The American Journal of Managed Care March 2011
Health Information Technology and Physicians' Perceptions of Healthcare Quality
Objectives: To investigate the relationship between the use of health information technology (HIT) and physician perceptions of providing high-quality care and to determine whether this relationship has changed over time.
Study Design: We used 2 waves of longitudinal data from the Community Tracking Study Physician Surveys, 2000-2001 and 2004-2005.
Methods: Three measures of HIT were examined: a binary variable measuring the use of at least 1 type of HIT, a continuous variable measuring the total number of HIT types, and a binary variable measuring use of all 5 HIT types related to “meaningful use” of HIT as defined by Centers for Medicare & Medicaid Services. Three multivariate models were estimated to study the effect of each HIT measure on physicians’ perception of providing high-quality care. Individual fixed-effects estimation also was used to control for individual time-invariant factors.
Results: Using at least 1 type of HIT significantly enhanced physicians’ perception of providing high-quality care in 2000-2001, but not in 2004- 2005. The marginal effect of adding 1 extra HIT type was positive and statistically significant in both periods. The association between using all 5 HIT types related to meaningful use and perceived quality was statistically significant in 2000-2001, but not in 2004-2005.
Conclusions: Health information technology has become a multifunctional system and appears to have enhanced physicians’ perception of providing high-quality care. Physicians’ perceptions of medical care quality improved as the number of HIT types used increased. This study supports more extensive use of HIT in physician practices.
(Am J Manag Care. 2011;17(3):e66-e70)
Data from the Community Tracking Study Physician Surveys were used to examine the relationship between use of health information technology (HIT) and physician perceptions of providing high-quality care.
- Using at least 1 type of HIT enhanced physicians’ perceived ability to provide high-quality care in 2000-2001, but not in 2004-2005.
- The more types of HIT that were adopted, the more likely physicians were to perceive the ability to provide high-quality care in both periods.
- Although most US physicians did not use HIT extensively in their practices, it appeared to promote quality of care.
The determinants of physicians’ adoption of HIT have been studied extensively.5-16 Previous studies have shown that HIT adoption rates vary considerably by physician specialty,5 practice types,8,9 practice revenues,7 patients’ characteristics,11 regional location of the practice,6 and other factors.8,10,12-16 A number of programs have been implemented to help bridge gaps in HIT adoption rates.17-29
Although the benefits of HIT are significant in theory, empirical evidence of its effects on healthcare outcomes is rather limited.30-32 This study seeks to understand the relationship between the adoption of HIT in medical practices and physicians’ perceptions of their ability to provide quality care to their patients.
Data and Sample
We used data from the Community Tracking Study (CTS) Physician Surveys maintained at the Center for Studying Health System Change.33 The survey sample includes 11,963 physicians in 2000-2001 and 6306 physicians in 2004-2005. Due to cost considerations, the 2004-2005 CTS survey sampled 50% fewer physicians than the 2000-2001 survey. The response rate of CTS Physician Surveys ranged from approximately 50% to 60%.34
The CTS survey comprises a nationally representative sample of physicians in the United States.35 Physicians were selected from 51 metropolitan areas and 9 nonmetropolitan areas, using a probabilistic stratified sampling strategy and including physicians who engaged in direct patient care for at least 20 hours per week. The survey questions asked about use of HIT in physicians’ practices, perception of the physician’s ability to provide quality care to patients, and a variety of physician and practice characteristics.
Perception of Providing High-Quality Care. This measure is based on physicians’ response to questions about their perceptions of providing quality care. Each physician was asked his or her opinion regarding the following statement: “It is possible to provide high-quality care to all of my patients.” Physician responses were based on a 5-point scale of (1) agree strongly, (2) agree somewhat, (3) neither agree nor disagree, (4) disagree somewhat, and (5) disagree strongly. We constructed a binary measure of being able to provide high-quality care equal to 1 if the physician responded either 1 or 2 on the scale and equal to 0 otherwise.
Health Information Technology Variables. Physicians from both waves were queried about the use of 7 HIT types. Specifically, physicians were asked if they used HIT to (1) obtain information about treatment alternatives or recommended guidelines; (2) exchange clinical data and images with other providers; (3) access patient progress notes, medication lists, or problem lists; (4) obtain information on formularies; (5) write prescriptions; (6) generate reminders about preventive services; and (7) communicate about clinical issues with patients by e-mail.
In order to promote the adoption of HIT in physician practices, the Centers for Medicare & Medicaid Services recently offered Medicare and Medicaid EHR Incentive Programs, which specify 3 main components of Meaningful Use Requirements: the use of a certified EHR in a meaningful manner (eg, e-prescribing); the use of certified EHR technology for electronic exchange of health information to improve quality of healthcare; and the use of certified EHR technology to submit clinical quality and other measures.21 Among the 7 HIT types we studied, the first 5 types described above appear to align most closely with these Meaningful Use Requirements. This study examines the effects of HIT implementation by testing the following hypotheses: (1) whether using at least 1 type of HIT enhances physicians’ perceived ability to provide high-quality care; (2) whether the addition of 1 extra HIT type improves physicians’ perception of quality care; and (3) whether using all 5 HIT types related to the Meaningful Use Requirements enhances physicians’ perceived ability to provide high-quality care. In addition, we investigated whether these relationships changed over time by comparing the estimated marginal effects of HIT between the 2 time periods considered.
Other Explanatory Variables. We also controlled for physician and practice characteristics that may affect the physician’s perception of healthcare quality. These characteristics included sex; race (white or nonwhite); the physician’s specialty (internal medicine, family/general practice, pediatrics, medical specialties, surgical specialties, psychiatry, and obstetrics and gynecology); board certification status; foreign medical graduate status; years of practice experience; yearly practice income; practice ownership (not an owner, part owner, or full owner); practice type (solo or 2 physicians, group with 3 or more physicians, health maintenance organizations (HMOs), medical school, hospital, or other practice type); percentage of practice revenues from Medicare, Medicaid, and managed care; and the competitive status of the physicians’ market area (not competitive, somewhat competitive, or very competitive). In addition, we included geographic indicators (60 CTS survey sites) to account for potentially relevant but unobserved geographic characteristics that could influence the adoption of HIT and/or physician perceptions about quality of care.7
Bivariate analysis began with a student t test for continuous variables and a X2 test for categorical variables to examine the use of HIT and physicians’ perceived ability to provide high-quality care. Multivariate probit regression was used to examine the effects of HIT types, using Stata version 11 (StatCorp LP, College Station, TX) for statistical analyses.
The adoption of HIT is potentially endogenous, as some unobserved factors may lead physicians to choose some specific HIT types. Just using HIT may lead physicians to think that they provide high-quality care when in fact they do not. Reverse causality is another potential reason for endogeneity. Endogeneity may bias the coefficient estimates for the HIT types upward. But given the number of different information technology measures and the lack of available instruments, instrumental variables estimation was not feasible. Instead, we estimated additional models that attempt to control for confounders adequately so that endogeneity concerns might be mitigated. First, we pooled 2 waves together as a panel, because we could identify the same physicians in 2 waves (6194 physicians in both 2000-2001 and 2004-2005 as the panel sample). Then we estimated all models described above by fixed-effects estimation. Probit estimation is not available for fixed effects, so we use the fixed-effects linear probability estimation as an alternative. The fixed-effects estimation helped us control for unobserved time-invariant physician characteristics and estimate the within-physician impact of HIT adoption on perceived quality with a linear probability model.36
Table 1 compares the 2 waves in the CTS Physician Surveys with respect to sample characteristics. The percentage of physicians who were able to provide high-quality care to all patients did not differ significantly between the 2 time periods (78% in 2000-2001 and 79% in 2004-2005). The proportion of physicians using at least 1 type of HIT in their practice increased significantly, from 75% in 2000-2001 to 85% in 2004-2005 (P <.01). The average number of HIT types used in 2000-2001 was 2.11. This number increased to 2.85 in 2004-2005 (P <.01). In 2000-2001, only about 4% of physicians used all 5 HIT types related to the Meaningful Use Requirements, but this percentage increased to 11% in 2004-2005.
Table 2 shows selected results of adopting at least 1 HIT type, using a binary measure. In 2000-2001, the use of at least 1 HIT type significantly increased the probability of physicians’ perceptions of providing high-quality care by 1.85% (P = .04). However, in 2004-2005, this marginal effect was reduced to 0.21% (P = .88). The effect of having at least 1 type of HIT was not statistically significant in the fixedeffects model (P = .36). Adding an extra HIT type increased this probability by 0.71% (P <.01) in 2000-2001 and by 0.62% (P = .03) in 2004-2005. The marginal effect of HIT on perceived quality of care only diminished slightly from 2000-2001 to 2004- 2005, even though physicians substantially increased the use of HIT in their practices. The fixed-effects estimation produced a larger effect: 0.86% (P <.01).
Table 2 also shows selected results from using all 5 HIT types related to the Meaningful Use Requirements. In 2000-2001, the marginal effect was 4.41% (P = .02) if physicians used all of these 5 HIT types, but it was not statistically significant in 2004-2005. The results from fixed-effects estimation were also not statistically significant.
Due to multicollinearity issues, we were unable to include 7 dummy variables for each HIT type in 1 equation. However, in an attempt to ascertain which HIT types might be included within the same regression model, we also performed stepwise regression (forward selection) by adding each HIT type into the estimation and requiring a 0.2 significance level for retaining an independent variable. In 2000-2001, only 2 HIT types were chosen by the forward selection: exchange clinical data and image (P <.01) and communicate about clinical issues with patients by e-mail (P = .11). In 2004- 2005, only the HIT types of communicating about clinical issues with patients by e-mail (P <.01) and accessing patient notes, medication lists, or problem lists (P = .11) were selected. Due to space considerations, the stepwise regression results are not reported here, but are available from the authors upon request.