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The American Journal of Managed Care December 2015
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EHR Adoption Among Ambulatory Care Teams
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EHR Adoption Among Ambulatory Care Teams

Philip Wesley Barker, MS; and Dawn Marie Heisey-Grove, MPH
Health IT—enabled information sharing promotes communication within care teams. This study examined health IT adoption rates among practices that employ nurse practitioners and physician assistants.

Objectives: This study provides information on the types of practices that employ 2 types of advance practice providers (APPs), nurse practitioners (NPs) and physician assistants (PAs), and the association between employment of APPs and health information technology (IT) adoption by the practice. 

Study Design: Three outcomes predicted the likelihood that practices employed at least 1 NP, at least 1 PA, or at least 1 of either type of APP; one outcome estimated electronic health record (EHR) adoption across practices; and 4 models assessed the EHR functionalities used by practices. 

Methods: Data from SK&A Information Services’ 2013 Office-Based Provider Database were used to estimate EHR adoption using a Poisson regression model. Independent variables included practice size, care setting, practice specialty, ownership, geographic region, whether a practice employed a NP, and whether a practice employed a PA. 

Results: In 2013, three-fourths of practices that employed at least 1 APP had adopted an EHR. Practices that employed at least 1 APP were 9% to 12% more likely to have an EHR that had advanced functionalities, compared with practices without an APP. 
Conclusions: This study found an association between employment of APP staff and practice-level adoption of EHRs and practice-level adoption of certain EHR functionalities. Practices that employ APPs are prepared to implement team-based approaches to care that may be further enhanced through the use of health IT. Future research should examine how practices with APPs are using health IT to promote better health and coordinate care.
Am J Manag Care. 2015;21(12):894-899
As healthcare delivery shifts to a patient-centered care coordination model, skilled advance practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs), will be necessary components of a care team. Sharing information across the care coordination team can be facilitated by health information technology (IT), so a better understanding of the intersection of practice staffing of APPs and health IT adoption is important.
  • Practices that employed NPs or PAs were more likely to adopt health IT.
  • Practices that employed NPs or PAs were more likely to have access to advanced health IT functionalities.
The “triple aim” of better care, smarter spending, and healthier individuals was originally described in a publication in 2008, although even at the time, those goals were not new.1 The authors described functions necessary to achieve balance within those 3 goals: patient engagement, expansion of the role of primary care providers, population health management, payment reform, and care coordination. Health information technology (IT) tools such as electronic health records (EHRs) enable a change in work flow and practice redesign, facilitate population health management, enhance communication between providers of care teams by enabling the safe and secure exchange of health information, and may improve patient care and safety through clinical decision and order entry support tools. In spite of these advanced functionalities, health IT is a tool that must be accompanied with a change in how care is delivered, with a focus on patient-centered care coordinated by a team of healthcare providers.

With an anticipated primary care physician shortage through 2020, implementation of team-based approaches could not only maintain, but also potentially increase access to, primary care services.2-5 Advance practice professionals (APPs), such as nurse practitioners (NPs) and physician assistants (PAs), are positioned to be key components of such care delivery teams. In team-based approaches, APPs can provide care for the more routine cases, freeing up physicians to care for patients with more complex health problems.6,7 APP-provided care has been demonstrated to be comparable with care provided by physicians—sometimes with lower costs and improvements in patient trust and satisfaction.8-11

Knowing that practices that employ APPs are prepared to implement team-based approaches to care, which could be further enhanced through the use of health IT, it is important to more fully examine the association between health IT adoption and the presence of APPs in a practice. Using national data from 2013, this study seeks to answer 3 questions: 1) What were the practice characteristics associated with having APPs on staff? 2) Were practices with APPs on staff more likely to adopt an EHR? 3) Among practices that adopted an EHR, were practices with APPs more likely to have adopted EHRs with advanced functionalities?

Data Source
The primary data source for this paper was the SK&A Office-Based Provider Database, a commercial product from SK&A Information Services, Irvine, California. SK&A Information Services maintains a database of all US office-based practices’ contact information (eg, phone number, street address). SK&A staff call each practice annually to collect information about the practice, including whether or not the practice has an EHR, type of personnel employed at the practice, personnel specialties, practice size, and other practice-specific data. Additional information on the data set has been published previously.12 Data gathered during 2013 were used.
Independent Variables
Variables used to characterize practices included the practice size, rural setting, geographic region, practice specialty, whether a practice employed an NP, practice employment of a PA, and practice ownership. Practice size was based on the number of full-time equivalent physicians (FTPs) practicing at a unique practice site in a given year, and ranged from less than 1 FTP to more than 10 FTPs.

Rural setting was a binomial variable that assessed whether the practice was located in a rural setting. Urban and rural designations were determined using the Health Resources and Services Administration Area Resource File (ARF).13 The site’s federal information processing standards (FIPS) code and zip code were used to match the ARF and SK&A data. Practices were considered to be urban if located in a Metropolitan core-based statistical area. The geographic region in which the practice was located was based on US Census Bureau regions.14

Practices were designated primary care if all practicing providers specialized in adolescent medicine, pediatrics, family practice, general practice, geriatrics, internal medicine, obstetrics, or gynecology. Practices were considered to have employed an NP or PA if, in a given year, the practice had at least 1 part- or full-time NP or PA on staff.

Practice ownership was based on 2 binary data fields that assessed whether the practice was hospital-owned or system-affiliated. These elements were combined to create 4 categories: owned by a hospital, affiliated with a health system, owned by a hospital and affiliated with a health system, and independent (neither hospital-owned nor system-affiliated).
Eight outcomes were measured for this study: 3 outcomes predicted the likelihood that practices employed NPs, PAs, or either type of APP; 1 outcome estimated EHR adoption, using employment of APPs as independent variables; and 4 outcomes estimated the likelihood that certain EHR functionalities were available among practices that had adopted EHRs.

EHR adoption was ascertained through responses to 2 questions from SK&A’s survey of office-based practices: “Are you currently utilizing electronic health record software?” or “Are you currently utilizing EHR software?” Respondents who answered “yes” to either question were coded as having an EHR. Nine percent of practices did not respond to this question. For a conservative approximation of EHR adoption, practices with a missing response were classified as non-adopters. Practices that had adopted an EHR were asked if their system offered any of 3 advanced functions: managing patient notes, electronic prescribing, and viewing patient lab reports and x-rays. Each of these functions was modeled individually as an outcome. In addition, an aggregate measure was created to assess whether practices had access to all 3 functions.
Data Analysis
Eight models were fitted using a Poisson regression that generated relative risk statistics with robust standard errors. This study used R Statistical Software (R Core Team, Vienna, Austria) to fit the models and produce these statistics, using a Poisson generalized linear model.15-18 All models used practice size, care setting, practice specialty, ownership, and geographic region as independent variables. EHR adoption and EHR functionality models included both independent variables for NP and PA employment. The NP employment model included the independent variable for the employment of PAs, and the PA employment model included the independent variable for the employment of NPs.

Practice Demographics
Nurse practitioners and PAs comprised nearly one-fifth of ambulatory care providers (Table 1). Twenty percent of practices employed at least 1 NP; 14% of practices employed at least 1 PA. Overall, 3 in 10 practices employed at least 1 NP or PA.

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