Assessing the level of healthcare information technology adoption in the United States: a snapshot

BACKGROUND

Comprehensive knowledge about the level of healthcare information technology (HIT) adoption in the United States remains limited. We therefore performed a baseline assessment to address this knowledge gap.

METHODS

We segmented HIT into eight major stakeholder groups and identified major functionalities that should ideally exist for each, focusing on applications most likely to improve patient safety, quality of care and organizational efficiency. We then conducted a multi-site qualitative study in Boston and Denver by interviewing key informants from each stakeholder group. Interview transcripts were analyzed to assess the level of adoption and to document the major barriers to further adoption. Findings for Boston and Denver were then presented to an expert panel, which was then asked to estimate the national level of adoption using the modified Delphi approach. We measured adoption level in Boston and Denver was graded on Rogers' technology adoption curve by co-investigators. National estimates from our expert panel were expressed as percentages.

RESULTS

Adoption of functionalities with financial benefits far exceeds adoption of those with safety and quality benefits. Despite growing interest to adopt HIT to improve safety and quality, adoption remains limited, especially in the area of ambulatory electronic health records and physician-patient communication. Organizations, particularly physicians' practices, face enormous financial challenges in adopting HIT, and concerns remain about its impact on productivity.

CONCLUSION

Adoption of HIT is limited and will likely remain slow unless significant financial resources are made available. Policy changes, such as financial incentivesto clinicians to use HIT or pay-for-performance reimbursement, may help health care providers defray upfront investment costs and initial productivity loss.

Barriers to the use of a personal health record by an elderly population

Personal health records(PHRs) are proposed as a strategy to make health care delivery increasingly patient-centered. Yet little work has been done in understanding the workflows of patients in their own homes, or influence of access, cognitive, physical, or literacy barriers on workflow and outcomes of using health records. Many populations may require assistance in using PHRs to improve their health out-comes. We studied PHR use by an elderly and disabled population and describe those barriers encountered by our patients.

Suicide risk during antidepressant treatment

OBJECTIVE

In March 2004 the U.S. Food and Drug Administration (FDA) warned physicians and patients regarding increased risk of suicide with 10 newer antidepressant drugs. Available data leave considerable uncertainty regarding actual risk of suicide attempt and death by suicide during antidepressant treatment. The authors used population-based data to evaluate the risk of suicide death and serious suicide attempt in relation to initiation of antidepressant treatment.

METHOD

Computerized health plan records were used to identify 65,103 patients with 82,285 episodes of antidepressant treatment between Jan. 1, 1992, and June 30, 2003. Death by suicide was identified by using state and national death certificate data. Serious suicide attempt (suicide attempt leading to hospitalization) was identified by using hospital discharge data.

RESULTS

In the 6 months after the index prescription of antidepressant treatment, 31 suicide deaths (40 per 100,000 treatment episodes) and 76 serious suicide attempts (93 per 100,000) were identified in the study group. The risk of suicide attempt was 314 per 100,000 in children and adolescents, compared to 78 per 100,000 in adults. The risk of death by suicide was not significantly higher in the month after starting medication than in subsequent months. The risk of suicide attempt was highest in the month before starting antidepressant treatment and declined progressively after starting medication. When the 10 newer antidepressants included in the FDA advisory were compared to older drugs, an increase in risk after starting treatment was seen only for the older drugs.

CONCLUSIONS

The risk of suicide during acute-phase antidepressant treatment is approximately one in 3,000 treatment episodes, and risk of serious suicide attempt is approximately one in 1,000. Available data do not indicate a significant increase in risk of suicide or serious suicide attempt after starting treatment with newer antidepressant drugs.

A survey of PDA use by palliative medicine practitioners

This paper describes the results of a Web survey on the use of personal digital assistants (PDAs) by physicians across Canada involved with the delivery of palliative medicine in different settings. Seventy-two physicians responded to the survey from April to July 2005. The survey revealed 58.3% of respondents currently use PDAs on a daily basis, mostly to organize their practice and to look up medical references. Some use their PDAs to store patient information and to access a central electronic patient record (EPR). In terms of potential PDA use in palliative medicine, six thematic areas are suggested: medical references, EPR, staying connected, personal productivity, clinical research, and issues/concerns. For implications, healthcare organizations should consider mobile technology as part of their information systems strategy. The feasibility of a portable EPR for palliative medicine should be explored, and an information-based approach can help advance palliative medicine research in Canada.

An Analysis of Early Studies Released by the Lung Imaging Database Consortium (LIDC)

Lung cancer remains an ongoing problem resulting in substantial deaths in the United States and the world. Within the United states, cancer of the lung and bronchus are the leading causes of fatal malignancy and make up 32% of the cancer deaths among men and 25% of the cancer deaths among women. Five year survival is low, (14%), but recent studies are beginning to provide some hope that we can increase survivability of lung cancer provided that the cancer is caught and treated in early stages. These results motivate revisiting the concept of lung cancer screening using thin slice multidetector computed tomography (MDCT) protocols and automated detection algorithms to facilitate early detection. In this environment, resources to aid Computer Aided Detection (CAD) researchers to rapidly develop and harden detection and diagnostic algorithms may have a significant impact on world health. The National Cancer Institute (NCI) formed the Lung Imaging Database Consortium (LIDC) to establish a resource for detecting, sizing, and characterizing lung nodules. This resource consists of multiple CT chest exams containing lung nodules that seveal radiologists manually countoured and characterized. Consensus on the location of the nodule boundaries, or even on the existence of a nodule at a particular location in the lung was not enforced, and each contour is considered a possible nodule. The researcher is encouraged to develop measures of ground truth to reconcile the multiple radiologist marks. This paper analyzes these marks to determine radiologist agreement and to apply statistical tools to the generation of a nodule ground truth. Features of the resulting consensus and individual markings are analyzed.

The fate of clinical department systems at the dawn of hospital-wide electronic health records in a Norwegian university hospital

OBJECTIVE

a) To document the presence and use of clinical department systems (CDS) in a university hospital that implemented a hospital-wide electronic health record (EHR) in 1999 and b) To compare clinical use of the CDS with that of the EHR.

METHOD

Identification of CDSs in use by contacting leaders and senior physicians at clinical departments at the hospital. Identification of key properties of each CDS by interviewing users.

RESULTS

We identified a total of 60 CDSs, of which 53 fell in one of four categories; Journal or documentation system tailored to a department or medical specialty (19 systems), Software bundled with electronic medical equipment (control/storage/presentation) (14 systems), Logistics/administration/planning/appointments (10 systems) and Database for medical research (10 systems). Many CDSs were described to outperform the EHR system with regard to ability to provide better patient overview and better support for registering patient data. CDSs are not integrated with the EHR and thus contain islands of data.

CONCLUSION

CDSs continue to fill important roles and there is no tendency towards that the hospital-wide EHR makes CDSs obsolete.

Removal of paper-based health records from Norwegian hospitals: effects on clinical workflow

Several Norwegian hospitals have, plan, or are in the process of removing the paper-based health record from clinical workflow. To assess the impact on usage and satisfaction of electronic health record (EHR) systems, we conducted a survey among physicians, nurses and medical secretaries at selected departments from six Norwegian hospitals. The main feature of the questionnaire is the description of a set of tasks commonly performed at hospitals, and respondents were asked to rate their usage and change of ease compared to previous routines for each tasks. There were 24 tasks for physicians, 19 for nurses and 23 for medical secretaries. In total, 64 physicians, 128 nurses and 57 medical secretaries responded, corresponding to a response rate of 68%, 58% and 84% respectively. Results showed a large degree of use among medical secretaries, while physicians and nurses displayed a more modest degree of use. Possibly suggesting that the EHR systems among clinicians still is considered more of an administrative system. Among the two latter groups, tasks regarding information retrieval were used more extensively than tasks regarding generating and storing information. Also, we observed large differences between hospitals and higher satisfaction with the part of the system handling regular electronic data than scanned document images. Even though the increase in use among clinicians after removing the paper based record were mainly in tasks where respondents had no choice other than use the electronic health record, the attitude towards EHR-systems were mainly positive. Thus, while removing the paper based record has yet to promote new ways of working, we see it as an important step towards the EHR system of tomorrow. Several Norwegian hospitals have shown that it is possible.

An electronic medical record in primary care: impact on satisfaction, work efficiency and clinic processes

User satisfaction with an electronic medical record (EMR) plays a decisive role in its implementation and subsequent use. We developed a survey tool to identify features of an EMR that contribute to user satisfaction and administered it in an adult primary care clinic. Most physician respondents were highly satisfied with the EMR and used all of its components. The EMR decreased the time to develop a synopsis of the patient and improved communication efficiency. Most respondents valued remote access to the EMR. Electronic messaging was an important component of improved care delivery according to 80% of the respondents. Access to online references within the EMR was not valued over web-based access for most respondents. Our results demonstrate acceptance of an EMR in adult primary care. Features such as remote access and electronic messaging were surprisingly useful and successful for primary care practice.

Barriers to electronic health record use during patient visits

The effectiveness of electronic health record (EHR)-based clinical decision support is limited when clinicians do not interact with the EHR during patient visits. To assess EHR use during ambulatory visits and determine barriers to such use, we performed a cross-sectional survey of 501 primary care clinicians. Of 225 respondents, 53 (24%) never or only sometimes used any EHR functionality during patient visits. Non-physician clinicians (e.g., nurse practitioners) were marginally more likely to be EHR non-users than physicians (39% versus 21%, respectively; p = .05). The most commonly reported barriers to using the EHR during patient visits were loss of eye contact with patients (62%), falling behind schedule (52%), computers being too slow (49%), inability to type quickly enough (32%), feeling that using the computer in front of the patient is rude (31%), and preferring to write long prose notes (28%). EHR developers and healthcare system leaders must address social, workflow, technical, and professional barriers if clinicians are to use EHRs in the presence of patients and realize the full potential of ambulatory clinical decision support.

Perceptions of Medicaid beneficiaries regarding the usefulness of accessing personal health information and services through a patient Internet portal

Increasing emphasis is being placed on the importance of information technology to improve the safety and quality of healthcare. However, concern is growing that these potential benefits will not be equally distributed across the population because of a widening digital divide along racial and socioeconomic lines. In this pilot study, we surveyed 31 Medicaid beneficiaries to ascertain their interest in and projected use of a healthcare patient Internet portal. We found that most Medicaid beneficiaries (or their parents/guardians) were very interested in accessing personal health information about themselves (or their dependents) online. Additionally, they were interested in accessing healthcare services online. We also found that many Medicaid beneficiaries have Internet access, including a slight majority with access to high-speed Internet connections. Our study revealed significant concern about the privacy of online health information.

Quality improvement for prevention of cardiovascular disease and stroke in an academic family medicine center: do racial differences in outcome exist?

OBJECTIVES

We evaluated whether a one-year, multifaceted quality improvement intervention improved adherence to 13 clinical guidelines for lipid screening, hypertension management, and diabetes management among White and African-American adult patients.

SETTING

An academic family medicine center.

PARTICIPANTS

Six faculty physicians and a clinical pharmacist participated between July 1, 2002, and June 30, 2003. Data from 2860 patients' electronic medical records were abstracted.

INTERVENTIONS

Performance reports and lists of patients eligible for each guideline measure were generated. Interventions targeted patients who needed improvement. Statistical analyses used generalized estimating equations to determine the intervention effect.

RESULTS

Significant improvements occurred in blood pressure control for all adults (OR= 1.44) and those with hypertension (OR=1.82), measures of total cholesterol (OR=1.10) and high-density lipoprotein cholesterol (OR= 1.27) for all patients, and measure of low-density lipoprotein cholesterol (OR=2.01) and blood pressure control (OR=1.71) for patients with diabetes mellitus. Significant decline was seen in measures of blood pressure for all patients (OR=.60). After adjusting for patient demographic factors, provider variability, and comorbidities, race was not associated with the change observed in any of the measures from baseline to follow-up.

CONCLUSIONS

Even though a multifaceted intervention can improve process of care measures for Whites and African Americans, further studies are needed to improve outcome measures, especially in African Americans.

Analyzing workflow in emergency departments to prepare for health information exchange

The New York Clinical Information Exchange (NYCLIX) was established to facilitate data sharing across 14 organizations. Workflow evaluations were conducted to identify mechanisms by which clinicians could be informed of NYCLIX data in the Emergency Department (ED). Interviews focused on the interval between patient arrival to the ED and clinician notification of a new patient arrival. Results revealed three EDs that were paper-based, two paperless and five using a combination of paper and electronic record.

Therapie schlafbezogener Atmungsstörungen mit positivem Atemwegsdruck

BACKGROUND

Computer-assisted cardiopulmonary polysomnography is generally required to differentiate common snoring from serious sleep-related breathing disorders (SRBD) such as sleep apnea.

METHODS

This study investigates data from 2,683 diagnostic and therapeutic cardiopulmonary polysomnographies of 1,087 patients over the period 2003-2004. Indications and efficacy of therapy using positive airway pressure (PAP) in SRBD are analyzed as well as alternative procedures.

RESULTS

Of the 1,087 patients, 260 (23.9%) needed PAP therapy. In 61% of the patients CPAP-therapy was applied, 19% needed Bi-PAP-ST and 10% Bi-PAP-S-therapy. A total of 91 patients (8.4%) were treated with alternative procedures, partially combined with positive airway pressure. In 760 patients (69.9%) PAP-therapy was controlled or SRBD was excluded.

CONCLUSION

There are no generally accepted guidelines for the therapy of SRBD. Indications for conservative and/or surgical procedures in the treatment have to be determined individually, depending on polysomnographic findings, subjective discomfort and physical comorbidities of the patients.

EHR and other IT adoption among physicians: results of a large-scale statewide analysis

Despite a national push toward the adoption of health information technologies, much is still unknown about the use of IT in physician's offices. We surveyed all primary care physicians and a 25 percent stratified random sample of other specialists (total n=14,921) in Florida to better understand current trends and factors related to the use of IT in the ambulatory setting. Data was analyzed using logistic regression modeling techniques to compute adjusted odds ratios. Covariates included practice size, medical training, practice type, age, race, and gender Routine office computer use (80 percent) was found to be very common for administrative functions. The use of quality enhancing technologies such as PDAs (37.5 percent), use of e-mail with patients (16.6 percent) and EHR (23.7 percent) was less common. Overall, large practice size, specialty practice, physician age and gender, and multi-specialty practice affiliation were significantly related to the use of many, but not all, of these IT applications in the ambulatory setting.

The transition to electronic documentation on a teaching hospital medical service

The transition to electronic medical records (EMRs) often includes the transition from paper to electronic documentation, a topic less well described in the literature than other aspects of EMR adoption. As part of a broader EMR project, we have participated in the transition to electronic notes on the Medicine service of a teaching hospital affiliated with the University of Washington. During a one year period beginning in February 2005 we adopted the use of semi-structured documentation templates permitting both encoded and narrative text components for admission, progress, and procedure notes, and for some discharge summaries. Currently over 1400 notes are entered each week. Fifty eight percent are entered by residents, 20% by attending physicians, and the remainder by other trainees and staff. The period of greatest change from paper to electronic notes occurred (by design) during the late spring and summer. Leadership, application functionality, speed, note writing time requirements, data availability, training needs, and other factors influenced adoption of this important part of our EMR.

Predicting the adoption of electronic health records by physicians: when will health care be paperless?

OBJECTIVES

The purpose of this study was threefold. First, we gathered and synthesized the historic literature regarding electronic health record (EHR) adoption rates among physicians in small practices (ten or fewer members). Next, we constructed models to project estimated future EHR adoption trends and timelines. We then determined the likelihood of achieving universal EHR adoption in the near future and articulate how barriers can be overcome in the small and solo practice medical environment.

DESIGN

This study used EHR adoption data from six previous surveys of small practices to estimate historic market penetration rates. Applying technology diffusion theory, three future adoption scenarios, optimistic, best estimate, and conservative, are empirically derived.

MEASUREMENT

EHR adoption parameters, external and internal coefficients of influence, are estimated using Bass diffusion models.

RESULTS

All three EHR scenarios display the characteristic diffusion S curve that is indicative that the technology is likely to achieve significant market penetration, given enough time. Under current conditions, EHR adoption will reach its maximum market share in 2024 in the small practice setting.

CONCLUSION

The promise of improved care quality and cost control has prompted a call for universal EHR adoption by 2014. The EHR products now available are unlikely to achieve full diffusion in a critical market segment within the time frame being targeted by policy makers.

Provider use of electronic health records in solo and small group practices

While conducting a study on the costs and benefits of electronic health records (EHRs) in solo and small group practices, use of the EHR to improve quality of care emerged as an important issue. An on-line provider survey was conducted to compliment our qualitative data. We found providers using an EHR were quite proficient at replicating their paper processes, but were less apt to use EHR features designed to improve quality of care.