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The American Journal of Managed Care October 2013
Dispensing Channel and Medication Adherence: Evidence Across 3 Therapy Classes
Reethi Iyengar, PhD, MBA, MHM; Rochelle Henderson, PhD, MPA; Jay Visaria, PhD, MPH; and Sharon Glave Frazee, PhD, MPH
Utilization of Lymph Node Dissection, Race/Ethnicity, and Breast Cancer Outcomes
Zhannat Z. Nurgalieva, MD, PhD; Luisa Franzini, PhD; Robert O. Morgan, PhD; Sally W. Vernon, PhD; and Xianglin L. Du, MD, PhD
The Mis-Measure of Physician Performance
Seth W. Glickman, MD, MBA; and Kevin A. Schulman, MD
Inefficiencies in Osteoarthritis and Chronic Low Back Pain Management
Margaret K. Pasquale, PhD; Robert Dufour, PhD; Ashish V. Joshi, PhD; Andrew T. Reiners, MD; David Schaaf, MD; Jack Mardekian, PhD; George A. Andrews, MD, MBA, CPE; Nick C. Patel, PharmD, PhD, BCPP; and James Harnett, PharmD, MS
Empirical Analysis of Domestic Medical Travel for Elective Cardiovascular Procedures
Jacob D. Langley, MS-HSM; Tricia J. Johnson, PhD; Samuel F. Hohmann, PhD, MS-HSM; Steve J. Meurer, PhD, MBA, MHS; and Andy N. Garman, PsyD
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Physician Capability to Electronically Exchange Clinical Information, 2011
Vaishali Patel, PhD, MPH; Matthew J. Swain, MPH; Jennifer King, PhD; and Michael F. Furukawa, PhD
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Jeffrey L. Solomon, PhD; Allen L. Gifford, MD; Steven M. Asch, MD; Nora Mueller, MAA; Colin M. Thomas, MD; John M. Stevens, MD; and Barbara G. Bokhour, PhD
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David T. Liss, PhD; Paul A. Fishman, PhD; Carolyn M. Rutter, PhD; David Grembowski, PhD; Tyler R. Ross, MA; Eric A. Johnson, MS; and Robert J. Reid, MD, PhD
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Erin R. Giovannetti, PhD; Sydney Dy, MD; Bruce Leff, MD; Christine Weston, PhD; Karen Adams, PhD, MT; Tom B. Valuck, MD, JD; Aisha T. Pittman, MPH; Caroline S. Blaum, MD; Barbara A. McCann, MSW; and Cynthia M. Boyd, MD, MPH

Physician Capability to Electronically Exchange Clinical Information, 2011

Vaishali Patel, PhD, MPH; Matthew J. Swain, MPH; Jennifer King, PhD; and Michael F. Furukawa, PhD
We assessed physicians' capability to electronically share clinical information with other providers and describe variation in exchange capability across states and electronic health record vendors.
Practice Characteristics. Although a number of practice characteristics were significantly associated with physicians’ capability to exchange different types of clinical information (Table), the single strongest significant predictor was adoption of an EHR (P <.001). Adjusting for other physician and practice characteristics, physicians with an EHR were 49 percentage points more likely to have computerized capability to provide clinical summaries to patients and 37 percentage points more likely to exchange clinical summaries with other providers compared with physicians with no EHR. The association between EHR adoption and the capability to exchange pharmacy data and lab data were similarly strong.

Practice ownership was also an important predictor of exchange capability. Practices owned by health maintenance organizations or healthcare corporations were significantly more likely to exchange all 6 types of clinical data compared with physician-owned or physician group–owned practices. Community  health centers were significantly less likely to have the capability to e-prescribe (P <.001) or receive lab results electronically (P <.05) compared with physician-owned or physician group–owned practices. Practices owned by hospitals or academic medical centers were significantly less likely to have the capability to e-prescribe (P <.001) but more likely to have the capability to receive lab results electronically (P <.001) and exchange clinical summaries with other providers (P <.001). 

Larger practice size was significantly associated with the capability to conduct all facets of electronic lab exchange and was a particularly strong predictor of the capability to incorporate lab results into an EHR. Practice size was also significantly associated with the capability to e-prescribe (P <.001). However, practice size was not a significant predictor of capability to exchange clinical summaries. 

Physicians practicing in multispecialty practices were more likely to have the capability to e-prescribe (P <.05), send lab orders electronically (P <.001), and exchange clinical summaries with other providers (P <.001) compared with singlespecialty practices. However, overall, practice type was not a strong predictor of exchange capability.

Physician Characteristics. Primary care physicians were more likely to have the capability to e-prescribe (P <.001) and engage in various forms of lab exchange (P <.001), as well as provide clinical summaries to patients (P <.05) compared with specialists. Age differences were not associated with most forms of exchange capability; physicians aged less than 50 years were only slightly more likely to possess the capability to provide clinical summaries to patients (P <.05) compared with older physicians.

Variation in Physician Exchange Capability by EHR Vendor

Among physicians using an EHR, capability to exchange different types of clinical information varied according to EHR vendor (Figure 3). Between 73% and 94% of physicians using an EHR reported that they possess the capability to eprescribe, depending upon their vendor. Most EHR vendors (between 80% and 99%) provide the capability to receive lab results electronically. Depending upon the EHR vendor, between 62% and 95% of physicians reported the capability to incorporate lab results into their EHR. Physicians’ capability to send lab orders electronically ranged from more than onethird (38%) to 87% depending upon the EHR vendor.

Large differences existed across EHR vendors with regard to capability to exchange clinical summaries. EHR vendor capability to  provide clinical summaries to patients ranged from 22% to 90% of physicians. Between one-fourth (24%) and three-fourths (77%) of physicians reported the capability to exchange clinical summaries with other providers, depending upon their EHR vendor.

DISCUSSION

In 2011, a majority of office-based physicians possessed the capability to electronically exchange lab and medication data, and approximately one-third could exchange clinical summaries with patients or other providers. These estimates represent a baseline in measuring progress of national programs under way to promote greater exchange activity.

Variation in exchange capability may be driven by market factors and policy levers, as well as idiosyncratic work flow issues associated with each type of clinical data.17 Greater physician capability to view laboratory results and e-prescribe may be due in part to the role of large vendors (eg, Surescripts) and to hospital-physician portals.7 In addition to the implementation of meaningful use stage 1 requiring physicians to eprescribe using a certified EHR, other national policies, most notably the Medicare Improvements for Patients and Providers Act, have also likely spurred e-prescribing uptake.18,19 Lower capability to incorporate lab results into an EHR may  be due to technical challenges in transforming unstructured laboratory results into a structured format that involves agreement on vocabularies and standards.20

Lower rates of physicians’ exchange of clinical summaries may reflect technical and operational barriers to care coordination.7 For example, some physicians reported that summaries are not integrated within their work flow, prompting them to fax information between providers with EHRs rather than transmit summaries electronically; some physicians also reported that standard clinical care summaries can contain extraneous information, making them difficult to use.4 Rates of exchange of clinical care summaries may also be lower because the survey assessed exchange activity as opposed to the capability to exchange. However, rates of clinical care summary exchange may increase with the implementation of stage 2 meaningful use, which requires physicians to exchange clinical summaries with other providers during transitions of care.

Although in theory EHRs are expected to facilitate exchange, few empirical studies have examined EHRs as a vehicle for exchanging data among providers. To date, stand-alone systems and proprietary web portals have facilitated accessto clinical data. Studies demonstrating the impact of HIE in an ambulatory care setting have largely been limited to portal users.21,22 Furthermore, EHRs have been criticized for their lack of interoperability, including their inability to facilitate exchange of data easily between providers.23 We found that a majority of physicians who have EHRs reported they have the capability to exchange different types of clinical information, and multivariate analyses demonstrated that having an EHR was the single strongest predictor of exchange capability for e-prescribing, laboratory test viewing and ordering, and exchanging clinical summaries. Although stand-alone systemsmay continue to play a significant role, our findings indicate that EHRs have the capability to exchange a wide variety of clinical information with patients, providers, and other entities, in addition to serving as a more comprehensive tool to improve patient care.

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

 
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