The state of the electronic health record in 2005

Physician Executive, July-August, 2005 by David Ollier Weber

Like an expert surfer who has pivoted deftly and caught the curl, Mid-Carolina Medical Group in Charlotte, N.C., now nestles securely in the trough of the information technology wave--zipping along with ease and showing off impressive new moves. (See "Beyond Electronic Health Records" page 12.)

A few other surfers are spaced out widely along this wave front too: Big Kahunas, mostly burly practices of 50 or more physicians. There's a smaller sprinkling of middleweights of Mid-Carolina's size. (The Charlotte group numbers 30 cardiologists.) But only here or there does one glimpse the slight, grinning figure of a solo practitioner or a group of fewer than nine physicians.

Far to the rear, still bobbing tremulously on their boards, anxiously peering toward the horizon, shivering a little in the breeze, lingers the vast mass of would-be surfers. They come in all sizes.

But wait! The sea is surging again beneath them. And there go a whole rank of others now ... paddling furiously, scrambling upright ... some wiping out or bailing, others gamely mastering the momentum.

Eventually the sun will set. The last stragglers will surf or drift ashore. Mid-Carolina and its cohorts, mean-while, will have drunk all the beer and strolled off to the luau arm-in-arm with the most attractive spectators.

Size matters

That is one overripe analogy for the state of electronic health information systems among U.S. physicians in 2005. Three recent surveys sketch the picture in more conventional terms.

Among 1,061 early responders to a random sampling in January of members of the Medical Group Management Association, only one in five said they are now using an electronic health record (EHR).

However, 40 percent of those without one told the MGMA they plan to acquire the technology within the next two years. Not long ago, noted the MGMA, fewer than one in 10 member practices had adopted an EHR.

(Although the terms "electronic health record" and "electronic medical record" are sometimes used inter-changeably, there is growing consensus that the latter signifies a more limited documentation system. EMR data reside solely within a practice or medical facility, EHRs are more comprehensive and broadly linked. At the behest of the Department of Health & Human Services, the Institute of Medicine developed a set of criteria for a true EHR in 2003.)

Results of a second survey, a poll of physician leaders taken annually by Modern Physician magazine, were reported in late January. About two in five respondents said they have already adopted an "electronic patient record"--a usage that further blurs distinctions. However, significant differences existed between the prevalence of electronic systems in large and small practices.

Almost two-thirds of leaders of the largest medical groups comprised of at least 300 physicians said they have gone electronic; two others reported their organizations are planning to do so within the next 12 months.

At the opposite end of the spectrum were groups of fewer than four physicians. Only about one in four in this category have invested in electronic patient records, according to the Modern Physician poll. What's more, an almost equal number from this group said they had no plans to acquire the technology "any time soon."

Physicians who practiced at or were affiliated with a hospital were most likely to be using an electronic record. More than half said they are today, and another 18 percent said they expect to be doing so before the year is out.

Distinguishing among digital health information technologies, the Commonwealth Fund last December reported findings from a mid-2003 survey of 1,837 randomly selected physicians nationwide. The results looked like this:

* More than 75 percent use electronic billing routinely or occasionally but far fewer make use of IT to improve practice efficiency and quality or to communicate with other physicians or patients

* Fifty-nine percent access patient test results electronically, either routinely or occasionally

* About 27 percent use an EMR routinely or occasionally, most often coupled with electronic access to lab results, less so to other decision aids such as alerts to prevent drug ordering errors

* Twenty-five percent order tests, procedures or drugs electronically, but only 17 percent do it routinely

* Fifty-four percent send routine checkup or preventive care reminders to patients, but only 21 percent do it electronically

The breakdowns according to practice size were telling. Almost three in five physicians in groups of 50 or more practitioners belly up to an EMR at least once in a while, the Commonwealth Fund found. That compared to just one in four in solo practice.

Salaried physicians were also more likely to use a digital system than their non-salaried peers--35 percent versus 21 percent. Figure 1 shows how the surfers in that opening scenario would be arranged along the wave:

Help in choosing

What's the problem? Why aren't more doctors leaping to hang ten as the digital wave inexorably swells beneath them?