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Original Research |

Meeting Meaningful Use Criteria and Managing Patient Populations: A National Survey of Practicing Physicians

Catherine M. DesRoches, DrPH; Anne-Marie Audet, MD; Michael Painter, MD; and Karen Donelan, ScD
[+] Article and Author Information

From Mathematica Policy Research, Cambridge, Massachusetts; Commonwealth Fund, New York, New York; Robert Wood Johnson Foundation, Princeton, New Jersey; and Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts.

Note: Drs. DesRoches and Donelan had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the analysis.

Acknowledgment: The authors thank John McCauley (Mathematica Policy Research) and Samantha Stalley (Mathematica Policy Research) for their contributions to the analysis and reporting of the data.

Grant Support: By the Robert Wood Johnson Foundation (grant 68812) and the Commonwealth Fund (grant 20110087).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2881.

Reproducible Research Statement: Study protocol: Available from Dr. DesRoches (e-mail, cdesroches@mathematica-mpr.com). Statistical code and data set: Not available.

Requests for Single Reprints: Catherine M. DesRoches, DrPH, Mathematica Policy Research, 955 Massachusetts Avenue, Suite 800, Cambridge, MA 02139; e-mail, cdesroches@mathematica-mpr.com.

Current Author Addresses: Dr. DesRoches: Mathematica Policy Research, 955 Massachusetts Avenue, Suite 800, Cambridge, MA 02139.

Dr. Audet: Commonwealth Fund, 1 East 75th Street, New York, NY 10021.

Dr. Painter: Robert Wood Johnson Foundation, PO Box 2316, Route 1 and College Road East, Princeton, NJ 08543.

Ms. Donelan: Mongan Institute for Health Policy, Massachusetts General Hospital, 50 Staniford Street, Suite 900, Boston, MA 02114.

Author Contributions: Conception and design: C.M. DesRoches, A.M. Audet, M. Painter, K. Donelan.

Analysis and interpretation of data: C.M. DesRoches, A.M. Audet, M. Painter, K. Donelan.

Drafting of the article: C.M. DesRoches, A.M. Audet, M. Painter, K. Donelan.

Critical revision of the article for important intellectual content: C.M. DesRoches, A.M. Audet, K. Donelan.

Final approval of the article: C.M. DesRoches, A.M. Audet, M. Painter, K. Donelan.

Provision of study materials or patients: K. Donelan.

Statistical expertise: C.M. DesRoches, K. Donelan.

Obtaining of funding: C.M. DesRoches, M. Painter, K. Donelan.

Administrative, technical, or logistic support: C.M. DesRoches, K. Donelan.


Ann Intern Med. 2013;158(11):791-799. doi:10.7326/0003-4819-158-11-201306040-00003
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Chinese translation

Background: Meaningful use, as defined by the Centers for Medicare & Medicaid Services, will require the aggregation of patient data to enable population assessment. Little is known about the proportion of physicians who are able to meet meaningful use criteria or their use of electronic health records (EHRs) to manage patient populations.

Objective: To evaluate physicians’ reports of EHR adoption and ease of use and their ability to use EHRs for patient panel management.

Design: National mailed survey of practicing physicians (response rate of 60%).

Setting: Late 2011 and early 2012.

Participants: 1820 primary care physicians and specialists in office-based practices.

Measurements: Proportion of physicians who have a basic EHR and meet meaningful use criteria and ease of use of computerized systems designed for patient population management tasks.

Results: A total of 43.5% of physicians reported having a basic EHR, and 9.8% met meaningful use criteria. Computerized systems for managing patient populations were not widespread; fewer than one half of respondents reported the presence of computerized systems for any of the patient population management tasks included in the survey. Physicians with such functionalities reported that these systems varied in ease of use. Physicians with an EHR that met meaningful use criteria were significantly more likely than those not meeting the standard to rate panel management tasks as easy.

Limitation: Ease-of-use measures are subjective.

Conclusion: Few physicians could meet meaningful use criteria in early 2012 and using computerized systems for the panel management tasks was difficult. Results support the growing evidence that using the basic data input capabilities of an EHR does not translate into the greater opportunity that these technologies promise.

Primary Funding Source: Commonwealth Fund and Robert Wood Johnson Foundation.

Figures

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Figure 1.

Percentage of physicians with basic EHR and meaningful use functions.

EHR = electronic health record; PCP = primary care physician.

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Figure 2.

Percentage of physicians with meaningful use functions.

PCP = primary care physician.

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Figure 3.

Number of meaningful use functions reported by PCPs and specialists.

PCP = primary care physician.

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Comment
Posted on June 28, 2013
Richard Schreiber, MD, FACP
Holy Spirit Hospital
Conflict of Interest: None Declared

DesRoches’, et al study1 is another demonstration that human behavior resists change, even if that change is beneficial.  I have two main disagreements with the authors. The conclusion that “few physicians could meet meaningful use (MU) criteria in early 2012” is just a restatement of the obvious and predictable fact that it was the very beginning of MU adoption.  Second, the statement that “perceived ease of use of systems that can help to manage patient populations should be of concern to policymakers” may be true, but the questions in their survey do not allow this conclusion.

 

Gross and Ryan2, 3 first described that adoption follows a sigmoid shaped curve, a phenomenon Rogers4 popularized.  Adoption of EHRs in general and meaningful use in particular is no different.  Ford, et al,5 quantified the internal and external factors that enable us to predict when EHR adoption will occur.  If we can identify the forces that influence meaningful use, we could predict its adoption rate or the speed of implementation of interoperability standards.  I contend that what is noteworthy is not the lack of motivation by physicians, or that adoption is initially slow, but that we need to identify the factors that are holding us back. 

 

The DesRoches, et al, study has important limitations that fail to elucidate these internal and external factors.  The survey was done in late 2011/early 2012.  That was very early in the MU attestation cycle.  Part of the lack of ability to use EHRs meaningfully is lack of knowledge of what MU is and how it is defined.   There had been a table published in August, 2009, but it was not nearly enough to go on.  The final regulations did not come out until July, 2010, and the survey was done merely a little more than a year later.  That means it was designed just as the rules were drawn up, before anyone could possibly have developed workflows or content to satisfy MU.  Even for those of us who felt prepared, the installation, configuration, and most significantly the adoption of the modules necessary for attestation were not in place right away.  It was only the most aggressive sites that qualified for MU 1 in FFY ending September, 2011.  That was predicted at the time and it was expected that there were going to be only a few early attesters.  How can we be surprised for performing at the expected rate?

 

I took the survey.  Indeed I just got the follow up survey in early June.  I was a primary care physician when I took the first survey, but I am not in primary care anymore.  The questions were not geared to my current form of practice (hospitalist), so I had to answer “n/a” several times.  That answer apparently occurred 1-2 % of the time on the survey.  How accurate were the definitions of primary and specialist care?  This raises the question of the accuracy of identification of primary care and specialist practitioners, and spotlights the absence of data relating to hospitalists, a rapidly growing and important subspecialty.

 

Physicians are very poor at acknowledging that they need to be trained for new workflows and use of new tools.  Many feel they already know how to use a computer and that an EHR should be totally intuitive.  They are completely wrong about the first assumption, but there is validity to the second.  The survey did not inquire about training, support, or technical skills assessments.  I feel that is a significant weakness that interferes with the authors’ ability to assert a cause and effect between usability and poor ability and/or adoption.  I hasten to add that I strongly feel that usability is an issue, but without assessing training, one cannot make any conclusions about usability.  Their conclusion about “ease of use” amounts to no more than an opinion and does not offer insight into the possible reasons for slow adoption.

 

A recent CMS publication of 22 May 20136 confirms that “more than half of all doctors and other eligible providers have received Medicare or Medicaid incentive payments for adopting or meaningfully using electronic health records (EHRs).”  The accompanying graph shows adoption is now in the middle of the accelerated phase.  The DesRoches study was published after the CMS release, but the data were collected long before MU 1 attestation had achieved its initial inflection point, barely one-fifth of the accumulated total as of now.  The results are therefore moot.  Even forgiving them for that delay, the answers to the survey would be exactly as I would have expected: generally favorable assessments from early adopters and generally unfavorable from the rest.  But even for the rest, who may not have felt ready for MU, almost 50% felt it was not hard to perform the tasks in their EHR.

 

We don’t need more studies that demonstrate adoption takes time, that about 20% of people are early adopters, that 20% are late adopters and may never accept change, and the rest are in between.  What we do need for widespread meaningful use of EHRs is establishment of interoperability standards that enable us to communicate across platforms; non-contradictory, harmonized regulations that allow us to move forward; and usability criteria to which all vendors adhere.  Rather than decry the failure of physicians to adopt electronic health records, let’s examine the roles of all facets of the healthcare industry—insurance companies, the pharmaceutical industry, and government included—as well as physicians and hospitals, in terms of their responsibilities to promote EHRs.  Rather than surveys, with all their limitations, we need metrics of these interactive forces, which policy makers could then use to accelerate adoption.  In the meantime, let’s not confuse perception (which is all a survey can assess) of adoption and usability, and attestation with the actual accomplishment of the same.

 

Richard Schreiber, MD, FACP

Chief Medical Informatics Officer

Holy Spirit Hospital

Camp Hill, PA

 

 

References

 

  1. DesRoches CM, Audet A-M, Painter M, Donelan K.  Meeting meaningful use criteria and managing patient populations: A national survey of practicing physicians.  Ann Intern Med 2013;158:791-799.
  2. Gross NC.  The diffusion of a culture trait in two Iowa townships. M.S. Thesis, Iowa State College, Ames. 1942
  3. Ryan B, Gross NC.  The diffusion of hybrid seed corn in two Iowa communities. Rural Sociology 1943;8:15–24. RS(E)
  4. Rogers EM. Diffusion of Innovations.  1962; Glencoe: Free Press.
  5. Ford EW, Menachemi N, Peterson L, Huerta TR.  Resistance Is Futile: But It Is Slowing the Pace of EHR Adoption Nonetheless.  J Am Med Inform Assoc 2009;16:274-281.
  6. Doctors and hospitals’ use of health IT more than doubles since 2012.  http://www.hhs.gov/news/press/2013pres/05/20130522a.html Accessed 7 June 2013.
Comment
Posted on July 2, 2013
Philip A. Verhoef, MD, PhD
University of Chicago
Conflict of Interest: None Declared

I read with interest the report of Desroches et al on assessing physician use of EHRs and whether or not such use was meaningful, as outlined by CMS (1). The fundamental flaw in their research question (and in CMS' misguided use of this metric) is that the meaningful use criteria pertain to patient care but the commercially available EHRs in use are invariably designed to optimize billing and insurance reimbursement. Thus, the finding that fewer than 1 in 10 physicians reported being able to use their systems to meet meaningful use criteria is hardly surprising; however, the commercial EHR has resulted in more money in the pockets of those physicians, even while it has failed to facilitate meaningful use or to demonstrate overall cost savings (2,3). Further, one need only look at the Veteran's Affairs VistA/CPRS as an example of an EHR that was designed to optimize patient care and which has been quite successful at achieving meaningful use. A state-wide modified VistA system was implemented by the West Virginia Department of Health for 1/10th the cost of the introduction of the EPIC system at West Virginia University. The VistA system within the VA allows easy exchange of information with other physicians around the country because all of the hospital inpatient and outpatient sites are linked. Both VA and non-VA hospitals using VistA are among the very few in the nation that achieve measurable meaningful use according HIMSS (4). Finally, the VistA system has won repeated accolades over the last 2 decades for its ease of use, for improving efficiency, and for optimizing prescription accuracy (5). Why, then, would a physician or health system implement anything other than the VistA EHR if they seek to use an EHR in a meaningful way, as CMS mandates? Stated differently, and in parallel with our current health financing crisis, why do we pay so much more for a privately delivered product that is so much less effective than that which was developed by taxpayer dollars?

 

1. Desroches CM, Audet A, Painter M, and Donelan K. Meeting meaningful use criteria and managing patient populations. Ann Intern Med 2013; 158:791-99

 2. Going electronic pays off. New MGMA report links EHRs with higher medical revenue. MGMA Connex. 2010; 10(9): 21-2

 3. Kellerman AL and Jones SS. What will it take to achieve the as-yet-unfulfilled promises of health information technology. Health Affairs 2013; 32: 63-8

 4. http.//www.himssanalytics.org/hc_providers/stage7hospitals.asp

 5. Evans DC, Nichol WP, and Perlin JB. Effect of the implementation of an enterprise-wide electronic health record on productivity in the Veterans Health Administration. health Econ Policy Law 2006: 1(Pt 2): 163-9.

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