Use of EHRs in U.S. Hospitals: A Review of Jha et al. (2009)

Use of Electronic Health R d i U S H it lRecords in U.S. Hospitals

A Review of Jha et al. (2009)

Nawanan Theera-Ampornpunt, M.D., M.S.UMN Health Informatics Journal ClubUMN Health Informatics Journal Club

September 24, 2009

Outline

Overview of Health IT AdoptionOverview of Health IT AdoptionU.S. EHR Adoption LandscapeJh t l (2009)’ St dJha et al. (2009)’s Study• Background• Methods• Results & Discussions• Summary

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Overviewf H lth IT Ad tiof Health IT Adoption

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Underlying Assumptiony g p

Adoption Use OutcomesAdoption Use Outcomes

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Underlying Assumptiony g p

• Better clinical outcomes

Individual Adoption & use

• Better clinical outcomes• Improved patient satisfaction• More provider productivity/satisfaction

• Improved operational efficiency• More patients

Organizational Adoption & Use

p• Reduced costs/increased revenues

Societal Adoption & Use

• Better individual health/quality of life• Better population health• Long-term cost savings

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Areas of IT Adoption Researchp

Adoption Use Outcomes

• Describe the state of adoption in a specific setting

• Describe the state of health IT use in a specific setting

• Determine if/when IT adoption & use will lead to better outcomessetting

• Compare adoption in 2 settings

specific setting

• Compare adoption in 2 settings

to better outcomes(+ what outcomes?)

• Compare impacts of same health IT in diff i• Identify facilitators and

barriers of IT adoption• Identify facilitators and

barriers of IT use

• Determine if/when

different settings

• Reveal mechanisms/pathways that translate adoption &

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adoption will lead to use that translate adoption & use to outcomes

U.S. EHR Adoption L dLandscape

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Past StudiesPast StudiesU.S. Ambulatory Setting U.S. Hospital Setting

A f 2005• 24% of physicians used EHRs

Systematic review by Jha et al. (2006)

As of 2005 As of 2005• No high quality estimate of hospital EHR adoption Jha et al (2006)y y ( )

2006• 28% of primary care physicians

hospital EHR adoption Jha et al. (2006)

• HIMSS 2005: 17% of hospitals had a fully integrated EHR (but low quality)

• M Lascholber (2005): 59% used an• 28% of primary care physicians used EMRs Schoen et al. (2006)

• 29.2% of office-based physiciansused full or partial EMRs Hing et al. (2007)

• M. Lascholber (2005): 59% used an EHR (high quality methods but problematic EHR definition)

p g ( )

2007-2008• 17% of physicians used basic or

2006• 11% of hospitals had fully and 57%had partially implemented an EHR

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17% of physicians used basic or fully functional EHRs DesRoches et al. (2008)

had partially implemented an EHR(but study used e-mail & fax surveys) AHA (2007)

Jha et al. (2009) Study( ) y

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Backgroundg

Rising costs and inconsistent quality of U SRising costs and inconsistent quality of U.S. health care system

ANDANDPotential of health IT to improve efficiency

d ff tiand effectivenessLEAD TO

Promotion of a national, interoperable health information system in ARRA*, with bipartisan y , psupport

10* American Recovery and Reinvestment Act of 2009

Backgroundg

Providers have been slow to adopt EHRs despiteProviders have been slow to adopt EHRs despite broad consensus on their benefitsPrior data: Hospital EHR adoption between 5 59%Prior data: Hospital EHR adoption between 5-59%• Different definitions• Use of convenience samples• Low response rates

Reliable estimates of EHR adoption prevalence in U.S. hospitals are lackingp g

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Backgroundg

PurposespTo provide more precise estimates of EHR adoption among U.S. hospitals

With a clear definition of key clinical functions constituting a hospital EHR system (“basic EHRs”)Also a definition of “comprehensive EHRs”

To evaluate hypotheses that larger, teaching, and i t h it l lik l t d t EHRprivate hospitals are more likely to adopt EHRs

To identify barriers to adoption to guide policymakers

Study commissioned by ONC*12* Office of the National Coordinator for Health Information Technology

Scope of Studyp y

Adoption Use Outcomes

• Describe the state of adoption in a specific setting

• Describe the state of health IT use in a specific setting

• Determine if/when IT adoption & use will lead to better outcomessetting

• Compare adoption in 2 settings

specific setting

• Compare adoption in 2 settings

to better outcomes(+ what outcomes?)

• Compare impacts of same health IT in diff i• Identify facilitators and

barriers of IT adoption• Identify facilitators and

barriers of IT use

• Determine if/when

different settings

• Reveal mechanisms/pathways that translate adoption &

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adoption will lead to use that translate adoption & use to outcomes

Methods

DesigngCross-sectional mail survey

SamplepAll acute care general medical and surgical hospitals that are member of the American Hospital Association (N = 4814)

Survey Administration (Mar - Sep 2008)Presented as an IT supplement to AHA’s annual survey of members, sent to hospital’s CEOCIO t i ll i d t l tCIOs are typically assigned to complete surveyMultiple phone calls and reminder letters

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Methods

Survey Developmenty pDeveloped an initial survey draft based on prior surveys and working with expertsFeedback sought from CIOs, hospital leaders, and survey expertsInput also obtained from a consensus panel of experts in health IT, health services research, survey research and health policyresearch, and health policy.Survey modifications approved by expert panel

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Methods

Survey ContentPresence/absence of 32 clinical functionalities of an EHR systemWh th th i h it l h d f ll i l t d thWhether their hospital had fully implemented these functions

in all major clinical unitsin all major clinical unitsin one or more (but not all) major clinical unitsin none of the unitsin none of the units

Whether certain factors were major or minor barriers or were not barriers to EHR adoption and whether pspecific policy changes would have a positive or negative effect on their decision to adopt

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Results

63 1% (3049 h it l ) d d63.1% (3049 hospitals) responded

Federal hospitals and those located outside the 50 states and D.C. were excluded, leaving 2952 hospitals in the sample

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Respondents vs. Nonrespondentsp p

Modest differences of responding & nonresponding hospital h t i ticharacteristics

18All comparisons p < 0.05 Jha et al. (2009)

Adoption of Functionalitiesp

• Large variations in implementation of key clinical functionalities

19Jha et al. (2009)

Adoption of Functionalities (C t )(Cont.)

20Jha et al. (2009)

Definitions of Basic & Comprehensive EHRsComprehensive EHRs

21Jha et al. (2009)

Definitions of Basic & Comprehensive EHRs (Cont )Comprehensive EHRs (Cont.)

22Jha et al. (2009)

Adoption of EHRsp

23Jha et al. (2009)

Organizational Factors Associated with EHR Adoptionwith EHR Adoption

24Jha et al. (2009)

Organizational Factors Associated with EHR Adoption (Cont )with EHR Adoption (Cont.)

25Jha et al. (2009)

Barriers to EHR Adoptionp

26Jha et al. (2009)

Facilitators of EHR Adoptionp

27Jha et al. (2009)

Discussion

M th 90% f U S h it l d tMore than 90% of U.S. hospitals do not use health IT that meets the requirement for a b i EHR tbasic EHR systemThough EHR adoption is low, many functionalities are widely implemented (e.g. lab & radiologic reports, imaging, medication lists)

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Discussion

Hi h l l f d i i t ith tHigh levels of decision support without comparable adoption of computerized order

t ti f d i ientry, suggesting presence of decision-support functions in only certain systems ( h )(e.g. pharmacy)Higher adoption among larger, urban, and teaching hospitals, reflecting greater availability of financial resources needed to acquire EHRs

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Discussion

EHR d ti t i l th i t diEHR adoption rate is lower than prior studies (but this study has better response rates, l & t i ti d fi iti )clearer & more restrictive definitions)

Much of health IT benefits come from decision support, which is not part of the “basic EHR” requirementsRisks of uneven adoption within the hospital unclear

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Discussion

Fi i l i id tifi d d i tFinancial issues identified as predominant barriers to adoptionImportance of physician resistance as barrier should be noted and addressed

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Policy Implicationsy p

R di h it l f i h lth ITRewarding hospitals for using health IT may play a central role in widespread adoptionOther potentially helpful approaches

Incentives to increase IT workforceHarmonizing standardsCreating disincentives for not usingCreating disincentives for not using technology may be helpful

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Limitations

N bi ld l d tNonresponse bias could lead to overestimation of EHR adoptionFocused on adoption, not actual use or effectiveness of EHR systemsNo information on adopted systems’ certificationLow adoption leads to limited power to identify predictors of EHR adoptionidentify predictors of EHR adoptionUser satisfaction out of scope

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Summaryy

V f U S h it l hVery few U.S. hospitals have a comprehensive EHR systemA small minority have a basic EHR systemCritical strategies to promote adoption g p pinclude financial support, interoperability, and training of IT support staffg pp

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References

Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009 Apr 16;360(16):1628-38.Jha AK, Ferris TG, Donelan K, DesRoches C, Shields A, Rosenbaum S, Blumenthal D How common are electronic health records in the UnitedBlumenthal D. How common are electronic health records in the United States? A summary of the evidence. Health Aff (Millwood). 2006 Nov-Dec;25(6):w496-507.Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines y y g pof care: primary care doctors’ office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006 Nov-Dec;25(6):w555-71.DesRoches CM, Rosenbaum S. Scanning the health information technology-

l t d li i t I Bl th l D D R h C F bi t Vrelated policy environment. In: Blumenthal D, DesRoches C, Foubister V, editors. Health information technology in the United States: where we stand, 2008 [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2008 [cited 2009 Sep 20]. p. 8-24. Available from: [ p ] phttp://www.rwjf.org/files/research/3297.31831.hitreport.pdf

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References

Continued progress: hospital use of information technology [Internet]. Chicago (IL): American Hospital Association; 2007 Feb [cited 2009 Sep 20]. 20 p. Available from: http://www.aha.org/aha/content/2007/pdf/070227-continuedprogress.pdf

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Questions?Q

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