Assessing EMR Adoption

1
Assessing EMR Adoption Implementationin
Physician Small Office Settings

• Presentation to WA State Health Information
  Infrastructure Advisory Board
• July 30, 2008
• Suzie Burke-Bebee, MSIS, MS, RN
• Office of the Assistant Secretary for Planning
  and Evaluation, Office of the Secretary,
  Department of Health and Human Services
• Aparna Higgins, MA
• Lead Investigator for Study while at Booz Allen
  Hamilton

2
Presentation Agenda

• Introduction
• EMR Adoption in the Physician Small Practice
  Setting
• Financial Aspects of EMR adoption
• Insights from Site Visits
• Implementation Roadmap
• Summary

3
Introduction - ASPE

• Principal advisor to HHS Secretary Mike Leavitt
  on health policy development
• responsible for policy coordination, legislation
  development, strategic planning, policy research,
  evaluation, and economic analysis

• EMR Study funded by ASPE
• Contractor Booz-Allen-Hamilton, Moshman
  Associates
• Conducted September 2005 - September 2006

4
What Factors Are Relevant to EMR Adoption in
Physician SmallPractice Settings?
Introduction ASPE Study

• Purpose of Study
• Clearly understand the economic and non-economic
  variables relevant to the successful
  implementation of an EMR in the physician small
  office setting

5
Introduction - Study Methodology
Developed Preliminary Economic Framework
Conducted Site Visits
Developed Proposed Economic Framework
Conducted LiteratureReview
Developed EMR Implementation Guidance for
Physician Offices
Input from Technical Expert Panel
6
Presentation Agenda

• Introduction
• EMR Adoption in the Physician Small Practice
  Setting
• Financial Aspects of EMR adoption
• Insights from Site Visits
• Implementation Roadmap
• Summary

7
Most Physicians are Not Using EMRs, Especially in
Small Practices

• Practices between 1-9 physicians account for over
  80 of physicians
• In practices larger than 9 physicians, adoption
  rates are significantly higher

88
Source Burt and Sisk, 2005 (study period
2001-2003)
8
Evolving Statistics on EMR adoption (refining
definition of EMR)

• EMR defined 2001-2003 e-documentation on patient
  condition and treatment
• Comprehensive EMRs defined 2006 with
• 4 specific features
• computerized orders for prescriptions
• computerized orders for tests
• reporting test results (lab, imaging)
• clinical notes

Source Hing et al., 2007 (study period 2006)
9
Comparing EMR adoption to EMR adoption
Source Hing et al., 2007 (study period 2006)
10
Modifiable and Non-Modifiable Factors
Associated with Adoption Reported in the
Literature

• Non-Modifiable Factors
• Practice Characteristics or Physician
  Characteristics
• Modifiable Factors
• Perception of Barriers and Benefits

11
Practice Characteristics Such as Size and Type of
Practice and Ownership Are Reported to be Related
to EMR Adoption
12
Based on Physician Surveys, There Are Many
Physician Perceptions Relating to Barriers and
Benefits of EMR Adoption

• Benefits and barriers are categorized into three
  groups
• Financial
• Technical
• Practice

13
Physicians Reported Both Financial Barriers and
Benefits Relevant to EMR Adoption
Barriers
Benefits
14
Physicians Reported Many Technical Barriers
Related to EMR Adoption

• Difficulty or inability to evaluate and select
  EHR
• Concern over the technical ability to use an EHR
• Lack of training
• Creating a migration plan
• Meeting technical/clinical requirements/usability
• EHR solutions are fragmented
• Lack of uniform standards (including
  terminologies)
• Risk of vendor going out of business
• Mistrust of vendors
• Lack of support

15
Many Reported Physician Perceptions Relating to
EMR Adoption
Barriers
Benefits
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Presentation Agenda

• Introduction
• EMR Adoption in the Small Physician Practice
• Financial Aspects of EMR adoption
• Insights from Site Visits
• Implementation Roadmap
• Summary

17
Many Reported Cost Components Relating to EMR
Implementation

18
Financial Benefits Are Reported to Accrue to the
Physician Office and Healthcare System

19
One Report Showed the More Advanced the EMR the
Greater the Net Benefits
Wang et al. (2003)
20
Functionality and Usability Variations Have Been
Shown to Affect Cost/Benefits

• Within functionality categories there are varying
  levels of sophistication (e.g., the level of
  decision-support in medication ordering, alerts,
  and provision of guidelines)
• Different functionalities have different
  implications for performance as well as for costs
  and benefits Wang (2003), Nebeker (2005)
• Usability also has implications for performance,
  costs, and benefits
• Usability can have a significant influence on
  physician use of an EMR
• Usability does not appear to be well measured,
  assessed or reported on in the literature

21
Presentation Agenda

• Introduction
• EMR Adoption in the Small Physician Practice
• Financial Aspects of EMR adoption
• Insights from Site Visits
• Implementation Roadmap
• Summary

22
Site Visits Phone Interviews to Explore/Confirm
Literature Findings
23
Site Visits Phone Interviews to Explore/Confirm
Literature Findings
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Research And Decision-Making Process Not a
Reported Barrier to EMR Adoption by the Sites

• In sites with multiple physicians, the physician
  lead was able to achieve unanimous buy-in from
  all the physicians in the practices
• In all cases, sites reported that all staff were
  very satisfied with the system post-implementation
  , including staff members who were initially
  reluctant
• In all cases but one, the physician lead had
  prior experience with EMRs
• Practices relied on a uniform set of sources to
  obtain information on EMRs
• Reviewing the literature
• Attending conferences or trade shows
• Consulting their respective specialty societies
  (e.g., AAFP)
• Speaking with peers and colleagues
• Visiting independent or reference sites
• Practices typically evaluated multiple EMR
  vendors prior to selection
• The majority of the sites did not believe the
  research on EMR research and decision-making
  process to be a barrier to adoption

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Functionality and Costs Reported by the Sites
Consistent With Those Found in the Literature

• The five visited sites demonstrated EMRs with
  very similar user-interfaces with the following
  list of functionalities
• Scheduling
• Documentation
• Order Entry (although level of sophistication
  varied)
• Patient history
• Report generation
• Basic decision support (e.g. drug interaction,
  dosage restrictions)
• Practices spent between 15K to 80K on the
  purchase of software which included a practice
  management system in most cases
• On-site training and implementation were included
  in the purchase price of the systems
• Practices varied in terms of ability to negotiate
  with vendors
• All practices needed 3-6 months prior to becoming
  fully operational

26
The Sites Reported Achieving Benefits From EMR
Adoption

• Impact on Workflow Efficiency (e.g. streamline
  lab and prescription ordering and results
  retrieval)
• Improvements in employee satisfaction/MD quality
  of life improvements.
• Personnel and other cost savings, and chart room
  storage savings (e.g., reduction in staff by 1.5
  FTE business office converted to exam rooms
  elimination of transcription)
• Improvements in charge capture
• Two sites demonstrated an increase in coding and
  billing rates/collections
• Several of the sites noted that the improved
  ability to document through an EMR allows the
  physicians the confidence to code properly
  without fear of audits
• Some of the sites noted a discount on malpractice
  insurance rates as a result of adoption

27
Improved Availability of Information Was Reported
by Sites as Improving Medical Decision-Making

• Impact on Quality
• While all sites felt that the EMR enhanced their
  decision-making abilities, they attributed this
  to the availability of data on patients
• None of the sites cited a reduction in medical
  errors or the ability to rely on the system for
  any decision support
• Practices did cite enhanced quality of patient
  care
• Many sites further cautioned that having
  reasonable expectations for adoption of EMRs is a
  critical success factor

28
Site Visits Confirmed Findings in the Literature
While Providing Additional Insights

• The visits to the sites confirmed the findings
  from the literature and confirmed our hypotheses
• Physicians are influenced by costs and benefits
  when adopting EMRs
• Benefits are financial and non-financial in
  nature
• Costs of EMR adoption include research and
  selection costs as well as initial productivity
  losses
• Previously accumulated human capital may be a
  significant factor in EMR adoption
• Prior experience with EMR
• Knowledge and experience with computer-related
  technology
• Multi-disciplinary education and training (e.g.
  medicine and electrical engineering)
• Physicians face uncertainty in the selection
  process
• Information from a variety of sources plays a key
  role in the decision process

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Visits LR Identified a Set of Key Elements
Affecting EMR Adoption

• Physician motivators for adoption
• Varying EMR functionalities
• EMR costs and benefits
• Existence of human capital
• Role of uncertainty
• Importance of information

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Presentation Agenda

• Introduction
• EMR Adoption in the Small Physician Practice
• Financial Aspects of EMR adoption
• Insights from Site Visits
• Implementation Roadmap
• Summary

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Implementation Roadmap
Purpose provide practical information to small
practices when considering EMR adoption
TOC

• Identify and evaluate potential vendors
• Select vendor and negotiate contract
• Implementation and beyond

• Introduction
• Develop understanding of EMR functionality
• Conduct internal preparation

Source Final Report at http//aspe.hhs.gov/sp/07/
adoption/index.htm
32
Presentation Agenda

• Introduction
• EMR Adoption in the Small Physician Practice
• Financial Aspects of EMR adoption
• Insights from Site Visits
• Implementation Roadmap
• Summary

33
Summary

• There are significant gaps in the survey and cost
  benefit literature
• The survey literature is limited, standardized
  definitions of EMRs are not used and correlations
  with different levels of functionality are not
  made
• Lack of uniformity when characterizing EMRs
• Lack of distinction between adoption and use
• Variations in sample size and response rates
• Correlations to physician and practice
  characteristics generally emphasize non-
  modifiable characteristics such as size,
  location, specialty, age, and others
• There is no detailed and comprehensive adoption
  survey that correlates different levels of
  functionality with costs, benefits and financial
  characteristics of the practice
• There is no detailed survey that captures the
  factors important to the decision to adopt and
  implement
• There is no detailed survey of non
  adopters/deferred adopters

34
Summary

• There is also a lack of robust empirically
  derived evidence on the costs and benefits
  associated EMR adoption
• Existing cost-benefit studies are based on
  simulation models that rely on expert opinion and
  extrapolation from literature sources
• At the time of this study, there was a single
  retrospective evaluation of EMR costs and
  benefits in 14 practices
• Such a lack of evidence can create uncertainty
  and result in deferred adoption

35
There Are Many Interesting Questions

• Limited evidence suggests that financial benefits
  are greater than costs. Why does the literature
  cite cost as the primary barrier to adoption?
• Lack of capital? Level of uncertainty/risk?
• Is the EMR market mature enough to reduce
  perception of product uncertainty/risk? Is the
  functionality sufficient?
• How significant will medical school-residency
  training with EMRs be in adoption?

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Questions?
37
Select References on EMR

• Audet AM, Doty MM, Peugh J, Shamasdin J, Zapert
  K, Schoenbaum S. Information technologies when
  will they make it into physicians' black bags?
  Medscape General Medicine 20046(4).
• Burt CW, Sisk JE. Which physicians and practices
  are using electronic medical records? Health
  Affairs 200524(5)1334-43.
• Hing ES, Burt CW, Woodwell DA. Electronic Medical
  Record Use by Office-Based Physicians and Their
  Practices United States 2006. Advance Data from
  Vital and Health Statistics, number 393 October
  26, 2007.
• Ford, E. W., Menachemi, N., Phillips, M. T,
  Predicting the adoption of electronic health
  records by physicians when will health care be
  paperless? in the J Am Med Inform Assoc, 2006
  Jan-Feb, vol 13, pp 106-12.
• Gans D, Kralewski J, Hammons T, Dowd B. Medical
  groups' adoption of electronic health records and
  information systems. Health Affairs
  200524(5)1323-33.
• Miller RH, West C, Brown TM, Sim I, Ganchoff C.
  The value of electronic health records in solo or
  small group practices. Health Affairs
  200524(5)1127-37.
• Wang SJ, Middleton B, Prosser LA, et al. A
  cost-benefit analysis of electronic medical
  records in primary care. American Journal of
  Medicine 2003114397-403.