The Rise of Electronic Health Record Adoption Among Family Physicians

Competing interests:   None declared

The recent article by Xierali et al., entitled "The Rise of Electronic Health Record Adoption Among Family Physicians" finds that EHR adoption by family physicians has markedly increased over the past decade and has outpaced the adoption rates of other doctors. This, of course, is good news because EHR adoption by family physicians, many of which are on the frontline of our healthcare system, is a prerequisite for realizing the expected national benefits of improved quality and reduced costs. However, despite the important contributions (not discussed here) of the Xierali et al article, we believe their study could have been strengthened if they (a) examined how practice and physician characteristics, such as practice size, multi- versus single-specialty, practice location, and physician age, played a role in the increase in EHR adoption rates; and (b) determined whether family physicians' EHR adoption rate differed from other primary care specialists (as opposed to all other doctors).

First, because the study did not consider the potential confounding effects of practice and physician characteristics, we still know little about why family physicians have higher EHR adoption rates. On the one hand, one could have reasonably expected family physicians to have lower adoption rates because they are often disproportionally affected (3) by historic EHR adoption barriers such as resource restrictions stemming from small practice size, rural location, and/or lack of time (1, 2). On the other hand, it is possible that family physicians are on average younger or choose to practice in certain settings that are associated with higher EHR uptake. Regardless, without accounting for measurable factors, as either covariates and/or interaction terms, in statistical models that examine differences between family physicians and their counterparts, we are left with unanswered questions.

Second, it is plausible that the higher adoption rates among family physicians may be due to a higher perceived benefit from EHRs relative to other doctors. Given the wide ranges of illnesses, conditions, and age groups seen by family physicians, and the fact that family physicians must coordinate the complex care of their patients in a fragmented US healthcare system, the need for computerized clinical decision support, medical guidelines, and easily accessible and transferable patient information may be more important to family physicians. One can speculate that the higher EHR adoption rates by family physicians may be partly explained (as we believe) by the fact that the AAFP has provided sustained leadership, awareness, and resources pertaining to the benefits of health information technology in family medicine (4). However, by not comparing EHR adoption rates of family physicians to other primary care specialists (who would presumably experience similar benefits), we are left with insufficient evidence to definitively know. So, is being a family doctor the key issue explaining the higher EHR adoption rate? Or, do higher anticipated benefits by all primary care specialists explain the observed trends?

In summary, while the Xierali et al article is a welcome addition to the literature, a richer understanding of why these EHR adoption trends are occurring has the potential to more insightfully influence future research and policy decisions regarding EHRs.

Nir Menachemi, PhD, MPH, Professor, Health Care Organization and Policy, University of Alabama at Birmingham
And
Christopher A. Harle, PhD, Assistant Professor of Health Services Research, Management and Policy, University of Florida

References
1. Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Services Research. 2010;10(1):231.
2. Menachemi N. Barriers to ambulatory EHR: who are 'imminent adopters' and how do they differ from other physicians? Informatics in Primary Care. 2006;14(2):101-8.
3. Rosenblatt RA. A View from the Periphery -- Health Care in Rural America. New England Journal of Medicine. 2004;351(11):1049-51.
4. Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. The Annals of Family Medicine. 2004;2(suppl 1):S3-S32.

Competing interests:   None declared

I am extremely grateful to the authors for documenting the EHR adoption rate by family physicians, and especially so because this report comes at something of a crossroads for the meaningful use of these tools within the US healthcare system and for family medicine in particular. It is one thing for adoption rates to be high (and in this case I think the estimate of 80% adoption by 2013 is both accurate and beyond any critical mass or tipping point in the uptake of the technology) and quite another for the outcomes of adoption to be proven to meet professional, patient/consumer, and societal goals for improvement.

Recent commentaries in Health Affairs, the New York Times, Washington Post, and by members of Congress, have pointed out, for example, the persistent lack of interoperablity (standards based, inter-vendor exchange of data) that limits the use of EHRs for worthwhile tasks such as care coordination, transitional care management, and patient engagement and participation in care, all of which are important objectives of the Patient-Centered Medical Home and Neighborhood initiatives.

So where do we go from here? is a question this report leads us to with some forcefulness.

Before addressing that issue, however, I'd like to point out that the report doesn't cover the period before 2005, and particularly doesn't mention the efforts on the part of many family physicians, both in practice and those who, like Randall Oates and Jonathan Bertman among others, developed EHR technologies for their peers to use. It also doesn't mention the action the AAFP took to encourage the early adoption of EHRs starting approximately in 2000. The Future of Family Medicine Project played a decisive role in setting up what was an AAFP-led "meaningful use" program in prototype form (without the billions of dollars in incentives!) that created significant momentum in family physician EHR adoption.

The Center for Health IT at the AAFP, of which I had the privilege to be the first director from 2003 to 2007, took its charge from the Future of Family Medicine Project and the response of the leadership of the AAFP, which was start a campaign to increase the numbers of family doctors in the US using EHRs, as a matter of primary importance to the specialty. For several years, the AAFP was the only physician membership organization that considered health IT to be a core competency, as opposed to an outsourced skill set, and the only membership organization with a full time physician informaticist on its staff. There are a great many people across the country who gave generously of their time and energy to assist "physicians like me, in practices like mine" to adopt EHRs successfully, and it is they who really got the ball rolling for family physicians to make this sometimes difficult transition from paper to EHRs. We need to recognize this historical fact.

Where we as a specialty have to go with this new capacity for computerized health records is to connect them across boundaries of geography, organizational affiliation, and multiple vendors' products, such that at the very least the most relevant summary data about our patients can follow them wherever they go in the system. Quality and safety concerns demand this. New forms of payment demand this. And we as leaders in primary care in this country ought to demand this.

Fortunately, Stage 2 Meaningful Use, starting in 2014, comes with a requirement that all EHR technologies that seek certification must be compliant with the Direct standard that permits secure e-mail exchanges to occur across those boundaries, and without customized interfaces or connections. I'd suggest that the ABFM and NAMCS surveys, starting in 2013, ask not only if the physician uses an EHR, but if the EHR has an integrated Direct compliant messaging module, and if the physician and practice are iusing Directed messages and attachments for the purposes of coordination of care and improvements in transitional care management.

There is the saying that it's not the destination, but the journey, that is important. And we're not even half way!

With very kind regards, DCK

Competing interests:   None declared