Adoption of Electronic Health Records in Primary Care Pediatric Practices
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ABSTRACT
BACKGROUND. Electronic health records may improve care delivery. Although professional organizations and federal agencies encourage widespread adoption, no national data are available regarding the penetration of electronic health records into primary care pediatric practices.
METHODS. We used a national mail survey of 1000 randomly selected primary care pediatricians conducted from August to November 2005.
RESULTS. The response rate was 58%. Overall, 21.3% of respondents had an electronic health record in their practice. The likelihood of having an electronic health record increased with practice size. Those in a practice network were more likely to have an electronic health record than those in other settings. Smaller and independent practices were less likely to be considering implementing an electronic health record. Although most electronic health records include some pediatric-specific functionality such as the ability to record immunizations, many do not offer decision support; only approximately one third included immunization prompts or alerts for abnormal laboratory results. Cost was a barrier for nearly all of those without an electronic health record; half of the respondents questioned whether electronic health records lead to improvement in quality of care, and many could not identify an electronic health record that would meet their practice requirements.
CONCLUSIONS. Electronic health records are concentrated in larger and networked pediatric practices. Smaller and independent pediatric practices, the most common types of practice, are unlikely to adopt electronic health records until the cost of implementing and maintaining the systems decreases, developing standards for interoperability are adopted, and electronic health records are widely perceived to improve quality of care by practicing general pediatricians. The lack of decision support in current electronic health records may limit the ability of these tools to improve care delivery.
Key Words: pediatrics ? primary health care ? medical records systems ? computerized ? attitude to computers
Abbreviations: EHR—electronic health record ? AAP—American Academy of Pediatrics
Electronic health records (EHRs) are thought to improve quality of care, reduce the risk of medical errors, and improve practice efficiency.1 Although the federal government has set a goal for widespread adoption of EHRs in medical practices within the next 10 years,2 little is known about the penetration of EHRs into primary care.
There are numerous barriers to the adoption of EHRs, including costs, lack of standards and interoperability with existing systems, and privacy concerns.3,4 Provider knowledge and attitudes regarding EHRs, including perception of the benefit of EHRs, may also influence adoption.5
To understand the penetration of EHRs, it is critical to evaluate not simply whether a practice has an EHR but the capabilities of the EHR. The Institute of Medicine has outlined the core functions that an EHR should support, including health information and data collection, results management, decision support, electronic communication and connectivity, patient support, administrative processes, and reporting and population health management.6 In addition to these core functions, the American Academy of Pediatrics (AAP) recommends that EHRs for pediatric practice include functions to track and assess child growth and development and deliver appropriate age-based preventive care services, including support for the complex and changing immunization recommendations.7 To help facilitate adoption of EHRs, the AAP provides a Web site for users to review their experience with specific EHRs.8 However, the extent to which these pediatric-specific requirements create a barrier to EHR adoption in the primary care setting is unknown.
Between 2001 and 2003, 17% of physician offices had an EHR.9 A 2003 study found that 27% of physicians had an EHR; however, child health providers were not included.10 A more recent study has found that only 14% of all medical group practices have an EHR.11 However, although nearly 3500 practices were surveyed, the overall response rate was only 21.1%.
Our primary goals with this study were to measure the penetration and functionality of EHRs into primary care pediatric practice; to identify plans for the adoption of EHRs; to understand the common barriers to the adoption of EHRs; and to evaluate attitudes toward EHRs among those with and without one.
METHODS
Sampling Frame
A national random sample of 1000 pediatricians was drawn from the American Medical Association Masterfile, a database of all licensed physicians in the United States. The sampling frame included all allopathic and osteopathic physicians in office-based direct patient care whose board certification and self-described primary specialty was pediatrics. Physicians with a sub-board or secondary specialty listing were excluded. Physicians 70 years of age, resident physicians, and physicians practicing at military or federal facilities also were excluded.
Survey Instrument and Administration
We developed separate survey instruments for those with and those without an EHR in their practice. We defined an EHR as a computerized replacement of the paper medical chart as the primary source of patient information. For those with an EHR, the instrument consisted of 40 questions that explored functionality and use of the EHR, perceived benefits of the EHR, reasons for and barriers to implementation, Internet access, and practice characteristics. For those without an EHR, the instrument consisted of 31 questions that explored attitudes regarding EHRs, future plans to implement an EHR, barriers to implementation, and practice characteristics. Both instruments consisted primarily of multiple-choice questions and 4-point Likert scales of agreement and took <10 minutes to complete. The instrument was pilot-tested by a convenience sample of pediatricians to ensure clarity.
The first survey mailing, accompanied by a cover letter, a small cash incentive, and business reply envelope, was sent during August 2005. Two subsequent mailings to nonresponders were sent at 3-week intervals. The cover letter outlined subject eligibility and directed eligible respondents to the appropriate survey instrument.
Data Analysis
Initially, general frequency responses to all survey items were determined. After this, Pearson 2 tests of independence or Fisher's exact test if any cell size was 5 were used to test for associations among the categorical variables. In these analyses, we categorized practices on the basis of the number of providers, including physicians, nurse practitioners, and physician assistants, into solo practices (1 provider), small practices (2–5 providers), and large practices (6 providers). Practice affiliation was based on self-report and categorized into private and independent, medical center or university health system affiliated, practice network, or public clinic. All analyses were performed with Stata 8.2 software (Stata Corp, College Station, TX). The University of Michigan Medical School Institutional Review Board approved this project.
RESULTS
Response Rate and Practice Characteristics
Of the 1000 pediatricians in the sample, 67 were ineligible and we were unable to contact 32. A total of 526 eligible surveys were returned after 3 mailings (response rate: 58%).12
Among the respondents, 57 (10.8%) were in solo practice, 204 (38.8%) were in small practices, 248 (47.1%) were in large practices, and 17 (3.3%) did not specify the size of their practice. More than half (62.9% [n = 331]) reported that they were in private and independent practices, some (16.2% [n = 85]) were affiliated with a medical center or university health system, and fewer were part of a practice network (7.6% [n = 40]) or public clinic (4.0% [n = 31]). Few practices (4.2% [n = 22]) reported other affiliation.
Proportion of Practices With an EHR
Overall, 21.3% (n = 111) reported having an EHR in their practice. The proportion with an EHR increased with practice size, from 3.5% in solo practices to 14.2% in small practices and 31.9% in large practices (P < .001). Those in a practice network were more likely (P < .001) to report having an EHR (47.5%) than those in independent practices (16.9%), affiliated with a medical center or university health system (28.2%), or in a public clinic (9.7%). Approximately half (45.1%) had had an EHR for >3 years, whereas 20.7% had had an EHR for <1 year and 34.2% had had an EHR for between 1 and 3 years.
Implementation Plans Among Those Without an EHR
Half (54.3% [n = 221]) of those in practices without an EHR reported that their practice is planning on implementing one in the future. However, among these practices, 20.8% (n = 46) are not planning on adoption within the next 2 years, and 12.7% (n = 28) have no time frame for adoption. The likelihood of planning to adopt an EHR was associated with increasing practice size (solo, 28.3%; small, 47.4%; large, 71.9%; P < .001) and was lower among private and independent offices than those with any other affiliation (49.3% vs 66.1%; P < .01).
Barriers to Adopting EHRs Among Those Without an EHR
Table 1 presents the perceived barriers to implementing an EHR among those practices that do not have one (n = 415). The most common reasons were the expense of implementation, the inability to find an EHR that meets their pediatric-specific requirements, and physician resistance. The proportion that identified expense as a barrier did not vary by practice size (P = .11) or affiliation (P = .36). More than half (58.1%) reported that their perception of a lack of improvement in patient care or clinical outcomes is a barrier to adopting an EHR in their practice.
Reasons for Implementation Among Those With an EHR
Common reasons for adopting an EHR included to improve documentation (69.1%) and quality of care (61.8%), to provide access to patient records at other practice sites (60.0%), to improve workflow (50.9%) and billing (42.7%), and to reduce medical errors (40%).
EHR Functionality
Among those with an EHR in their practice (n = 111), nearly all reported that their EHR features the ability to record patient-encounter notes (99.1%), problem summary lists (89.2%), allergy lists (91.9%), vaccine administration (87.4%), and growth parameters (83.8%). Most (77.5%) reported that their EHR includes well-child visit templates, approximately half (48.7%) provide specific preventive services prompts, and some (36.9%) provide immunization prompts. Although nearly all (95.5%) EHRs provide laboratory and radiograph results, only some (33.3%) have alerts for abnormal results. Most (86.5%) EHRs include prescription writing, and more than half (62.2%) include alerts for dose checking or potential interactions. Few (22.5%) also provide rule-based order sets and treatment plans. Some (35.1%) EHRs include suggestions for billing or coding of services. Respondents reported using the EHR during the time of a patient encounter to document the encounter (82.9%), to look up patient information (96.4%), and to write prescriptions (81.1%).
EHR Implementation
Approximately half (54.1% [n = 60]) reported that a third-party vendor developed the EHR, and some (21.6% [n = 24]) reported that the health system to which the practice belongs provided the system. Only 10.8% (n = 12) reported that the EHR was developed within the practice, alone, or in partnership with external developers. Approximately half (52.3% [n = 58]) needed to add a full-time staff member and another 9.9% (n = 11) needed to add a part-time staff member to maintain the EHR.
Among those in the practice before the EHR was implemented (69.4% [n = 77]), most reported that the expense of implementation (78.4%), increase in physician workload (76.3%), and physician resistance (73.7%) were concerns before implementation. However, during implementation, these worries were actually only minor problems for most (expense, 63.6%; increase in workload, 56.9%; physician resistance, 70.9%).
Attitudes Among Those With and Without an EHR
Nearly half (42.5%) of those without an EHR in their practice reported that traditional paper-based health records are not as good as EHRs, compared with most (71.6%) of those with an EHR (P < .001). Table 2 presents the perceived impact of EHRs among those with and without an EHR in their practice. Regardless of EHR status, most reported that EHRs could have a positive impact on practice operation, with more of those with EHRs in their practice reporting that EHRs improve documentation completeness and that EHRs are more confidential and secure than paper records. Those with EHRs in their practice were more likely to believe that EHRs result in long-term savings and less likely to believe that they are too expensive to implement or maintain. Those with an EHR were also more likely to believe that EHRs improve quality of care. Although more of those with EHRs reported that EHRs reduce the risk of medical errors, this difference did not achieve statistical significance.
DISCUSSION
We found that approximately 1 in 5 pediatric practices has an EHR. These EHRs were primarily used to organize patient data; only approximately half provide decision support (eg, preventive services prompts) as recommended by the Institute of Medicine6 and the AAP7 to optimize the role of these tools in improving health care delivery. EHR penetration increased with practice size and was greater among practices in a network. Future implementation plans may increase the differences in EHR penetration by practice size and affiliation.
The cost of implementing and maintaining an EHR is a major barrier to adopting an EHR. Small and independent practices face substantial financial risk, and it can take years before there is a return on the investment.13 However, cost was not the only significant barrier to adoption. Concerns about practice operation, including physician resistance, system downtime, and increased workload, were common. Compared with pediatricians with an EHR, those without one were less likely to believe that these systems would improve documentation or improve quality of patient care. More than half of the pediatricians without an EHR cited lack of belief that these systems improve care as a barrier to adoption. Although prompts for preventive services can improve care,14 many of the EHRs in use do not provide this feature.
Many pediatricians were unable to identify an EHR that would meet their practice requirements and interface with their existing practice systems. The US Department of Health and Human Services has funded projects to develop standards for interoperability and data representation and resource centers for the dissemination of information about EHRs.15 However, until commercially available systems mature and adopt these developing standards, smaller and independent practices, which are the most common pediatric practice type, will be unlikely to take the financial risk necessary to adopt an EHR.
As EHRs mature, functionality and the degree to which practices take advantage of available functions will likely increase. One important limitation of this study is that we were unable to directly assess how the EHRs were actually used within the practice and the effect of the EHR on practice operation and patient outcome. There may be significant variation between EHRs in the sophistication of functionality (eg, immunization prompts) and the degree to which individual practices and providers take advantage of functionality. Another important limitation is that our assessment of the benefits of EHRs and the barriers to adoption are based on self-report. We did not prospectively follow practices through the process of EHR adoption. Practices that have successfully managed to adopt an EHR may minimize the challenge and overestimate the impact it has had on the quality of care that they provide.
We have provided a view of current EHR penetration that can be used as a baseline for measuring our progress toward making the transition for all practices from traditional paper-based records to EHRs. To continue this transition, future efforts will need to address the concerns of those in smaller and independent practices and focus on implementing systems that lead to improved care delivery.
ACKNOWLEDGMENTS
This project was supported by the Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan.
FOOTNOTES
Accepted Jan 10, 2006.
Address correspondence to Alex R. Kemper, MD, MPH, MS, Program on Pediatric Health Services Research, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705. E-mail: alex.kemper@duke.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr Kemper’s current address is Program on Pediatric Health Services Research, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705.
REFERENCES
Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in U.S. primary care. J Am Med Inform Assoc. 2003;10 :1 –10
US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. Health IT (HIT) adoption initiative. Available at:
www.hhs.gov/healthit/measuring.html. Accessed January 6, 2006
Hersh W. Health care information technology: progress and barriers. JAMA. 2004;292 :2273 –2274
Middleton B, Hammond WE, Brennan PF, Cooper GF. Accelerating US EHR adoption: how to get there from here—recommendations based on the 2004 ACMI retreat. J Am Med Inform Assoc. 2005;12 :13 –19
Johnson KB. Barriers that impede the adoption of pediatric information technology. Arch Pediatr Adolesc Med. 2001;155 :1374 –1379
Institute of Medicine; Dick RS, Steen EB, Detmer DE, eds. The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press; 1997
American Academy of Pediatrics, Task Force on Medical Informatics. Special requirements for electronic medical record systems in pediatrics. Pediatrics. 2001;108 :513 –515
American Academy of Pediatrics, Council on Clinical Information Technology. EMR review project. Available at: www.aapcocit.org/emr. Accessed January 6, 2006
Burt CW, Hing E. Use of Computerized Clinical Support Systems in Medical Settings: United States 2001–03. Hyattsville, MD: National Center for Health Statistics; 2005
Audet AM, Doty M, Peugh J, Shamasdin J, Zapert K, Schoenbaum S. Information technologies: when will they make it into physicians' black bags? MedGenMed. 2004;6 :2
Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption of electronic health records and information systems. Health Aff (Millwood). 2005;24 :1323 –1333
Council of American Survey Research Organizations. On the definition of response rates: a special report of the CASRO Task Force on Completion Rates. Available at: www.casro.org/resprates.cfm. Accessed January 6, 2006
Miller RH, West C, Brown TM, Sim I, Ganchoff C. The value of electronic health records in solo or small group practices. Health Aff (Millwood). 2005;24 :1127 –1137
Anand V, Biondich PG, Liu G, Rosenman M, Downs SM. Child health Improvement Through Computer Automation: the CHICA system. Medinfo. 2004;11 :187 –191
US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. Directory of federal HIT programs. Available at: www.hhs.gov/healthit/federalprojectlist.html. Accessed January 6, 2006
Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan(Alex R. Kemper, MD, MPH, )
BACKGROUND. Electronic health records may improve care delivery. Although professional organizations and federal agencies encourage widespread adoption, no national data are available regarding the penetration of electronic health records into primary care pediatric practices.
METHODS. We used a national mail survey of 1000 randomly selected primary care pediatricians conducted from August to November 2005.
RESULTS. The response rate was 58%. Overall, 21.3% of respondents had an electronic health record in their practice. The likelihood of having an electronic health record increased with practice size. Those in a practice network were more likely to have an electronic health record than those in other settings. Smaller and independent practices were less likely to be considering implementing an electronic health record. Although most electronic health records include some pediatric-specific functionality such as the ability to record immunizations, many do not offer decision support; only approximately one third included immunization prompts or alerts for abnormal laboratory results. Cost was a barrier for nearly all of those without an electronic health record; half of the respondents questioned whether electronic health records lead to improvement in quality of care, and many could not identify an electronic health record that would meet their practice requirements.
CONCLUSIONS. Electronic health records are concentrated in larger and networked pediatric practices. Smaller and independent pediatric practices, the most common types of practice, are unlikely to adopt electronic health records until the cost of implementing and maintaining the systems decreases, developing standards for interoperability are adopted, and electronic health records are widely perceived to improve quality of care by practicing general pediatricians. The lack of decision support in current electronic health records may limit the ability of these tools to improve care delivery.
Key Words: pediatrics ? primary health care ? medical records systems ? computerized ? attitude to computers
Abbreviations: EHR—electronic health record ? AAP—American Academy of Pediatrics
Electronic health records (EHRs) are thought to improve quality of care, reduce the risk of medical errors, and improve practice efficiency.1 Although the federal government has set a goal for widespread adoption of EHRs in medical practices within the next 10 years,2 little is known about the penetration of EHRs into primary care.
There are numerous barriers to the adoption of EHRs, including costs, lack of standards and interoperability with existing systems, and privacy concerns.3,4 Provider knowledge and attitudes regarding EHRs, including perception of the benefit of EHRs, may also influence adoption.5
To understand the penetration of EHRs, it is critical to evaluate not simply whether a practice has an EHR but the capabilities of the EHR. The Institute of Medicine has outlined the core functions that an EHR should support, including health information and data collection, results management, decision support, electronic communication and connectivity, patient support, administrative processes, and reporting and population health management.6 In addition to these core functions, the American Academy of Pediatrics (AAP) recommends that EHRs for pediatric practice include functions to track and assess child growth and development and deliver appropriate age-based preventive care services, including support for the complex and changing immunization recommendations.7 To help facilitate adoption of EHRs, the AAP provides a Web site for users to review their experience with specific EHRs.8 However, the extent to which these pediatric-specific requirements create a barrier to EHR adoption in the primary care setting is unknown.
Between 2001 and 2003, 17% of physician offices had an EHR.9 A 2003 study found that 27% of physicians had an EHR; however, child health providers were not included.10 A more recent study has found that only 14% of all medical group practices have an EHR.11 However, although nearly 3500 practices were surveyed, the overall response rate was only 21.1%.
Our primary goals with this study were to measure the penetration and functionality of EHRs into primary care pediatric practice; to identify plans for the adoption of EHRs; to understand the common barriers to the adoption of EHRs; and to evaluate attitudes toward EHRs among those with and without one.
METHODS
Sampling Frame
A national random sample of 1000 pediatricians was drawn from the American Medical Association Masterfile, a database of all licensed physicians in the United States. The sampling frame included all allopathic and osteopathic physicians in office-based direct patient care whose board certification and self-described primary specialty was pediatrics. Physicians with a sub-board or secondary specialty listing were excluded. Physicians 70 years of age, resident physicians, and physicians practicing at military or federal facilities also were excluded.
Survey Instrument and Administration
We developed separate survey instruments for those with and those without an EHR in their practice. We defined an EHR as a computerized replacement of the paper medical chart as the primary source of patient information. For those with an EHR, the instrument consisted of 40 questions that explored functionality and use of the EHR, perceived benefits of the EHR, reasons for and barriers to implementation, Internet access, and practice characteristics. For those without an EHR, the instrument consisted of 31 questions that explored attitudes regarding EHRs, future plans to implement an EHR, barriers to implementation, and practice characteristics. Both instruments consisted primarily of multiple-choice questions and 4-point Likert scales of agreement and took <10 minutes to complete. The instrument was pilot-tested by a convenience sample of pediatricians to ensure clarity.
The first survey mailing, accompanied by a cover letter, a small cash incentive, and business reply envelope, was sent during August 2005. Two subsequent mailings to nonresponders were sent at 3-week intervals. The cover letter outlined subject eligibility and directed eligible respondents to the appropriate survey instrument.
Data Analysis
Initially, general frequency responses to all survey items were determined. After this, Pearson 2 tests of independence or Fisher's exact test if any cell size was 5 were used to test for associations among the categorical variables. In these analyses, we categorized practices on the basis of the number of providers, including physicians, nurse practitioners, and physician assistants, into solo practices (1 provider), small practices (2–5 providers), and large practices (6 providers). Practice affiliation was based on self-report and categorized into private and independent, medical center or university health system affiliated, practice network, or public clinic. All analyses were performed with Stata 8.2 software (Stata Corp, College Station, TX). The University of Michigan Medical School Institutional Review Board approved this project.
RESULTS
Response Rate and Practice Characteristics
Of the 1000 pediatricians in the sample, 67 were ineligible and we were unable to contact 32. A total of 526 eligible surveys were returned after 3 mailings (response rate: 58%).12
Among the respondents, 57 (10.8%) were in solo practice, 204 (38.8%) were in small practices, 248 (47.1%) were in large practices, and 17 (3.3%) did not specify the size of their practice. More than half (62.9% [n = 331]) reported that they were in private and independent practices, some (16.2% [n = 85]) were affiliated with a medical center or university health system, and fewer were part of a practice network (7.6% [n = 40]) or public clinic (4.0% [n = 31]). Few practices (4.2% [n = 22]) reported other affiliation.
Proportion of Practices With an EHR
Overall, 21.3% (n = 111) reported having an EHR in their practice. The proportion with an EHR increased with practice size, from 3.5% in solo practices to 14.2% in small practices and 31.9% in large practices (P < .001). Those in a practice network were more likely (P < .001) to report having an EHR (47.5%) than those in independent practices (16.9%), affiliated with a medical center or university health system (28.2%), or in a public clinic (9.7%). Approximately half (45.1%) had had an EHR for >3 years, whereas 20.7% had had an EHR for <1 year and 34.2% had had an EHR for between 1 and 3 years.
Implementation Plans Among Those Without an EHR
Half (54.3% [n = 221]) of those in practices without an EHR reported that their practice is planning on implementing one in the future. However, among these practices, 20.8% (n = 46) are not planning on adoption within the next 2 years, and 12.7% (n = 28) have no time frame for adoption. The likelihood of planning to adopt an EHR was associated with increasing practice size (solo, 28.3%; small, 47.4%; large, 71.9%; P < .001) and was lower among private and independent offices than those with any other affiliation (49.3% vs 66.1%; P < .01).
Barriers to Adopting EHRs Among Those Without an EHR
Table 1 presents the perceived barriers to implementing an EHR among those practices that do not have one (n = 415). The most common reasons were the expense of implementation, the inability to find an EHR that meets their pediatric-specific requirements, and physician resistance. The proportion that identified expense as a barrier did not vary by practice size (P = .11) or affiliation (P = .36). More than half (58.1%) reported that their perception of a lack of improvement in patient care or clinical outcomes is a barrier to adopting an EHR in their practice.
Reasons for Implementation Among Those With an EHR
Common reasons for adopting an EHR included to improve documentation (69.1%) and quality of care (61.8%), to provide access to patient records at other practice sites (60.0%), to improve workflow (50.9%) and billing (42.7%), and to reduce medical errors (40%).
EHR Functionality
Among those with an EHR in their practice (n = 111), nearly all reported that their EHR features the ability to record patient-encounter notes (99.1%), problem summary lists (89.2%), allergy lists (91.9%), vaccine administration (87.4%), and growth parameters (83.8%). Most (77.5%) reported that their EHR includes well-child visit templates, approximately half (48.7%) provide specific preventive services prompts, and some (36.9%) provide immunization prompts. Although nearly all (95.5%) EHRs provide laboratory and radiograph results, only some (33.3%) have alerts for abnormal results. Most (86.5%) EHRs include prescription writing, and more than half (62.2%) include alerts for dose checking or potential interactions. Few (22.5%) also provide rule-based order sets and treatment plans. Some (35.1%) EHRs include suggestions for billing or coding of services. Respondents reported using the EHR during the time of a patient encounter to document the encounter (82.9%), to look up patient information (96.4%), and to write prescriptions (81.1%).
EHR Implementation
Approximately half (54.1% [n = 60]) reported that a third-party vendor developed the EHR, and some (21.6% [n = 24]) reported that the health system to which the practice belongs provided the system. Only 10.8% (n = 12) reported that the EHR was developed within the practice, alone, or in partnership with external developers. Approximately half (52.3% [n = 58]) needed to add a full-time staff member and another 9.9% (n = 11) needed to add a part-time staff member to maintain the EHR.
Among those in the practice before the EHR was implemented (69.4% [n = 77]), most reported that the expense of implementation (78.4%), increase in physician workload (76.3%), and physician resistance (73.7%) were concerns before implementation. However, during implementation, these worries were actually only minor problems for most (expense, 63.6%; increase in workload, 56.9%; physician resistance, 70.9%).
Attitudes Among Those With and Without an EHR
Nearly half (42.5%) of those without an EHR in their practice reported that traditional paper-based health records are not as good as EHRs, compared with most (71.6%) of those with an EHR (P < .001). Table 2 presents the perceived impact of EHRs among those with and without an EHR in their practice. Regardless of EHR status, most reported that EHRs could have a positive impact on practice operation, with more of those with EHRs in their practice reporting that EHRs improve documentation completeness and that EHRs are more confidential and secure than paper records. Those with EHRs in their practice were more likely to believe that EHRs result in long-term savings and less likely to believe that they are too expensive to implement or maintain. Those with an EHR were also more likely to believe that EHRs improve quality of care. Although more of those with EHRs reported that EHRs reduce the risk of medical errors, this difference did not achieve statistical significance.
DISCUSSION
We found that approximately 1 in 5 pediatric practices has an EHR. These EHRs were primarily used to organize patient data; only approximately half provide decision support (eg, preventive services prompts) as recommended by the Institute of Medicine6 and the AAP7 to optimize the role of these tools in improving health care delivery. EHR penetration increased with practice size and was greater among practices in a network. Future implementation plans may increase the differences in EHR penetration by practice size and affiliation.
The cost of implementing and maintaining an EHR is a major barrier to adopting an EHR. Small and independent practices face substantial financial risk, and it can take years before there is a return on the investment.13 However, cost was not the only significant barrier to adoption. Concerns about practice operation, including physician resistance, system downtime, and increased workload, were common. Compared with pediatricians with an EHR, those without one were less likely to believe that these systems would improve documentation or improve quality of patient care. More than half of the pediatricians without an EHR cited lack of belief that these systems improve care as a barrier to adoption. Although prompts for preventive services can improve care,14 many of the EHRs in use do not provide this feature.
Many pediatricians were unable to identify an EHR that would meet their practice requirements and interface with their existing practice systems. The US Department of Health and Human Services has funded projects to develop standards for interoperability and data representation and resource centers for the dissemination of information about EHRs.15 However, until commercially available systems mature and adopt these developing standards, smaller and independent practices, which are the most common pediatric practice type, will be unlikely to take the financial risk necessary to adopt an EHR.
As EHRs mature, functionality and the degree to which practices take advantage of available functions will likely increase. One important limitation of this study is that we were unable to directly assess how the EHRs were actually used within the practice and the effect of the EHR on practice operation and patient outcome. There may be significant variation between EHRs in the sophistication of functionality (eg, immunization prompts) and the degree to which individual practices and providers take advantage of functionality. Another important limitation is that our assessment of the benefits of EHRs and the barriers to adoption are based on self-report. We did not prospectively follow practices through the process of EHR adoption. Practices that have successfully managed to adopt an EHR may minimize the challenge and overestimate the impact it has had on the quality of care that they provide.
We have provided a view of current EHR penetration that can be used as a baseline for measuring our progress toward making the transition for all practices from traditional paper-based records to EHRs. To continue this transition, future efforts will need to address the concerns of those in smaller and independent practices and focus on implementing systems that lead to improved care delivery.
ACKNOWLEDGMENTS
This project was supported by the Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan.
FOOTNOTES
Accepted Jan 10, 2006.
Address correspondence to Alex R. Kemper, MD, MPH, MS, Program on Pediatric Health Services Research, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705. E-mail: alex.kemper@duke.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr Kemper’s current address is Program on Pediatric Health Services Research, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705.
REFERENCES
Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in U.S. primary care. J Am Med Inform Assoc. 2003;10 :1 –10
US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. Health IT (HIT) adoption initiative. Available at:
www.hhs.gov/healthit/measuring.html. Accessed January 6, 2006
Hersh W. Health care information technology: progress and barriers. JAMA. 2004;292 :2273 –2274
Middleton B, Hammond WE, Brennan PF, Cooper GF. Accelerating US EHR adoption: how to get there from here—recommendations based on the 2004 ACMI retreat. J Am Med Inform Assoc. 2005;12 :13 –19
Johnson KB. Barriers that impede the adoption of pediatric information technology. Arch Pediatr Adolesc Med. 2001;155 :1374 –1379
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