Much like other technological breakthroughs in medicine, health information technology (HIT) such as electronic medical records (EMR) are assumed to diffuse more slowly to patients and communities that are under-served.
Researchers undertook a challenging question: how well have physicians added health information technology (HIT) to their practices among those who tend to care for Americas under-served communities versus those caring for more affluent communities. Study authors utilized the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS), mapping the use of electronic medical records (EMRs) to patient and practice characteristics. Over 2,300 physicians participated in the survey.
EMRs were categorized as either limited or comprehensive based on the types of functions available to clinicians. To be classified as a comprehensive EMR, the system must perform the following four features: (1) computerized orders for prescriptions, (2) computerized orders for tests, (3) electronic access to lab test results, and (4) clinical notes for physicians. Two other components important for EMRs but not accounted for by the NAMCS included: patient problem lists and lists of medications taken by patients. Among the EMRs in use, those with limited function rarely offered computerized orders for tests (21 percent), computerized results for lab tests (49 percent), or computerized prescriptions (36 percent). Only 63 percent allowed for physician note writing. By definition, comprehensive EMRs had all four functions. Additionally, comprehensive EMRs often provided patient demographics (96 percent) and reminder prompts for guideline based interventions (70 percent).
In univariate analysis, practices with higher proportions of charity care patients were less likely to have an EMR. Other practice characteristics associated with not having an EMR included non-metropolitan location, Northeast United States, solo practice, and no HMO affiliation. In multiple regression analysis, a method which adjusts for all variables simultaneously, practices with larger Hispanic populations were statistically less likely to have comprehensive EMRs. The Northeast region as well as non-metropolitan areas continued to demonstrate a relative dearth of technology compared to regions such as the West and metropolitan centers. Solo practices were 60 percent less likely than other practices to have comprehensive EMRs. By far, the strongest factor prompting the adoption of EMRs was whether or not a practice was under HMO control. Those practices owned by HMOs were nearly 8 times more likely to have a comprehensive electronic medical record.
Integration of computer technology into the day-to-day practice of medicine has proceeded at a snails pace. In the current study, only 27 percent of all physicians practiced in an office setting utilizing an electronic medical record. Fever than half of these physicians had access to a comprehensive EMR.
This study reciprocates findings of most prior ones, that medical practices that are smaller, outside of metropolitan areas, or not affiliated with managed care are less likely to have an EMR system. However, the goal of this study – to uncover potential disparities for practices disproportionately caring for the under-served (Medicaid, charity care, or minority patients) – failed. While there was a statistically significant decrease in the prevalence of EMRs in practices with more Hispanic patients, this was only 2 percent less likely.
What may seem surprising to some is that medical practices with more Medicaid and charity care patients are just as likely to have EMRs as practices with greater proportions of privately insured patients.
The American Recovery and Reinvestment Act of 2009 (PL 111-5, commonly known as the Stimulus) allocated over $19 billion for health information technology. As these funds are delivered to the public, policy makers should attempt to direct money towards the nations solo practitioners so that these physicians might catch up to the rest of their peers. Linking funds to participation in Medicare, Medicaid, and CHIP would encourage physician participation in these programs but remains less important to aiding EMR adoption by solo practitioners.
Li, C. and West-Strum, D. Patient Panel of Underserved Populations and Adoption of Electronic Medical Record Systems by Office-Based Physicians. Health Services Research. 2010. Online in advance of print.
Cedric K. Dark, MD, MPH