Despite efforts to increase the use of information technology in health care by the federal and state governments, the potential to improve care through electronically stored and shared clinical information remains largely a promise, with nearly three-quarters of medical groups in California still relying on paper records, according to a new study published by the California HealthCare Foundation.
The State of Health Information Technology in California -- the first comprehensive look at HIT adoption in the state -- reveals that large majorities of physician practices, hospitals, clinics, and long-term care facilities, as well as patients, are still far from realizing the benefits of HIT. Reasons for the slow pace of adoption range from implementation costs to concerns about security and confidentiality.
"HIT can play a significant role in preventing medical errors, giving patients the appropriate level of care, and making health care more efficient," said Jonah Frohlich, CHCF senior program officer. "HIT is not a cure-all for what ails our health care system, but where it is used, it has helped support better care."
The Larger the Medical Group, the More Likely It Uses HIT
California leads the nation in physicians using electronic health records (EHRs), with 37% of physicians reporting use of EHRs, compared with 28% nationally, according to the snapshot. In California, the larger the medical practice, the more likely it uses EHRs. Some 79% of Kaiser Permanente physicians reported using EHRs, followed by 57% of patients in large practices of ten or more physicians. But EHR usage dropped considerably among small/medium practices (25%) and solo practitioners (13%).
This trend surfaces in another new CHCF report, Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field. Author Bruce Merlin Fried writes that, despite President Bush's 2004 plan to ensure that most Americans have interoperable electronic health records by 2014, "the vast majority of practicing physicians, those who practice alone or in small groups, are no closer to using HIT now than they were three years ago."
Yet even when physicians have EHRs, they often fail to take advantage of the full capability these powerful systems can offer. The snapshot reveals that only 12% of California physicians use alerts to warn them about potential adverse drug events, receive electronic warnings about abnormal lab results, and send reminder notices to patients about regular or preventive follow-up care.
Manual Medication Orders Persist
Most California physicians still prescribe medications using handwritten orders. This puts patients at greater risk of receiving prescriptions that they are allergic to, that adversely interact with medication they are already taking, or that are simply incorrect. While electronic prescribing systems can prevent many such adverse events, only about one-quarter of California physicians routinely use electronic prescribing.
Few Hospitals Embrace HIT
Only 13% of hospitals have fully implemented EHRs and only 11% are fully using bar-coding technology for the administration of drugs. "Institutions that lag behind on HIT are likely to continue seeing avoidable treatment errors," said Frohlich.
Community Clinics Need to Use Disease Registries
Disease registries are powerful tools for ensuring that patients most at risk are getting appropriate treatment. While many California community clinics have disease registries in place to track their patients with diabetes, few clinics use registries for other conditions, such as asthma, cancer screening of women, or immunizations. Even when clinics have disease registries in place, however, their medical directors report relatively low use of the registries by individual providers.
Consumer Concerns about HIT
According to the snapshot, nearly half of adults reported that they had used the Internet to obtain medical or health information within the past year. And while more than half of adults said they were very or somewhat interested in the ability to schedule medical appointments online, 29% said security and confidentiality issues made them "not at all interested" in receiving email from their doctor's office and 39% said they were "not at all interested" in accessing personal health records online for the same reasons.
Provider Concerns about HIT
The major barrier for EHR adoption by medical groups was cost (59%), followed by the difficulty and expense of implementation (42%), uncertainty about how to select the right product (31%), and resistance to changes in practice style (30%). Among long term care facilities, the lack of integration with other systems was the most commonly cited barrier to HIT adoption.
Open Source EHRs: Opportunities and Challenges
A third new CHCF report, Open Source EHR Systems for Ambulatory Care: A Market Assessment, looks at free and open source software (FOSS) and whether FOSS systems are suitable for widespread adoption and effective use as EHRs in physician offices. The report provides detailed assessments of a number of FOSS EHR systems and describes both the advantages and limitations to the software. The FOSS approach offers advantages such as lower acquisition and maintenance costs, greater opportunity for customization and enhancement, decreased barriers to interoperability, and less vulnerability to vendor failure or product termination. Limitations cited include a general lack of decision-support capabilities, greater reliance on free text relative to coded clinical data, and less support for electronic prescribing and lab-test ordering, although this varies by specific system.
Role of the Federal Government
Many of the two-dozen HIT thought leaders (provider, payer, physician, health information exchange, consumer, vendor, philanthropy, and association representatives) interviewed for the perspectives report called on both the U.S. Congress and the federal government to accelerate HIT adoption through the creation of incentives and regulations, and the leveraging of government purchasing power.
"These three reports," said Frohlich, "underscore the significant gaps in HIT use across California and the nation. They point to the need for a strategy to help providers and institutions adopt these technologies to improve health care delivery and efficiency and to reduce medical errors throughout our health care system."
The three CHCF reports and an HIT glossary of terms are available through the links below.