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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.
EHR Adoption
Practices with an NP or PA had higher adoption rates (74% and 76%, respectively) than practices without an APP (58%) (Figure). Among practices that adopted an EHR in 2013, 80% adopted an EHR that managed patient notes, 77% adopted an EHR that managed electronic prescriptions, and 76% adopted an EHR that viewed patient laboratory reports and x-rays (Table 1).
 
Practice Characteristics Associated With Employment of Nurse Practitioners and Physician Assistants
Factors that best predicted employment of APPs were practice size, rural setting, and primary care specialty (Table 2). Primary care practices were twice as likely to employ APPs compared with multi-specialty practices, when controlling for other factors. Rural practices were almost 50% more likely to employ a NP, and 41% more likely to employ a PA, than urban practices; larger practices were also more likely to employ NPs and PAs. Regionally, northeastern and western practices were less likely to employ NPs than midwestern practices; however, those same regions had higher PA employment. Practices that employed 1 type of APP were also more likely to employ other APPs. Controlling for all other characteristics, practices that employed at least 1 PA were 44% more likely to also employ an NP, and practices that employed at least 1 NP were 36% more likely to also employ a PA, compared with practices that did not employ these APPs.
 
Practice Characteristics Associated With EHR Adoption
After controlling for other practice characteristics, ownership, practice size, and employment of NPs and PAs were statistically associated with EHR adoption (Table 2). Controlling for all other characteristics, practices with at least 1 NP were 12% more likely to adopt EHRs than practices without an NP, while practices with at least 1 PA were 15% more likely to adopt an EHR than practices without a PA.
 
Practice Characteristics Associated With EHR Functional Capabilities
Compared with overall EHR adoption, differences in availability of specific EHR functionalities were smaller. Controlling for other practice characteristics, practice specialty, size, and employment of APPs were major predictors for the availability of an EHR system that could manage clinical notes, electronically prescribe, or permit viewing of laboratory results and x-rays. Practices with either an NP or a PA on staff were more likely to have an EHR with any of these functionalities than practices that did not employ a similar APP. In addition, practices that employed either an NP or PA were 9% to 12% more likely to use an EHR with all 3 functionalities than practices without those APPs.

DISCUSSION
This research found that, after controlling for other practice-level characteristics, there were strong associations between the employment of APPs and EHR adoption. Three-fourths of practices that employed an APP had adopted an EHR compared with 60% of practices without these staff members. In addition, practices that employed APPs were more likely to have EHRs that had high-level functions promoting communication (eg, managing clinical notes, viewing laboratory results and x-rays) and patient safety (eg, electronic prescribing), when compared with practices not staffed with APPs.

The intersection of health IT-enabled care and the availability of APPs within a practice has only been minimally researched to date 19,20 Drs Adler-Milstein and Jha proposed that the use of skilled labor for EHR-related tasks allows physicians to “off-load self-contained tasks that they previously performed,” such as preventive care or care based on clinical care guidelines.19 In addition, practices that delegated EHR-related work to support staff have demonstrated improved clinician productivity.21 By performing some of the more routine care tasks, APPs provide more time for the physician to manage complex care situations. These results demonstrate that the largest practices were 2 times more likely to have an APP on staff and 34% more likely to have an EHR compared with those practices with less than 1 FTP, thereby positioning larger practices to be able to take fuller advantage of the high-level EHR functions.

Notably, although practices with less than 1 FTP were more likely to be staffed with an APP than solo physician practices, these practices were least likely to have adopted an EHR. This suggests that staffing with APPs is not sufficient to facilitate EHR adoption. Howard et al reported that among small primary care practices, unless the practice had redesigned its work flow, clinicians complained of increased documentation times and increased complexity in performing tasks such as ordering and reviewing laboratory results.22 Thus, in order to fully maximize the advantages of having APPs on staff and having adopted health IT, a practice should consider making changes that enhance patient flow within the office, improve data collection, and enhance the teamwork that allows APPs and other office staff to work to the highest level of their training. In resource-constrained practices, such as small and rural practices, implementing these work flow changes may require financial and technical assistance.

These analyses provided practice-level estimates on the adoption and availability of EHR functionalities, but did not provide information on which providers within the practice were using the EHRs, nor did it provide information on how the practices were using their EHRs. Other analyses have shown that APPs eligible for the Medicaid EHR Incentive Program achieved meaningful use of certified health IT at a lower rate than eligible physicians.23 In order for a team-based approach to patient care to work, members of the care team should be able to use the health IT to the highest level of their training. Although practices that employ APPs have higher rates of access to these EHR functionalities than practices without those staff, it is not clear from these data which healthcare providers were actually using those EHR functions.

These results provide statistical associations between practice characteristics and the adoption and use of health IT. It is difficult with these statistical analyses, however, to determine causality. The associations between EHR adoption and APP employment may be the result of underlying factors influencing both, such as the presence of innovative physicians who are both more likely to adopt EHRs and hire APPs. Prior work has shown that practices that adopted EHRs were more likely to have innovative physicians on staff.24 The associations identified here may be a result of having innovative physicians on staff, and those physicians promoting team-based care, as well as EHR adoption. More work in this area is necessary, but these results do demonstrate that practices with APPs on staff have higher rates of health IT adoption and use, and thus, are primed to take the next steps to delivery system reform.

CONCLUSIONS
Adoption of any EHR is progress toward greater integration with the healthcare system and the triple aim of better health, smarter spending, and healthier people. However, practices must have health IT that facilitates communication, promotes patient safety, and allows healthcare providers to coordinate care effectively and easily. Future research should examine how practices with APPs are using health IT to promote better health and coordinate care, as APPs become a more integral part of office-based care coordination teams to provide coordinated, patient-centered care.

Author Affiliations: HHS, Office of the National Coordinator for Health IT (PWB, DH-G), Washington, DC.

Source of Funding: None.

Author Disclosures: The authors 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 (PWB, DH-G); analysis and interpretation of data (PWB, DH-G); drafting of the manuscript (PWB, DH-G); critical revision of the manuscript for important intellectual content (PWB, DH-G); statistical analysis (PWB); and supervision (DH-G).

Address correspondence to: P. Wesley Barker, MS, US Department of Health and Human Services, Office of the National Coordinator for Health IT, 200 Independence Ave, SW, Ste 745H.3, Washington, DC 20201. E-mail: Wesley.Barker@hhs.gov.
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