While almost half of physicians in Massachusetts are now using an EHR, a figure much higher than the national average, only about 1 in 4 office practices has adopted, due in part to the fact that small practices are much less likely to adopt. Other correlates of adoption were whether a practice is based within a hospital and whether a practice teaches medical students or residents. In addition, practices that employ computer technology other than EHRs, including electronic mail, computerized scheduling systems, and electronic prescribing, were more likely to have EHRs. While these factors may not be causal in the adoption of EHRs, their presence suggests that larger, financially stronger, and more technologically advanced practices have greater potential for undertaking the financially expensive and technologically challenging conversion from paper to electronic health records. That the most commonly cited barriers to HIT adoption were financial costs and loss of productivity further supports the notion that financial barriers must be addressed to increase adoption rates.
The EHR adoption rates in this study (23% of practices and 45% of physicians overall) were considerably higher than the national average of 17.6% of physicians reported in the 2003 National Ambulatory Medical Care Survey (NAMCS). 10
A 2005 statewide survey in Florida found that about 24% of physicians in that state used EHRs, though that study was limited by a low response rate (28%). 31
Nevertheless, both the Florida and the Massachusetts surveys came to similar conclusions regarding the factors associated with EHR adoption, especially practice size, and the barriers to adoption.
A key issue in all surveys regarding electronic health record adoption is what constitutes an EHR. For example, the NAMCS study did not define EHR, other than indicating that it excluded billing records. 10
In such studies, it is possible that physicians indicating the presence of EHR may have systems with limited functionality. Like the study by Menachemi et al., 31
our study used an explicit definition of EHR, and as a result the rates in the present study are likely to be robust estimates of the adoption of functional EHRs. The recently released results of the 2005 NAMCS survey do incorporate measures of EHR functionality in addition to the previously administered yes/no question about the use of electronic medical records. 32
While the Massachusetts EHR adoption level is more than double the national average, most of these physicians are concentrated in large group practices, with the four largest groups (Partners, CareGroup, Boston Medical Center, and Harvard Vanguard) combined including approximately 4000 physician users, accounting for approximately 44% of the State’s EHR users. The large majority of physicians practicing in smaller practices still do not use EHRs. This finding is especially striking given that Massachusetts, a state with extensive commerce in technology and communications, has multiple academic health centers and large practice organizations that have been using EHRs for more than a decade. The lack of widespread adoption in this market illustrates the barriers facing physicians in small- and medium-sized practices across the country.
From the physician perspective, many barriers constrain the adoption or expansion of computer technology in office practice. Most physicians indicated that financial factors, including start-up financial costs, ongoing financial costs, and loss of productivity, were barriers to technology adoption; among physicians whose practices had not yet adopted EHRs, more than 80% cited these factors as barriers. Prior studies have also suggested the importance of overcoming financial barriers to EHR adoption. 5,10,11
In addition, our study revealed that a majority of physicians pointed to technical factors, including lack of computer skills, lack of technical support, lack of uniform standards, and technical limitations of systems, as important barriers. Furthermore, a majority of physicians (55%) noted concerns about privacy or security as a barrier to technology adoption in their practice. These findings suggest that overcoming the financial barriers represent a necessary but insufficient intervention for expanding EHR adoption.
In the context of Rogers’ framework of the diffusion of innovations, our results support the notion that organizational factors play a critical role in determining how rapidly EHRs will be adopted. Of these organizational factors, the number of physicians in the practice and whether a practice is affiliated with the hospital seem to drive EHR adoption. While this study focused on the practice as the unit of analysis and did not focus on individual physician characteristics, we did observe that practices teaching medical students and residents were more likely to have adopted EHRs, independent of practice size, specialty, and hospital affiliation. It is possible that a practice’s teaching status is a surrogate marker for physicians with a propensity toward technology or quality improvement efforts, for example; other dimensions of this study suggest that these factors may also be associated with EHR adoption. Alternatively, the possibility exists that medical students and residents, who generally spend at least some of their training in hospital settings, are functioning as catalysts for the office practices that house them to adopt EHRs and other HIT that may be more prevalent in the inpatient setting.
A variety of organizations, ranging from hospitals and managed care organizations to medical societies and national coalitions such as Leapfrog, have launched efforts to enhance the adoption of EHRs in office practice. In his 2004, 2005, and 2006 State of the Union addresses, President George W. Bush has called for efforts to expand the use of health information technology. 16–18
There has been bipartisan support for the National Coordinator for Health Information Technology’s goal of universal EHR adoption by 2014, 20
including legislation promoting the use of EHRs coauthored by Senators Bill Frist, Hillary Clinton, Edward Kennedy, and Mike Enzi (Senate Bill 1418). 33
This legislation achieved unanimous approval in the U.S. Senate and is currently in a House subcommittee. 33
While the national agenda encourages adoption of EHRs, physicians in Massachusetts cited their own practice more often than any external organization as an influence on their decisions in this area. One-third to one-half of physicians noted that local or regional organizations influence the EHR adoption decision, and fewer than 3 in 10 physicians indicated that state or national entities, such as the state medical society, the state quality improvement organization, or the Leapfrog Group influenced this decision. National and statewide organizations may need to localize their efforts to be effective.
These data also underscore the fact that, from the policy perspective, while many factors are at play, probably the single most important concern is addressing the issue of the financial incentives for small practices. 6
The more fundamental problem is that while providers incur the costs of purchasing an electronic record, nearly all the benefits accrue to payers and purchasers. 34
While it would almost certainly help if payers paid providers more if they used an electronic record, small practices may also need support of other types such as low- or zero-interest loans if they are to make the conversion.
The principal limitation of this study is that it was conducted in a single state, Massachusetts. However, it captured the responses from a broad range of physicians across the urban and non-urban locales of the Commonwealth and included small and large practices from primary care and all medical and surgical office-based specialties.