vendors to EHR vendors providing HIE solutions. This suggests the possibility that hospitals are pursuing varied approaches to connectivity and that the policy strategy of letting the market develop different approaches to exchange may be allowing hospitals to choose the approach that works best for them.

We were somewhat surprised to find that medical home model participation was significantly associated with engaging in all 4 interoperability domains, and ACO participation alone was not. This finding could be explained by the fact that care coordination activities are core requirements of most medical home programs, and hospitals therefore have to invest in some level of sending, receiving, and integrating information. The National Committee for Quality Assurance specifically recommends that medical homes invest in interoperability and HIE capabilities for the purposes of care coordination and ensuring high-quality care.

 We also found that being a member of a system was associated with engagement in interoperability. We suspect that hospitals that are part of a system are more likely to share patients with other members of the system, making interoperability more valuable, as well as have established relationships and policies with other members of the system that make exchange easier.

Many of the characteristics that we hypothesized would be related to interoperability engagement were not, including several that have historically been associated with EHR adoption. Large hospitals, teaching hospitals, and urban hospitals were not more likely to be engaged, despite being more likely to have comprehensive EHR systems.

 This suggests that a different set of factors influence interoperability engagement compared with EHR adoption.

 For example, large hospitals may have been able to leverage their greater resources in EHR adoption, but the increased complexity that comes with being a larger facility may make engaging in interoperability more difficult. Although there is a growing understanding of the barriers to interoperability,

 our findings suggest the need for further exploration across different hospital settings.

Our findings related to predictors of clinical information availability from outside providers also yielded interesting insights. That find and receive were both associated with clinical information availability reinforces the notion that different types of information access are needed for different clinical scenarios. Whereas finding is needed in emergency care or when the provider does not know where the patient has previously received care,

 receiving data supports planned care transitions.

 Integrating appears to offer additional value, likely by decreasing the workload for clinicians to view and incorporate information into workflow and decision making. A recent systematic review of the HIE literature found that the key barriers reported from a provider standpoint were workflow disruptions and technical trouble with the interface.

 By integrating clinical information directly into hospital EHRs, clinicians are more likely to have access to outside information.

Our findings should be interpreted with some key limitations in mind. First, we used self-reported survey data and were not able to verify the accuracy of responses. However, data from the AHA IT Supplement are widely used to track hospital EHR adoption and have been validated against other sources.

 Our measures of engagement in the 4 interoperability domains and measure of availability of clinical information from outside providers are dichotomous, thus limiting our ability to measure the breadth of engagement and the degree to which information are available. Although survey questions related to the domains of send and receive refer specifically to summary of care records,

 the questions related to the domains of find and integrate refer to any clinical patient information. Another measurement challenge is the fact that respondents could have differentially interpreted what it meant to engage in a domain “routinely.”

In addition, we focused on hospital characteristics and only included 2 market-level measures related to exchange partner density. Prior work suggests that market forces play an important role in hospitals’ decisions to pursue interoperability,

 and this points to the need for additional research focused on examining these dynamics. Finally, our cross-sectional data captures a recent snapshot of interoperability and, although we speculate on some potential causal relationships, we cannot empirically assess them. It is important to note that our study reports slightly different results than previous ONC publications on US hospital interoperability engagement using the same data source.

 This discrepancy is due to our decision to include all hospitals in our results rather than only nonfederal, acute care hospitals. Although federal and specialty hospitals are not subject to the same policy environment as general hospitals—because the same patients may receive care at both types of hospitals&mdash;we felt it was important to include all hospitals in our measures.

Our findings have important policy implications. First, the measures of interoperability engagement that we examine in this study are part of the final set of measures that will be used to report to Congress to assess the extent to which interoperability is occurring on a widespread basis by 2018, as mandated by the Medicare Access and CHIP Reauthorization Act (MACRA) rule.

 Our findings lend credibility to these measures, given that we found they are strongly associated with increased availability of outside information. However, given that we also found a majority of hospitals do not engage in all 4 domains, there is a need for ongoing policy efforts to increase such engagement. Efforts to enable interoperability should not solely focus on sending information during care transitions—which is heavily emphasized in current Meaningful Use criteria&mdash;but also on finding, receiving, and integrating information. MACRA takes a step in this direction by encouraging providers to not only send, but also receive and incorporate, patient care records eletronically.

 However, they would need to be expanded in at least 2 key ways: the MACRA rules only apply to eligible providers, not hospitals, and they set a fairly low bar with regard to integrating information. Progress in the integration domain would also likely be sped up by efforts to identify and implement the best available data standards that enable receiving and integrating data across systems. As a start, vendors representing 90% of the hospital EHR market have committed to implement “national interoperability standards and best practices”

that are part of the Shared Nationwide Interoperability Roadmap.

Although delivery and payment reform should also drive hospitals toward greater engagement in interoperability, our findings suggest that these forces have not yet fully matured.  Specifically, while medical home model participation was associated with engaging in all 4 domains of interoperability, participation in only ACOs was not. Reform efforts could become more forceful levers if interoperability-sensitive outcome measures were developed and then tied to participation and payment.

 Regardless, as delivery and payment reform accelerate, hospitals will need cost-effective options to seamlessly exchange information. Linking interoperability to various initiatives and funding sources, such as state innovation model funding, new Health Information Technology for Economic and Clinical Health match funding for Medicaid, and Medicaid managed care contracting, could help address remaining gaps across the country with regards to interoperability engagement.

Articles

A national assessment of hospital engagement in key domains of interoperability, characteristics associated with engagement in interoperability, and the relationship between interoperability and provider access to clinical data.

US Hospital Engagement in Core Domains of Interoperability

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.

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

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.

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.

 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.

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.

 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.

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.

 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.

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.

Early indicators suggest strong physician participation in initiatives to support health IT adoption and to reform healthcare payment and delivery.

 However, evidence on whether provider participation in these initiatives has translated to better care delivery is just beginning to emerge.

 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.

 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.

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,

 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,

 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.

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.

 The first wave of the Physician Workflow Survey was conducted in 2011 as a follow-up to the 2011 NAMCS Electronic Health Records Survey.

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.

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).

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 

]). The results for the category-level measures were substantively similar to the results for the individual process measures.

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 

 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 

 (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). 

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. 

Finally, we conducted multivariate logistic regression to assess whether, among EHR adopters, certain EHR-related factors were associated with a higher likelihood that EHR users routinely perform the care processes using computerized tools. The analysis sample for these regressions was the subset of office-based physicians who were using an EHR. We estimated 18 logistic regression models (1 for each of the 14 individual process measures and the 4 summary measures), regressing the dependent variable (whether or not the physician routinely performed the process of interest using computerized tools) on the 3 EHR-related characteristics: met MU criteria, EHR installation year, and staff received EHR training. The models also included the same control variables as above and the ACO or PCMH participation variable. We used the regression results to calculate the average incremental effects of the EHR related factors.

All analyses were conducted using Stata 11.2 (StataCorp LP, College Station Texas), using weights to account for nonresponse and adjusting standard errors for the complex survey design. We used a regression model that predicts the likelihood of responding to the survey, to develop weights to ensure that our survey was nationally representative.

EHR Use and Participation in ACO or PCMH Initiatives

In 2012, a majority of office-based physicians were using an EHR (62%), with about half of all physicians using an EHR that was certified to meet MU criteria (48%) (

). Over 1 in 5 physicians (22%) were participating in either an ACO (16%) or PCMH (9%) (Figure 1)—4% reported participating in both models, 13% in ACO only, and 6% in PCMH only (data not shown). A majority of physicians participating in these models used an EHR certified for MU (Figure 1). Overall, 18% of physicians reported using an EHR and participating in an ACO or PCMH. Additionally, 44% of physicians reported using an EHR but not participating in one of these care delivery models, and the remaining 38% of physicians did not use an EHR.

The majority of physicians reported performing at least 1 care process routinely in the categories of care coordination (89%), patient communication (69%), and population management (67%) (

). Less than half (44%) reported performing quality measurement processes routinely. There was variation in the extent to which physicians routinely performed specific processes within each category (eg, the population management processes ranged from 13% for creating lists of patients by lab results to 58% for providing patients with reminders for follow-up or preventive care). Among physicians who routinely performed a given process, the majority reported that the process was computerized.

Relationship Between EHR Use, Participation in ACO or PCMH Initiatives, and Performance of Care Processes

Physicians using EHRs were significantly more likely to perform care processes across all 4 categories (

). For example, physicians using EHRs were 15 percentage points more likely than physicians without EHRs to routinely perform at least 1 population management process. Similarly, physicians participating in new delivery models were significantly more likely to routinely perform these processes. The magnitude of the incremental effects for EHR use and ACO or PCMH participation were similar (ie, there were no statistically significant differences between the incremental effects [test not shown]).

Physicians who were using EHRs in combination with participation in ACO or PCMH initiatives had the highest likelihood of routinely performing the care processes (

). Among physicians not participating in either type of initiative, using an EHR was associated with a 14 to 27 percentage point greater likelihood of routinely performing at least 1 care processes in 3 of the 4 categories (not care coordination). However, across all categories, physicians who had 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. The same results were found in analyses of the individual care processes in each category (eAppendix Table 3).

Relationship Between EHR-Related Factors and Performance of Care Processes Among Physicians Using EHRs

Among the 62% of physicians using an EHR in 2012, those with EHRs certified to meet MU criteria were significantly more likely to routinely perform at least 1 care process in a computerized manner across all 4 categories (

). For example, physicians using EHRs certified to meet MU criteria were 15 percentage points more likely than physicians using other EHRs to routinely perform at least 1 population management process in a computerized manner. The same results were found in analyses of the individual care processes in each category

Physicians at practices with longer experience with their current EHR were more likely to routinely perform 1 or more processes in a computerized manner across all categories. Assistance with initial EHR implementation and assistance with training staff to use the EHR were not significantly associated with the likelihood of routinely performing any care process in a computerized manner in the categories.

The National Quality Strategy has prioritized several areas for improvement, including population management and prevention, quality measurement and reporting, care coordination, and patient engagement.

 This study finds that US physicians’ rates of performing these care processes varied; although a majority reported routinely conducting at least 1 care process related to care coordination, patient communication, and population management, less than half reported performing at least 1 quality measurement process routinely.

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.

Vaishali Patel, PhD

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