Although much attention has been focused on the adoption of electronic health records, 9,12
simply having an EHR may not lead to improved quality and safety of health care. In this statewide survey of a cohort of physicians in Massachusetts in 2005 and 2007, we found that many physicians have EHRs but their systems do not have key functions, such as order entry and decision support, that many argue are necessary for improved safety and quality of ambulatory care. Furthermore, even when these functions are available, more than 1 in 5 physicians report that they do not use each of them regularly. With the notable exception of electronic prescribing, which has been embraced with increased intensity among physicians in ambulatory care, and some subtle usage increases among early EHR adopters who had EHRs in 2005, there was little change in the availability and use of key EHR functions from 2005 to 2007. These findings underscore the fact that simply assessing EHR adoption is not sufficient for understanding the potential impact of EHRs on medical practice.
The relative stagnancy in the availability and use of key EHR functions from 2005 to 2007 is surprising, given the increasing competition in the marketplace among EHR vendors, 13
the publication of the Certification Commission for Healthcare Information Technology (CCHIT) standards for EHR functionality, 14
and the previously reported increase in the proportion of practices that have EHRs. 12
While some may argue that little progress can be detected in the time span of two years, others will point out that both EHR adoption and usage will need to advance rapidly if the nation is to achieve the goal of universal EHR implementation by 2014. 15
Given that the rate of EHR adoption in Massachusetts already exceeds the average rate of adoption across the United States, 9
it is notable that there was little change in how physicians used these systems in the few years before this study. This may indicate that even if substantial increases in adoption are achieved, the desired quality gains may not be realized in the near term.
While fewer than half (45%) of physicians with EHRs in 2005 had electronic prescribing, 7 in 10 physicians with EHRs (71%) had this function available in 2007, with similar increases in the use of this feature. A variety of factors may have contributed to these increases, including the fact that this functionality is now relatively well developed in many EHRs; in addition, there is improved availability of electronic prescribing hubs in Massachusetts that can route electronic prescriptions to pharmacies after checking for insurance coverage and compliance with formularies. 16
Much of the increased usage of electronic prescribing in Massachusetts may be attributable to pilot initiatives sponsored by health plans. 17
In addition, large commercial pharmacies in Massachusetts, as in the rest of the nation, are now increasingly accustomed to accepting electronic prescriptions. Despite the increased availability and use of electronic prescribing, it is important to note that more than one half of physicians who have this function available in their EHR do not use it regularly. Attention needs to be directed to identifying the barriers to and facilitators of using electronic prescribing and other key functions, and interventions should attempt to assist physicians in using this technology effectively.
Strengths of this study include its high response rate and its ability to report longitudinally on a cohort of physicians randomly sampled from across Massachusetts. While prior studies have examined trends and correlates of EHR adoption, 11,12
and some have begun to examine the availability and use of key functions, 9,10
previous reports have not been able to examine how these measures change over time within a cohort of physicians.
One limitation of this study is that it was restricted to Massachusetts. The rate of EHR adoption in Massachusetts—35% of practices in this study—is higher than adoption rates nationally. 9
Furthermore, Massachusetts has been on the leading edge of HIT adoption, including the ongoing efforts of the Massachusetts e-Health Collaborative to spearhead EHR adoption and healthcare information exchange across the Commonwealth. 18
These observations suggest that the gaps in EHR usage observed in this study are likely to be at least as wide as in many other states, a hypothesis that should be tested.
Another limitation is that our estimates of the availability and use of EHR functions were based on the self-report of responding physicians. This statewide survey was not designed to verify the reported availability and usage of EHR functions. It is possible that physicians did not report the availability of functions that they do not routinely use; if this underreporting of availability occurred, then our findings would tend to overestimate actual usage of available functions further highlighting the observed gaps. Similarly, if social desirability bias led physicians to overestimate their actual usage of key EHR functions, then the true usage gaps would be even greater than observed.
The findings of this study have important implications for physicians, practices, and health policy makers. This study suggests that physicians need support, training, or other interventions to increase their use of key EHR functions that are likely to improve quality and safety of health care. Practices undertaking the purchase of a new EHR or upgrading an existing system should examine carefully the functions available in the EHRs they are considering. At a minimum, systems should be certified by CCHIT as having minimum functionality for ambulatory EHRs. 14
In addition, we hypothesize that physicians would benefit from training to optimize their use of functions offered in their EHRs. Moreover, adopting an EHR may be a necessary foundation for quality improvement, but physicians and staff likely need considerable additional support in workflow redesign and change management to harness the benefits of these systems.
For policy makers, this study raises important questions for the expansion of HIT to improve quality and safety. Given the wide gaps in the availability and use of key functions that are essential to clinical quality, such as alerts, reminders and order entry, incentives could target adoption initially, but should quickly move to targeting quality performance, as has been done in the United Kingdom. 19
Incentives for using EHRs and, in particular, electronic prescribing, are becoming more prevalent in the United States, as well. 20,21
In summary, physicians' reported adoption rates of EHRs increased over the period of study, as did use of e-prescribing, but the use of other functions generally did not. Moreover, there was essentially no change reported by providers in the availability of functions. These findings suggest that while EHRs may be necessary for broad quality improvement in the outpatient setting, they are unlikely to be sufficient. Policymakers should consider financial incentives not only for EHR adoption but also for use of key EHR functions likely to improve quality and safety. Ultimately, physicians and practices may need support and guidance to transform the way they are delivering care.