Clinical Information Technology Adoption Varies Across Physician Specialties

Uneven Clinical IT Adoption Across Medical Specialties

Practice setting and size were the strongest predictors of whether physicians had access to clinical information technology, but meaningful variation also existed across medical specialties, according to findings from HSC's nationally representative 2004-05 Community Tracking Study (CTS) Physician Survey. Because clinical IT held the potential to improve care coordination between primary care physicians and specialists, support quality improvement efforts, and facilitate reporting activities, gaps in adoption among certain specialties risked undermining these goals.

Measuring IT Access by Clinical Activity

Rather than asking physicians about specific technologies, the CTS survey asked about the availability of IT in their practice for five distinct clinical activities: obtaining information about treatment alternatives or recommended guidelines; accessing patient notes, medication lists, or problem lists; writing prescriptions; exchanging clinical data and images with other physicians; and exchanging clinical data and images with hospitals. Physicians who reported access to IT for all five activities were classified as having an electronic medical record (EMR).

This activity-based approach captured a wider range of technologies than a simple EMR question would have. Physicians could access electronic patient notes through various mechanisms — a full EMR system, a practice management application, or a Web-based portal — and any given application might support some or all of the five activities. An important caveat: because the survey asked about IT availability in the practice rather than personal use or frequency of use, the estimates should be understood as an upper bound on physicians actually using clinical IT on a regular basis.

How the Three Major Specialty Categories Compared

Across the broad categories of primary care, medical specialties, and surgical specialties, surgeons consistently trailed medical specialists in IT access. Surgeons reported lower rates for four of the five clinical activities and were also less likely to have all five functions associated with an EMR. Primary care physicians fell behind medical specialists in two specific areas: accessing electronic patient notes and exchanging clinical data with other physicians.

Looking at the overall numbers for all physicians in 2004-05: 65 percent had IT access for obtaining guidelines, 50 percent for accessing patient notes, 22 percent for writing prescriptions, 50 percent for exchanging data with physicians, 66 percent for exchanging data with hospitals, and just 12 percent had access to all five activities (the EMR threshold).

Wide Gaps Among Subspecialties

The differences became much more pronounced when looking at individual subspecialties. Among medical subspecialists, psychiatrists stood out as notably behind their peers. Compared to the reference group of other medical subspecialists, psychiatrists were significantly less likely to have IT access for every activity except prescription writing. Their EMR rate was just 6 percent, compared with 12 percent for other medical subspecialists. Oncologists presented the opposite picture, reporting significantly higher rates than the comparison group for obtaining guidelines and exchanging data with both hospitals and physicians.

Emergency medicine physicians reported among the highest rates across multiple activities — 74 percent for accessing patient notes, 70 percent for physician data exchange, and 83 percent for hospital data exchange. However, the researchers noted that emergency physicians' responses likely reflected access to IT within hospital emergency departments rather than office-based settings, making direct comparisons with office-based specialties problematic.

Among surgical subspecialties, ophthalmologists lagged the comparison group of general and other surgical subspecialists across nearly all measures. Their EMR rate was only 2 percent, the lowest of any subspecialty studied. They were significantly less likely to access patient notes (23 percent vs. 56 percent for the reference group), write prescriptions electronically (9 percent vs. 17 percent), exchange data with physicians (43 percent vs. 62 percent), and exchange data with hospitals (45 percent vs. 73 percent). Obstetrician-gynecologists also fell behind the surgical reference group for accessing notes and exchanging data with physicians and hospitals.

Within primary care, the main difference was that pediatricians and general/family physicians were less likely than internists to have IT access for electronic patient notes. Internists led with 53 percent access for notes, compared with 45 percent for family physicians and 40 percent for pediatricians.

Clinical Needs as a Driver of Adoption Patterns

The variation by subspecialty persisted even after accounting for differences in practice setting and size, the primary drivers of IT adoption. Two indirect measures of financial resources — physician income and the proportion of practice revenue derived from Medicaid — were not generally associated with reported IT access, suggesting that financial capacity alone did not explain the specialty gaps.

Instead, specialty-specific clinical workflows appeared to influence which IT functions physicians found relevant. Clinical data exchange with hospitals, for example, was central to the work of general surgeons but far less pertinent to ophthalmologists, who frequently performed procedures in ambulatory surgery centers or office-based settings. Surgeons generally had less need for electronic prescribing because they typically prescribed a narrow set of on-formulary medications for short durations, in contrast to medical specialists and primary care physicians managing chronically ill patients on multiple long-term medications.

In other cases, the available EMR products may not have met the specific clinical requirements of certain specialties. Ophthalmologists needed enhanced drawing features and imaging storage capabilities for conditions like glaucoma monitoring. Pediatricians required growth tracking tools and pediatric-specific dosing calculations. Supporting this explanation, a 2005 survey found that 81 percent of pediatricians without EMRs cited the inability to find a system meeting pediatric-specific requirements as a barrier to adoption.

Implications for Health System Goals

The uneven adoption landscape had real consequences for the health system's ability to achieve its IT-related goals. Care coordination between primary care physicians and specialists depended on both parties having the infrastructure to exchange clinical information electronically. Quality improvement and reporting activities likewise required consistent IT capabilities across the care continuum. When entire subspecialties lagged significantly — psychiatry and ophthalmology being the starkest examples — the effectiveness of system-wide IT initiatives was diminished.

Addressing these gaps would require both broader market availability of specialty-tailored EMR products and a better understanding of the distinct clinical workflows that shaped adoption decisions in different fields of medicine. A one-size-fits-all approach to clinical IT promotion was unlikely to close the gaps identified in this research.

About the Data

This Data Bulletin reported findings from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians involved in direct patient care across the continental United States. The survey was conducted in four rounds: 1996-97, 1998-99, 2000-01, and 2004-05. The physician sample was drawn from the American Medical Association and American Osteopathic Association master files and included nonfederal, office- and hospital-based physicians spending at least 20 hours per week in direct patient care. Residents and fellows were excluded. Information technology questions were first added to the 2000-01 survey round. The 2004-05 survey included responses from more than 6,600 physicians, with a response rate of 52 percent.

Sources and Further Reading

Grossman, Joy M., and Marie C. Reed. "Clinical Information Technology Gaps Persist Among Physicians." Issue Brief No. 106, Center for Studying Health System Change (November 2006).

Blumenthal, David, et al. "Health Information Technology in the United States: The Information Base for Progress." Robert Wood Johnson Foundation, Princeton, New Jersey (2006).

Kemper, Alex R., et al. "Adoption of Electronic Health Records in Primary Care Pediatric Practices." Pediatrics, Vol. 118, No. 1 (July 2006).