We evaluated the current use of basic computer-based information technologies by a representative sample of U.S. primary care and specialist physicians. Our goals were to characterize current rates of basic IT use and to determine the role of physician, practice, and patient panel characteristics in IT adoption. We chose 5 activities that require little capital investment, do not depend on an existing electronic health record system, and have been widely adopted by other industries and by the general population. Recent consumer- and patient-focused studies, for example, have found that 70% of Americans report online access and between 40% and 75% of internet users use the internet to look for health-related advice or information.26,27
In contrast, we found that a minority of physicians have incorporated IT tools into everyday patient care, that very few physicians (1%) use all 5 tools, and that 1 in 10 never use any of the 5 basic IT tools assessed in the survey. By focusing on IT tools that can be used to support clinical care even in the absence of an electronic health record, our findings extend the results of other recent surveys that found low prevalence of EHR adoption6,28,29
to provide a fuller inventory of current IT-related clinical practices.
We identified wide variation in IT use both by IT tool and according to physician and practice characteristics. Of the 5 tools surveyed, real-time CDS and online journal access were the most frequently used, whereas e-mail communication—particularly with patients—was less prevalent. Thus, many physicians appear comfortable with IT for information retrieval but are less inclined to use IT for patient communication. Our results are consistent with prior reports that have found generally low rates of CDS adoption in clinical practice.30,31
One recent study found that physicians have 2 unanswered questions for every 3 patients, yet access electronic information retrieval only 0.3 to 9 times per month.32
More effective integration of IT clinical information retrieval systems into clinical work-flow may be required to reduce this apparent gap in knowledge acquisition.
E-mail communication, with patients or between clinicians, raises concerns about patient confidentiality and professional liability and generally lacks mechanisms for physician reimbursement.33,34
Given that nearly three-quarters of U.S. adults currently report e-mail or internet access,35
the low rate of physician-patient e-mail communication suggests a lack of appropriate clinical infrastructure rather than lack of patient access.36,37
Low use may also reflect negative attitudes, resistance, and/or inertia among physicians. Consumer surveys have found that up to 70% of Internet users would engage in e-mail communication with their physicians if given the opportunity.27
Realizing the full potential of patient-physician e-mail communication will require addressing reimbursement mechanisms and concerns about inappropriate message acuity and patient confidentiality.38–41
Although e-mail communication was more frequent between clinicians, absolute rates remained low (30%), even for physicians practicing in rural communities (who presumably have greater barriers to collaborative care than their peers located at large urban-based medical centers). Our results indicate that the promise of IT for augmenting the practice rural medicine remains unfulfilled.9
The most substantial differences in IT use were found by practice setting. With the exception of online CME, adoption of IT was greatest among physicians working in academic or HMO practices (although the small absolute number of HMO physicians in our study limited our power to show statistically significant differences in the univariate analyses). Physicians in solo/2-person practice were least likely to use IT tools, even after adjusting for demographic and practice variables. In contrast, the geographic location and patient characteristics of the practices had little impact on prevalence of IT use in adjusted analyses. The crucial role of practice setting has also been seen in surveys of EHR use.29
This pattern implies that system-level factors may play an important role in whether physicians use IT in clinical care.
Our findings suggest 2 specific lessons for IT adoption: (1) innovation—notably by academic clinical centers—has been slow to diffuse across other practice settings in medicine, and (2) system-level approaches to designing care—a method typical of HMOs—may be critical to facilitate IT adoption. Larger practices may also be more likely to adopt innovations because with more members they may be more likely to include an “early adopter” or innovator within the practice to influence the overall group.42
The challenge remains how to identify and overcome barriers to use in more traditional private and community-based practices where most clinical care occurs.43
Unlike electronic medical record systems, which require a substantial initial capital investment and effective linkage between data systems,44
the technological barriers to e-mail communication and internet access are modest. Thus, the low rate of IT adoption found in this national survey reveals a marked reluctance by the majority of practicing U.S. physicians to embrace basic IT tools as part of usual care.
This study has several limitations. Although the primary focus of the survey was medical professionalism rather than IT use, responding physicians may have differed from nonrespondents in ways that correlate positively with IT adoption. In addition, “social desirability bias” might have lead respondents to overestimate IT use. These potential biases raise the possibility that the reported rates of technology adoption considerably overestimate the true estimates for the population of practicing physicians in the specialties surveyed. Also, we assessed only the most basic IT tools and thus cannot comment on adoption of integrated EHRs with advanced decision support—the current state-of-the-art in clinical information technology and medical informatics. In particular, our very basic definition of CDS allowed for the use of any computerized information resources rather than specifying the real-time, patient-linked automated decision support that is characteristic of more advanced CDS found in the EHR environment. Finally, this study was not designed to determine whether more frequent IT use was associated with better quality of care, one of the primary goals driving IT adoption.
The results of this large, nationally representative survey indicate that adoption of basic IT tools by practicing clinicians remains limited. Substantial systematic changes in the way medical practices are organized, such as secure e-mail systems linked to EHRs and reimbursement mechanisms for electronic consultation, may be necessary to increase e-mail communication.45,46
Changes in physician training, underscored by the greater use of IT tools by more recent medical school graduates, offers another means to fundamentally change the practice of medicine through more effective integration of information technology.