Limited Information Technology for Patient Care in Physician Offices

Physicians and Information Technology: A Long Way to Go

While the Institute of Medicine (IOM) identified information technology as playing a central role in systematically improving the quality of clinical care and reducing health care costs, the health care industry adopted IT at a notably slow pace compared with other sectors. By the early 2000s, momentum for both public and private initiatives to promote IT adoption in hospitals and physicians' offices was building, and the federal government had stepped up efforts to foster the use of clinical technology.

Although the use of IT in physicians' offices could potentially improve quality and reduce costs, implementation was expensive. Practices faced significant up-front investments in capital, training, and the integration of IT systems with existing administrative and clinical processes. The business case for physician implementation of IT to improve care was still being made, since the benefits of lower costs and improved health were uncertain and tended to accrue more directly to health plans, employers, and patients than to physicians themselves. As a result, many physician practices were reluctant to adopt IT beyond administrative and management systems that directly affected revenues.

IT Benchmarks from the 2001 Physician Survey

HSC's 2001 Community Tracking Study (CTS) Physician Survey provided the first nationally representative data on the availability of information technology in physicians' offices across specialties, practice settings, and geographic areas. In the survey, physicians were asked whether computers or other forms of IT were used in their practice to support five clinical functions: obtaining treatment guidelines, exchanging clinical data with other physicians, accessing patient notes, generating treatment reminders for the physician's use, and writing prescriptions.

The use of IT in each of these five areas had been shown to improve the quality of care in at least one of three key quality domains identified by the IOM: effectiveness, timeliness, and patient safety. While other aspects of clinical practice could benefit from IT -- such as decision support -- the five clinical applications represented a broad spectrum of activities relevant to the quality of care patients received during office and follow-up visits.

The vast majority of patients were treated in physician practices that lacked significant IT support for patient care in 2001. One-quarter of all physicians were in practices with no computer or other form of IT support for any of the five functions, and another quarter had IT available for just one function. In contrast, only about a tenth of physicians were in practices with IT support for four or five functions.

Adoption of IT varied considerably by function. Just slightly more than half of physicians (53 percent) reported that their practices used IT to obtain information on treatment guidelines, the highest adoption rate of any of the five functions. Other rates were each below 50 percent: clinical data exchange stood at 41 percent, accessing patient notes at 37 percent, and treatment reminders at 24 percent. Electronic prescribing was least likely to be available, at just 11 percent.

Practice Size Matters

There was significant variation in the availability of information technology across practice settings. The almost 70 percent of physicians in traditional settings -- solo practices, small groups with up to 50 physicians, or practices owned by hospitals -- were least likely to be in practices using IT, with adoption rates ranging between 8 percent and 50 percent for the five functions examined.

For most of the functions, physicians in large groups of more than 50 physicians and medical school faculty practices were about 50 percent more likely to report IT availability compared with physicians in traditional practice settings. And physicians practicing in staff- or group-model HMOs were more than twice as likely as those in traditional practice settings to have IT support for patient care.

Physicians in traditional practice settings were even less likely to be in practices with IT support for multiple functions. Just 7 percent of physicians in small practices reported having IT support for four or five of the functions examined, compared with 20 percent of physicians in large groups and medical schools and more than 50 percent of those in staff or group HMOs.

Readier access to capital and administrative support staff, the ability to spread acquisition and implementation costs among more physicians, and active physician leadership may explain why larger practices were more likely to adopt IT to support patient care. In addition, large groups and HMOs offered greater opportunities and incentives for quality and efficiency gains through IT, such as improved care coordination. However, IT support in medical school faculty practices, hospital-based practices, and large practices may have been relatively more difficult to implement than in staff and group HMOs because of more complex governing structures, competing interests, and a fluctuating patient base. Since staff and group HMO practices were integrated with insurance, they could capture the benefits of IT investment that typically went to insurers.

Other Factors Play a Minor Role

Other factors such as physician age, specialty, and whether the practice was in an urban or rural area played relatively minor roles as underlying drivers of IT adoption. Older physicians were less likely than younger physicians to have IT support in their practices for all of the clinical functions except generating treatment reminders.

Rates of IT adoption also differed between primary care physicians and specialists. Primary care physicians reported higher rates of adoption of technology to generate treatment reminders and prescribe electronically, while specialists had higher rates of adopting technology to exchange clinical data and access patient notes. Multivariate analysis confirmed that practice setting was, by far, the most important driver of IT adoption among the factors examined.

Some policy makers had proposed focusing special efforts on speeding IT development in rural communities, expecting that IT would diffuse more slowly in those areas. For the most part, however, physicians in nonmetropolitan areas were just as likely as those in metropolitan areas to report that their practice had access to IT support, despite the fact that physicians in nonmetropolitan areas were more likely to be in smaller practices. Metropolitan and nonmetropolitan differences for the proportion of physicians in practices with limited IT support were not statistically significant.

Although differences between urban and rural areas were not large, there was considerable variation in the availability of IT across the 12 metropolitan CTS communities. More than 60 percent of physicians in three markets -- Phoenix, Lansing, and northern New Jersey -- had limited access to IT support for patient care, compared with less than 45 percent in Boston, Little Rock, and Seattle. These market differences remained after accounting for factors such as practice setting and physician age and specialty, suggesting other community-level factors were driving variation.

Policy Options for Accelerating IT Adoption

Because barriers to IT adoption appeared to be greatest for smaller traditional physician practices, policy makers may have needed to design policies specifically aimed at these physicians. While some approaches to speed IT adoption -- particularly those addressing financial barriers -- could provide incentives for smaller practices, others were less likely to be successful, especially in the near term.

Direct grants or loans to acquire IT and strategies to lower acquisition costs were two examples of approaches that may have been more successful with smaller practices. Some advocates had encouraged the development of a government-sponsored funding mechanism to provide capital to physicians and other providers, similar in concept to the Hill-Burton Act that permitted significant hospital expansion. WellPoint Networks Inc. and other health plans had implemented programs to provide computer equipment or other IT support to physicians. The American Academy of Family Physicians' electronic medical record initiative offered a relatively inexpensive mini-electronic record, coupled with organizational discounts, to reduce costs to smaller physician practices. Some state and local governments and private entities, with support from the U.S. Department of Health and Human Services, were funding community data exchange initiatives that made patient information available to physicians over the Internet, minimizing costs for individual practices.

Other proposals may have been less effective in promoting adoption in traditional practice settings. A number of health plan and purchaser initiatives were underway to provide financial incentives to physicians to improve quality, and similar proposals were under review for Medicare. While some programs had explicit IT incentives, those that focused on performance targets offered only indirect motivation -- adopting IT may have improved a practice's ability to meet quality targets, but that alone did not address the financial barriers to adoption for smaller practices. IT investments typically had to be made up-front, while incentive payments from quality initiatives were small, accrued incrementally on a per-patient basis, and applied to a limited portion of a practice's patient base. Until major health plans or Medicare offered practices significant financial incentives, quality initiatives were not likely to stimulate substantial IT adoption among smaller practices.

Sources and Further Reading

This Issue Brief (No. 89, September 2004) was authored by Marie C. Reed and Joy M. Grossman and published by the Center for Studying Health System Change (HSC). The findings were drawn from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians involved in direct patient care conducted in 2000-01. The sample was drawn from the American Medical Association and American Osteopathic Association master files and included active, nonfederal, office- and hospital-based physicians who spent at least 20 hours a week in direct patient care. The survey contained information on approximately 12,400 physicians with a response rate of 59 percent.

Institute of Medicine. Crossing the Quality Chasm. National Academy Press, Washington, D.C. (2001). U.S. Department of Health and Human Services. The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. Framework for Strategic Action, Washington, D.C. (July 21, 2004). Chambliss, M.L., et al. "The Mini-electronic Medical Record: A Low-cost, Low-risk Partial Solution." Journal of Family Practice (December 2001).

HealthIT.gov — Federal resources on health information technology.

Agency for Healthcare Research and Quality — Research on health care quality and IT adoption.

Centers for Medicare and Medicaid Services — Federal programs supporting health IT adoption.