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Health Information Technology for Ambulatory Care in Health Systems
Yunfeng Shi, PhD; Alejandro Amill-Rosario, MPH; Robert S. Rudin, PhD; Shira H. Fischer, MD, PhD; Paul Shekelle, MD; Dennis Scanlon, PhD; and Cheryl L. Damberg, PhD
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Nate C. Apathy, BS; and A. Jay Holmgren, MHI
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Margae Knox, MPH; Elizabeth J. Murphy, MD, DPhil; Timi Leslie, BS; Rachel Wick, MPH; and Delphine S. Tuot, MDCM, MAS

Health Information Technology for Ambulatory Care in Health Systems

Yunfeng Shi, PhD; Alejandro Amill-Rosario, MPH; Robert S. Rudin, PhD; Shira H. Fischer, MD, PhD; Paul Shekelle, MD; Dennis Scanlon, PhD; and Cheryl L. Damberg, PhD
Health systems are important in driving electronic health record adoption in ambulatory clinics, although the uptake of key functionalities varies across systems.
ABSTRACT

Objectives: The adoption and use of health information technology (IT) by health systems in ambulatory care can be an important driver of care quality. We examine recent trends in health IT adoption by health system–affiliated ambulatory clinics in the context of the federal government’s Meaningful Use and Promoting Interoperability programs.

Study Design: We analyzed a national sample of 17,861 ambulatory clinics affiliated with 1711 health systems, using longitudinal data (2014-2016) from the HIMSS Analytics annual surveys.

Methods: We used descriptive analyses and linear probability models to examine the adoption of electronic health records (EHRs), as well as 16 specific functionalities, at the clinic level and the system level. We compared the differential trends of adoption by various characteristics of health systems.

Results: We find that the adoption of an EHR certified by the Office of the National Coordinator for Health IT (ONC) increased from 73% to 91%. However, in 2016, only 38% of clinics reported having all 16 health IT functionalities included in this study. Small health systems lag behind large systems in ambulatory health IT adoption. Patient-facing functionalities were less likely to be adopted than those oriented toward physicians. Health information exchange capabilities are still low among ambulatory clinics, pointing to the importance of the ONC’s recent Promoting Interoperability initiative.

Conclusions: The relatively low uptake of health IT functionalities important to care improvement suggests substantial opportunities for further improving adoption of ambulatory health IT even among the current EHR users.

Am J Manag Care. 2020;26(1):32-38
Takeaway Points
  • The adoption of an electronic health record (EHR) certified by the Office of the National Coordinator for Health Information Technology (ONC) among ambulatory clinics increased from 73% to 91% between 2014 and 2016.
  • However, in 2016, only 38% of clinics reported having all 16 health information technology (IT) functionalities included in this study.
  • Small health systems significantly lag behind large systems in adoption.
  • Patient-facing functionalities were less likely to be adopted than functionalities oriented toward physicians.
  • Health information exchange capabilities are still low, pointing to the importance of the ONC’s continuing focus on interoperability.
  • Our findings suggest substantial opportunities for further improving adoption of ambulatory health IT even among the current EHR users.
Advancing the adoption and use of health information technology (IT) has been an important focus of the federal government’s efforts to improve quality of care during the past decade. Two major pieces of legislation promoted health IT adoption: the Health Information Technology for Economic and Clinical Health (HITECH) Act,1 enacted as part of the American Recovery and Reinvestment Act of 2009, and the Patient Protection and Affordable Care Act2 in 2010. The multistage incentive programs under HITECH, commonly known as Meaningful Use, provided more than $30 billion to about a half-million healthcare providers and were essential to the initial adoption of and sustained use of health IT.3 Nevertheless, the penetration of health IT has proceeded at different paces for hospitals and providers in ambulatory settings. For example, by 2013, more than 59% of hospitals had adopted at least a basic electronic health record (EHR), whereas the proportion of clinics using an EHR was estimated to be about 48%.4 As the adoption and use of health IT grow, evidence supporting the positive impacts of health IT has also been accumulating, although not all health IT implementations have produced effective results.5 Furthermore, there is evidence of unintended consequences, such as physician burnout.6 Although most empirical studies linking IT to quality of care using large national samples were conducted in hospital settings,7,8 a recent study found that higher rates of ambulatory EHR adoption at the county level were associated with reductions in hospitalization between 2003 and 2012.9

Along with policies to promote health IT adoption, significant and rapid changes have been occurring in the organizational landscape of healthcare, with health systems assuming an increasingly important role in delivering care.10 A typical health system, often formed through consolidation with the expectation of better clinical integration and higher-value care, can include multiple hospitals, numerous ambulatory clinics, and even an insurance plan. Some studies have found positive associations between care quality and increased integration of care delivery (ie, various healthcare services being delivered with coordination among different providers) within health systems,11,12 although whether the formation of health systems actually leads to quality improvement is still an open question.13

However, little is known about how the adoption and use of health IT varies across health systems. Different health systems may vary in their capabilities of pooling resources to overcome cost, implementation, or usage barriers to health IT, and they may also employ different strategies to adopt and implement IT.14 In this study, we examine the recent trends in the adoption of health IT by health system–affiliated ambulatory clinics and make 2 important contributions to this topic. First, despite the large existing literature on health IT adoption in hospitals, relatively few studies have examined adoption in the ambulatory setting at the national level. Most previous research on ambulatory health IT either examined only basic EHR adoption without measuring adoption of specific functionalities15 or studied selected functionalities using cross-sectional data.16 One recent study examined use of specific functionalities among a cohort of 566 small primary care clinics.17 Our study extends this work by analyzing the adoption of 16 health IT functionalities with a longitudinal sample of ambulatory care clinics between 2014 and 2016. Second, our study focuses on clinics that are affiliated with (ie, owned, leased, or managed by) health systems to provide an understanding of ambulatory health IT adoption from a delivery system perspective. Specifically, we identify patterns of adoptions at both the ambulatory clinic level and the health system level and examine how adoption varies by clinic and health system characteristics. Our analysis provides an up-to-date understanding of the advancement of adoption of health IT in the ambulatory setting and the extent to which a core set of functionalities are being adopted to support patient care.

METHODS

Data and Sample

We used 2014-2016 data from the HIMSS annual surveys of ambulatory clinics, provided by HIMSS Analytics LOGIC Market Intelligence Platform. The HIMSS surveys collected detailed information on the adoption and use of health IT for more than 75% of ambulatory care clinics affiliated with health systems.18 HIMSS defines a health system as an organization that owns at least 1 hospital.14 Although data from hospital surveys conducted by HIMSS have been widely used in previous health IT research,19 the HIMSS ambulatory survey data have been used in only a relatively small number of studies and government reports.20 Despite its limited use to date, the HIMSS ambulatory health IT database is an important source of information because of the longitudinal survey design and the large sampling frame.21

For our analysis, we included only ambulatory clinics that responded to the survey in all 3 years. They accounted for 92% of all clinics surveyed in 2014. Because we intended our analysis to be focused on ambulatory clinics in which providers directly interact with patients in delivering primary and/or specialty care, as these care sites were likely to benefit from the commonly adopted health IT functionalities,22 we excluded certain types of facilities (eg, urgent care, podiatry, and wellness centers). Finally, we excluded 6% of the clinics because they did not report the adoption statuses of all the functionalities examined in this study. Our final study sample contained 17,861 clinics and 1711 health systems (Table 1).

Health IT Functionalities

The National Academy of Medicine identified 8 core areas of health IT that are instrumental to the improvement of quality, safety, and efficiency in care delivery: health information and data, results management, order entry and management, decision support, electronic communication and connectivity, patient support, administrative processes, and reporting and population health.23 In our study, we measured the adoption of an ambulatory EHR system certified by the Office of the National Coordinator for Health IT (ONC), as well as the adoption of 16 specific health IT functionalities, which represent 7 of the 8 core areas defined by the National Academy of Medicine (Table 2) and were included by HIMSS in its annual survey of ambulatory care clinics. These specific functionalities are also at the center of the 3 stages of Meaningful Use programs (eg, clinical decision support) as well as their recent extension, Promoting Interoperability (eg, capabilities of exchanging health information).3,24 Functionalities in the area of reporting and population health were not covered in the HIMSS ambulatory surveys during our study period.


 
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