Use of EHRs in U.S. Hospitals: A Review of Jha et al. (2009)

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Theera-Ampornpunt N. Use of electronic health records in U.S. hospitals: a review of Jha et al. (2009). Presented at: Health Informatics Journal Club; 2009 Sep 24; Institute for Health Informatics, University of Minnesota, Twin Cities, MN. Invited speaker.

Based on Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009 Apr 16;360(16):1628-38. Available from: http://content.nejm.org/cgi/content/full/360/16/1628

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Use of EHRs in U.S. Hospitals: A Review of Jha et al. (2009)

  1. 1. Use of Electronic Health Records in U.S. Hospitals R d i US H it l A Review of Jha et al. (2009) Nawanan Theera-Ampornpunt, M.D., M.S. UMN Health Informatics Journal Club September 24, 2009
  2. 2. Outline Overview of Health IT Adoption U.S. EHR Adoption Landscape Jha t l (2009)’ Study Jh et al. (2009)’s St d • Background • Methods • Results & Discussions • Summary 2
  3. 3. Overview of Health IT Adoption f H lth Ad ti 3
  4. 4. Underlying Assumption y g p Adoption Use Outcomes 4
  5. 5. Underlying Assumption y g p • Better clinical outcomes • Improved patient satisfaction Individual • More provider productivity/satisfaction Adoption & use • Improved operational efficiency • More patients p Organizational • Reduced costs/increased revenues Adoption & Use • Better individual health/quality of life • Better population health Societal • Long-term cost savings Adoption & Use 5
  6. 6. Areas of IT Adoption Research p Adoption Use Outcomes • Describe the state of • Describe the state of • Determine if/when IT adoption in a specific health IT use in a adoption & use will lead setting specific setting to better outcomes (+ what outcomes?) • Compare adoption in 2 • Compare adoption in 2 settings settings • Compare impacts of same health IT in • Identify facilitators and • Identify facilitators and different settings diff i barriers of IT adoption barriers of IT use • Reveal • Determine if/when mechanisms/pathways adoption will lead to use that translate adoption & use to outcomes 6
  7. 7. U.S. EHR Adoption Landscape L d 7
  8. 8. Past Studies U.S. Ambulatory Setting U.S. Hospital Setting As f A of 2005 As of 2005 • 24% of physicians used EHRs • No high quality estimate of Systematic review by Jha et al. (2006) y y ( ) hospital EHR adoption Jha et al. (2006) al • HIMSS 2005: 17% of hospitals had a 2006 fully integrated EHR (but low quality) • 28% of primary care physicians • M Lascholber (2005): 59% used an M. used EMRs Schoen et al. (2006) EHR (high quality methods but • 29.2% of office-based physicians problematic EHR definition) used full or partial EMRs Hing et al. (2007)) p g ( 2006 2007-2008 • 11% of hospitals had fully and 57% • 17% of physicians used basic or had partially implemented an EHR fully functional EHRs DesRoches et al. (2008) (but study used e-mail & fax surveys) AHA (2007) 8
  9. 9. Jha et al. (2009) Study ( ) y 9
  10. 10. Background g Rising costs and inconsistent quality of U S U.S. health care system AND Potential of health IT to improve efficiency and effectiveness d ff ti LEAD TO Promotion of a national, interoperable health information system in ARRA*, with bipartisan y , p support * American Recovery and Reinvestment Act of 2009 10
  11. 11. Background g Providers have been slow to adopt EHRs despite broad consensus on their benefits Prior data: Hospital EHR adoption between 5 59% 5-59% • Different definitions • Use of convenience samples • Low response rates Reliable estimates of EHR adoption prevalence in U.S. hospitals are lacking p g 11
  12. 12. Background g Purposes p To provide more precise estimates of EHR adoption among U.S. hospitals With a clear definition of key clinical functions constituting a hospital EHR system (“basic EHRs”) Also a definition of “comprehensive EHRs” To evaluate hypotheses that larger, teaching, and private hospitals are more lik l t adopt EHR i t h it l likely to d t EHRs To identify barriers to adoption to guide policymakers Study commissioned by ONC* * Office of the National Coordinator for Health Information Technology 12
  13. 13. Scope of Study p y Adoption Use Outcomes • Describe the state of • Describe the state of • Determine if/when IT adoption in a specific health IT use in a adoption & use will lead setting specific setting to better outcomes (+ what outcomes?) • Compare adoption in 2 • Compare adoption in 2 settings settings • Compare impacts of same health IT in • Identify facilitators and • Identify facilitators and different settings diff i barriers of IT adoption barriers of IT use • Reveal • Determine if/when mechanisms/pathways adoption will lead to use that translate adoption & use to outcomes 13
  14. 14. Methods Design g Cross-sectional mail survey Sample p All acute care general medical and surgical hospitals that are member of the American Hospital Association (N = 4814) Survey Administration (Mar - Sep 2008) Presented as an IT supplement to AHA’s annual survey of members, sent to hospital’s CEO CIOs CIO are t i ll assigned t complete survey typically i d to l t Multiple phone calls and reminder letters 14
  15. 15. Methods Survey Development y p Developed an initial survey draft based on prior surveys and working with experts Feedback sought from CIOs, hospital leaders, and survey experts Input also obtained from a consensus panel of experts in health IT, health services research, survey research, research and health policy policy. Survey modifications approved by expert panel 15
  16. 16. Methods Survey Content Presence/absence of 32 clinical functionalities of an EHR system Whether their hospital h d f ll i l Wh th th i h it l had fully implemented th t d these functions in all major clinical units in one or more (but not all) major clinical units in none of the units Whether certain factors were major or minor barriers or were not barriers to EHR adoption and whether p specific policy changes would have a positive or negative effect on their decision to adopt 16
  17. 17. Results 63.1% 63 1% (3049 h hospitals) responded it l ) d d Federal hospitals and those located outside the 50 states and D.C. were excluded, leaving 2952 hospitals in the sample 17
  18. 18. Respondents vs. Nonrespondents p p Modest differences of responding & nonresponding hospital characteristics h t i ti All comparisons p < 0.05 Jha et al. (2009) 18
  19. 19. Adoption of Functionalities p • Large variations in implementation of key clinical functionalities Jha et al. (2009) 19
  20. 20. Adoption of Functionalities (Cont.) (C t ) Jha et al. (2009) 20
  21. 21. Definitions of Basic & Comprehensive EHRs Jha et al. (2009) 21
  22. 22. Definitions of Basic & Comprehensive EHRs (Cont ) (Cont.) Jha et al. (2009) 22
  23. 23. Adoption of EHRs p Jha et al. (2009) 23
  24. 24. Organizational Factors Associated with EHR Adoption Jha et al. (2009) 24
  25. 25. Organizational Factors Associated with EHR Adoption (Cont.) (Cont ) Jha et al. (2009) 25
  26. 26. Barriers to EHR Adoption p Jha et al. (2009) 26
  27. 27. Facilitators of EHR Adoption p Jha et al. (2009) 27
  28. 28. Discussion More th 90% of U S h M than f U.S. hospitals d not use it l do t health IT that meets the requirement for a basic b i EHR system t Though EHR adoption is low, many functionalities are widely implemented (e.g. lab & radiologic reports, imaging, medication lists) 28
  29. 29. Discussion High levels of d i i support without Hi h l l f decision t ith t comparable adoption of computerized order entry, suggesting presence of decision- t ti fd i i support functions in only certain systems (e.g. pharmacy) ( h ) Higher adoption among larger, urban, and teaching hospitals, reflecting greater availability of financial resources needed to acquire EHRs 29
  30. 30. Discussion EHR adoption rate i l d ti t is lower th prior studies than i t di (but this study has better response rates, clearer & more restrictive d fi iti l t i ti definitions) ) Much of health IT benefits come from decision support, which is not part of the “basic EHR” requirements Risks of uneven adoption within the hospital unclear 30
  31. 31. Discussion Financial i Fi i l issues id tifi d as predominant identified d i t barriers to adoption Importance of physician resistance as barrier should be noted and addressed 31
  32. 32. Policy Implications y p Rewarding h R di hospitals f using h lth IT may it l for i health play a central role in widespread adoption Other potentially helpful approaches Incentives to increase IT workforce Harmonizing standards Creating disincentives for not using technology may be helpful 32
  33. 33. Limitations Nonresponse bi could l d t N bias ld lead to overestimation of EHR adoption Focused on adoption, not actual use or effectiveness of EHR systems No information on adopted systems’ certification Low adoption leads to limited power to identify predictors of EHR adoption User satisfaction out of scope 33
  34. 34. Summary y Very few U.S. hospitals h V f US h it l have a comprehensive EHR system A small minority have a basic EHR system Critical strategies to p g promote adoption p include financial support, interoperability, and training of IT support staff g pp 34
  35. 35. References Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009 Apr 16;360(16):1628-38. Jha AK, Ferris TG, Donelan K, DesRoches C, Shields A, Rosenbaum S, Blumenthal D How common are electronic health records in the United D. States? A summary of the evidence. Health Aff (Millwood). 2006 Nov- Dec;25(6):w496-507. Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines y y g p of care: primary care doctors’ office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006 Nov-Dec;25(6):w555-71. DesRoches CM, Rosenbaum S. Scanning the health information technology- related policy environment. I Blumenthal D D R h C F bi t V l t d li i t In: Bl th l D, DesRoches C, Foubister V, editors. Health information technology in the United States: where we stand, 2008 [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2008 [ [cited 2009 Sep 20]. p. 8-24. Available from: p ] p http://www.rwjf.org/files/research/3297.31831.hitreport.pdf 35
  36. 36. References Continued progress: hospital use of information technology [Internet]. Chicago (IL): American Hospital Association; 2007 Feb [cited 2009 Sep 20]. 20 p. Available from: http://www.aha.org/aha/content/2007/pdf/070227- continuedprogress.pdf 36
  37. 37. Q Questions? 37

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