In the context of significant increases in public and private sector attention and resources devoted to promoting the adoption of EHRs and other IT platforms, it is critical to understand where we stand currently in the uptake of these technologies among those serving children. The present study is, to our knowledge, the first of its kind to demonstrate on a statewide basis what many have reported anecdotally or in single site studies – namely that general pediatricians are significantly slower to incorporate EHRs into their office practice than other physicians. It also provides the first quantitative estimate of the proportion of physicians who have access to essential functionalities including those specific to pediatric patients [27
] (e.g., growth charts and weight based dosing).
There are many factors that likely contribute to the slow rate of adoption among general pediatricians. Compared to family physicians, general pediatricians in our sample were significantly more likely to practice in solo or small practices (data not shown), which has been shown to be associated with slower adoption of EHRs [18
]. Pediatric sub-specialists did not differ significantly from general pediatricians with respect to practice size configurations. However, after controlling for practice size, and other factors, pediatricians were still less likely to be EHR users than both family physicians and pediatric sub-specialists. A possible explanation may be related to the initial startup and ongoing maintenance costs of EHRs to physician practices [28
]. Given that general pediatricians have the lowest median incomes of all physicians [30
] and often rely heavily on Medicaid reimbursements which are well below those of Medicare, they may not be able to overcome many of the financial burdens necessary to adopt EHR. In our sample, general pediatricians rated financial barriers as a major barrier to EHR significantly more often than other CHPs and were significantly more likely to report that there practice was comprised of a higher percentage of Medicaid patients (data not shown). Nevertheless, while financial barriers are clearly sizable, other important barriers exist as well. For example, the lack of time needed to acquire and implement and EHR system, which was among the top barriers for all CHPs, is particularly problematic for general pediatricians who indicated this barrier most frequently. Overall, a better understanding of adoption barriers among child health providers is warranted. It should be noted, that our group has utilized the data representing all the physicians from the current study (not just CHPs), in a more in-depth analysis examining barriers to EHR systems by physicians. That study, which is forthcoming in a separate journal, examined barriers among physicians of differing adoption intentions [31
]. Similarly, pediatric and health quality researchers should focus on this issue of barriers to greatly benefit the national debate on EHR use.
Much of the patient safety and quality improvement benefits associated with EHR use are attributable to key functions available in many systems. These functions include, but are not limited to, clinical decision support, preventive service reminders, electronic order and prescription entry, allergy and medication lists, and electronic connection to other sources of clinical data (i.e., pharmacy or laboratory). EHR systems lacking some or more of these important functions may not provide the same overall patient safety and quality related benefits. In the present study, we find that general pediatricians are significantly less likely to routinely use an EHR system. Moreover, when an EHR system was present, general pediatricians and pediatric sub-specialists were significantly less likely than other doctors, including family physicians, to report the presence of key patient safety function such as electronic prescription and order entry, allergy lists, and connections to information from local pharmacies.
Given that EHRs and these key functionalities hold significant promise for improving the quality and safety of health care, the implication of our findings is that the quality and safety of care for children and adolescents may not improve as quickly as for other populations unless specific attention is paid to the needs of child health providers and child health care. It should be noted that many EHR vendors may not have designed their systems around pediatric needs. If so, present functions in EHR systems may be more difficult to use in pediatric patients.
The information in the present study may be limited in several ways. The generalizability of our research may be limited by the cross-sectional nature of this single state study. Additionally, we recognize that the potentially low response rate may be a limiting factor. However, after employing established methodologies to detect bias, we found no evidence of response bias in our sample [32
]. Nevertheless, the possibility always exists that physicians who participated in our study by completing the six-page questionnaire were more interested in IT than those who chose not to participate. If that were the case, our findings may be an overestimate of overall adoption rates. However, it is important to note that our response rate is comparable to published studies utilizing survey methodologies with physicians [25
]. In addition, Florida may differ from other states in ways that could plausibly affect IT adoption. For example, the Governor established a health information technology advisory board in 2003, which has met around the state with key stakeholders, and may have raised the visibility and focus on IT over the last two years.