When It Comes to EHR Adoption, Practice Size Matters

by Kate Ackerman, iHealthBeat Senior Editor

It's no secret that small physician practices are less likely than larger practices and hospitals to adopt and use electronic health record systems.

The federal government's meaningful use incentive program aims to drive widespread EHR adoption. But, small practices are lagging behind and face a much steeper climb to get to meaningful use.

According to the Center for Health Care Strategies, nearly 60% of physicians work in practices with four or fewer doctors, and about 65% of U.S. physician visits occur at these small practices. If small practices are left behind in the push for meaningful use, most patients will be, too.

A study published in this month's Journal of the American Medical Informatics Association aims to better understand the unique barriers that small practices face.

Ashish Jha -- associate professor of health policy and management at the Harvard School of Public Health and co-author of the study -- said, "If we're ever going to get to be a country that has widespread use of EHRs, we're going to have to figure out the small practice problem."

Using data from a 2008 New England Journal of Medicine study on physician EHR adoption, Jha and his colleagues assessed the variation by physician practice size in EHR adoption and use, barriers to adoption and perceived benefits of EHRs.

Sowmya Rao -- an associate professor at the University of Massachusetts Medical School and lead author of the study -- said this is the first study to systematically examine the issue using nationally representative data.

Jha said, "We know from other studies that physicians who work in small practices are much less likely to have EHRs than others," adding, "What we really wanted to try to understand is can we get insights into why those differences exist because ... that will be very helpful in helping us think about how to overcome that barrier."

Study Findings

As expected, the study -- which was sponsored by the Office of the National Coordinator for Health IT and the Robert Wood Johnson Foundation -- confirmed previous findings that smaller practices are less likely to have EHR systems. Fewer than 2% of physicians in a solo- or two-physician practice reported having a fully functional EHR system, and 5% reported having a basic EHR system. Meanwhile, 13% of physicians in practices of 11 or more doctors reported having a fully functional EHR system, and 26% said they have a basic system in place.

Not surprisingly, doctors in the smallest physician practices were more likely than physicians from larger practices to report financial barriers to EHR adoption.

However, a more significant difference among small and large physician practices when it comes to EHR adoption barriers is a concern about future obsolescence.

Rao said, "Because I think [small practices] only have so much money they can invest, they want to make sure what they get meets their needs and will not go obsolete in the near future."

Jha said, "Imagine if you're in a 50-physician practice, you probably have a few people in your practices who have a lot of technical expertise or you have the resources that you can hire somebody who can scope out the landscape and identify the right EHR for you." However, that's not the case for smaller practices, according to Jha. He added that "a lot of the vendors that are targeting small practices are, I think, less stable. They're not the big vendors. The big vendors are going after the big practices."

Interestingly, doctors from small practices were not any more likely to report general resistance or concerns about productivity as barriers.

In addition, the study found that when small physician practices "actually used EHRs, the perceived benefits were similar to large practices," Rao said.

However, adoption does not guarantee EHR use. The study found large gaps in the use of individual EHR functions, such as electronic clinical notes and electronic prescribing. Jha said that finding "is troubling because it says that [small practices] ... figured out how to get the capital to put the resources into it but haven't been able to overcome the next set of barriers, which is actually figuring out how to use the EHR [system] in their practice."

Effect of Meaningful Use Incentives, Regional Extension Centers

The JAMIA study is based on data from 2007 to 2008, before the launch of the meaningful use incentive program. Jha noted that ONC has access to 2010 data on EHR adoption but those data are not yet publicly available.

Rao said she expects the billions of dollars in funding allocated for Medicare and Medicaid incentive payments under the meaningful use incentive program to help drive up EHR adoption rates across practice size. However, she noted that "it's not just financial help that these small practices are looking for."

Although the study was based on older data, Jha said that small physician practices likely face the same barriers today, including concerns that EHR systems will not meet their needs or will become obsolete.

The HITECH Act, part of the 2009 federal economic stimulus package, allocated $677 million for the creation of 62 regional extension centers throughout the country to help health care providers become meaningful users of EHRs. The RECs specifically are designed to target small physician practices, as well as small, rural and critical-access hospitals.

Jha said that RECs need to "develop real expertise in the needs of small practices." He added that "for regional extension centers to be effective, they really have to understand both the market of vendors that target these small practices and they have to have real expertise in helping physicians not just select the right product but then also get it implemented effectively."

Jha said, "The truth is, I don't know if RECs have developed expertise in that area," adding, "I haven't seen any data or heard much in stories one way or the other about how good these RECs have been in helping these small practices move forward."

Variation in the effectiveness of different RECs also is a concern, Jha said. "What you're invariably going to see is that a few regional extension centers are going to be great and others are going to struggle," he said, adding, "The job of the Office of the National Coordinator is to identify the good ones and get them to teach everybody else because what we don't want is ... large pockets of providers not moving forward because they were unlucky enough to be in a place where the regional extension center wasn't effective."

Predictions for Future EHR Use; Continued Tracking Key

Jha said that in speaking with clinical leaders from both small and large practices, he believes that "the large practices are going to do much better in getting to meaningful use at least in the next couple of years."

Acknowledging that predictions in health IT adoption often are wrong, Jha said, "I think if you took practices of 50 physicians or more, my guess is that in five years from now, 90% of them will have EHRs, [and] probably some number close to that will be meaningful users of EHRs." He added, "So I'm not worried about those guys. I think the one-to-three-, one-to-five- physician practices is where the big challenge is going to be. And, I don't know that we'll hit 50% in that group in five years. I hope we do, but I think it's going to be a real challenge."

Jha called tracking EHR adoption and use over time "fundamental." He said, "The challenge for the whole country is going to be tracking it very closely to make sure the small physician practices don't fall off the adoption curve."

Jha said, "Tracking what happens to small practices over time is the closest surrogate we have to tracking whether meaningful use is going to be successful or not." He continued, "If they can't get small practices up and running ... I think meaningful use, and the whole HITECH Act, is not going to be thought of as a success." However, if small practices do become meaningful users of EHRs, "it'll be thought of as a broadly successful program," Jha said.

As soon as the 2010 data on EHR adoption become available, Jha and his colleagues plan to conduct additional studies looking at how EHR adoption, use and barriers at small physician practices have changed.

Chris Councilor
This article hits the nail right on the head. Smaller practices have limited resources, RECs are partnering with a small handful of big EHR vendors that don't fit everyone's needs and they don't have the ability or bandwidth to provide proper practice assessments for the small offices. They key is to provide a good practice assessment then offer considerations, functionality requirements and a shortlist of vendors that match the characteristics of the practice. From there, providers are in a much better position to demo and select the right EHR for them.

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