Electronic health record adoption in small physician practices is increasing much faster than adoption in large physician groups, according to a recent SK&A survey. That fact, plus the overall growth in EHR usage shown by several recent polls, bodes well for the government achieving its goal of having EHRs in most practices by 2014.
But a closer look at the numbers indicates that EHR adoption still has a long way to go.
For example, in its survey of 240,000 practice sites, SK&A -- a subsidiary of the health care technology and services company Cegedim -- found that the percentage of one-doctor practices with EHRs zoomed to 37% from 31% a year earlier, while 47% of two-doctor practices reported having EHRs, up from 41% a year earlier. But 77% of groups with 25 or more doctors said they had EHRs -- more than twice the percentage of soloists who had them.
Overall, 46% of respondents in the SK&A poll said they had EHRs in January, compared with 40% a year earlier. But this number -- like the even higher figures in other surveys -- overstates the percentage of physicians who have what the government defines as a "basic EHR." And the percentage of doctors who have a "fully functional" EHR, one expert estimates, is less than 15%.
Factors in Accelerated Growth
The federal incentive program for meaningful use of EHRs has caused much of the recent increase in adoption, according to Jason Mitchell, assistant director of the Center for Health Information Technology at the American Academy of Family Physicians. "Meaningful use has had a fairly significant impact across the board for primary care doctors, subspecialists, and doctors in small practices," he said. "We're going to see this more fully during 2012."
Catherine DesRoches, senior scientist at Mathematica Policy Research, agrees that meaningful use has contributed to the growth in EHR adoption, especially by small practices. These practices tend to view acquisition of EHRs as a daunting challenge, both financially and technically, she noted. But the combination of government incentives and enhanced support from medical societies and other parties has pushed many small practices over the edge to adoption, she said.
In contrast, the government-funded regional extension centers so far have not had much effect, according to DesRoches. "The regional extension centers haven't been in existence that long, and they've been very focused in their first year on getting up and running and enrolling physicians," she said.
Mitchell agreed. While some of the RECs have used their federal funds effectively, he said, "it's easily an 18-month process for a practice to go from thinking about being electronic to becoming an adept meaningful user. The REC has had some impact, but it hasn't been the root cause" of the adoption increase.
Mitchell and some other observers believe that the growth in EHR acquisition will continue unabated. Research firm Kalorama Information recently reported that EHR sales were up 14.2% in 2011. Bruce Carlson, publisher of Kalorama's reports, told Healthcare IT News that sales would accelerate even further in the next two years because of Medicare penalties that will hit physicians who don't demonstrate meaningful use of EHRs, starting in 2015.
But DesRoches is not so sure about that. She thinks that EHR adoption -- which already has leveled off for large groups -- might also plateau for small practices at some point, perhaps at a lower level than for the big groups. EHR acquisition is more difficult and financially risky for small practices than for large organizations, she pointed out. And, though cloud-based EHRs reduce some of the technical complexity, she said, EHRs as a whole are not becoming easier to use.
"Some practices may decide that the [government] incentives are not worth the cost of implementing the technology, or that the cost of implementing the technology outweighs the [Medicare] penalties," she observed.
What the Numbers Mean
The big question about the EHR adoption data is what kinds of systems physicians are using. In its most recent survey, CDC found that 57% of office-based physicians said they had an EHR, but only 34% reported having a system that met the CDC's criteria for a basic EHR. In that survey, CDC defines a basic EHR as one that includes patient history and demographics, a "problem" or diagnosis list, physician notes, medications, allergies, electronic prescribing, and the ability to view laboratory and imaging results electronically.
Other surveys show that a large percentage of EHRs fail to meet that definition. Only one-third of the respondents in the SK&A survey said their EHRs included physician notes and e-prescribing. In a Medical Group Management Association survey of practices with three or more physicians, 51% reported using an EHR, but just slightly more than half of those practices used systems that could generate problem lists.
Mitchell argued that the definitions of basic EHRs and full-featured systems are still "a matter of debate, and there's a level of subjectivity in that determination." From AAFP's viewpoint, for example, no EHR that lacks a patient registry is fully functional. Yet almost no current EHR system has a registry that is sufficient for doing population health management, he said.
The health care industry as a whole, Mitchell said, views any EHR that is certified for meaningful use as fully functional. This definition runs the gamut from expensive, complex systems designed for large multispecialty groups, like Epic, to inexpensive products aimed at small practices, such as Amazing Charts, he noted.
DesRoches, who co-wrote a key Health Affairs study on EHR adoption in 2006, maintained that the proper way to define an EHR is on the basis of its functionality. "If you want an electronic record that can be used in ways that policymakers envisioned will have some effect on care, you need to have a system with a certain set of functions. So I'm very skeptical about claims that 55% of doctors have an EHR if you don't know what specific things are in that EHR," she said.
Meaningful use is one yardstick for measuring that. For physicians to meet the Stage 1 meaningful use criteria, DesRoches said, they must have more than a basic EHR. Among other things, their system must be able to exchange data with other EHRs and must have at least one clinical decision support tool, such as a drug interaction checker. Both of those functions are characteristics of more advanced EHRs.
In CDC's previous survey based on 2009 and preliminary 2010 data, the agency found that 25% of physicians had a basic EHR and 10% had a "fully functional" system. While the latter definition included some features that were added to the "basic" category in the latest CDC survey, other advanced functions, such as interoperability, decision support and lab ordering, are not considered part of a basic EHR under the most recent definition.
Based on the "fully functional" EHR definition that was used up until 2011, DesRoches estimated that somewhere between 12% and 15% of physicians now have a fully functional EHR.
Nevertheless, Mitchell believes that meaningful use already has raised the bar for EHR functionality and will continue to do so in Stage 2. "It's not the highest level that we really need to get to, but it's an expansion from where we've been the past few years," he said.