Clinical and Health Affairs
EHR Adoption and Use: Results from the 2010 Minnesota Ambulatory Clinic Survey
By Kari Guida, M.P.H., and Martin LaVenture, Ph.D., M.P.H.
■ Use of an electronic health record (EHR) system is considered key to improving patient care. Hospitals and clinics around the country are in the process of adopting these systems as the federal government rolls out incentives for using them. This article summarizes the results of a 2010 survey of ambulatory clinics in Minnesota regarding their adoption and use of EHRs and their ability to electronically exchange information with other providers.
Effective use of electronic health record (EHR) systems and other health information technologies holds great promise for improving the quality of the medical care patients receive. Today, hospitals and clinics throughout the United States are in the process of implementing EHR systems in part to become eligible for financial incentives from the federal government. The American Recovery and Reinvestment Act of 2009 authorized the Centers for Medicare and Medicaid Services (CMS) to create incentives for “meaningful use”—that is, using EHRs to aid with clinical decision- making at the point of care and for electronically exchanging information with other providers.
In order to gain a better understanding of the extent to which clinics in the state have used and are using EHRs, the Minnesota Department of Health surveyed area clinics in 2010. The survey was required by the Minnesota Statewide Quality Reporting and Measurement System (Minnesota Rules, Chapter 4654). The Department of Health contracted with MN Community Measurement, a quality-improvement collaborative, to develop and administer the survey. It consisted of 65 questions about clinics’ implementation and use of EHRs, their progress toward meeting the measures required for receiving meaningful use incentives, their ability to exchange health information through them, and the barriers to adoption and meaningful use of EHRs.
Methods
The 2010 Minnesota HIT Ambulatory Clinic Survey was emailed in February of that year to primary and specialty care clinics in Minnesota, Wisconsin, and Iowa that were registered with MN Community Measurement. The survey was resent to nonrespondents and newly registered clinics in May. In total, the survey went to 1,285 clinics in Minnesota and 97 in Wisconsin and Iowa. The Minnesota clinics had an 87% (1,121 of 1,285) response rate, while the Wisconsin and Iowa clinics had a 79% (77 of 97) response rate. The results highlighted in this article apply only to the Minnesota clinics.
Results
■ EHR Adoption
Two-thirds of the clinics that responded to the survey (750 of 1,121) said they have an EHR system and are using it in all or some areas (Table 1). A majority (73%) of those clinics rely solely on electronic records; they do not maintain paper charts and describe themselves as
Resources for Clinics and Providers
The Minnesota Medical Association (www.mnmed.org/) provides education for and help to physicians wanting to take advantage of the Centers for Medicare and Medicaid Services incentive program.
REACH (www.khareach.org), the Regional Extension Center for Health Information Technology, offers services to Minnesota provider groups of all types and sizes across the continuum of care. REACH offers meaningful use bootcamps and tool kits for EHR adoption.
The MN e-Health Initiative (www.health.state.mn.us/e-health/index.html) is a public/private collaborative dedicated to accelerating adoption and use of health information technology. Its website includes resources, tools, and online guides related to EHR implementation.
The Minnesota Department of Human Services (www.dhs.state.mn.us/ehrincentives) is implementing the MN EHR Incentive Program for Medicaid. Its website includes the MN EHR Incentive Program information, eligibility criteria for providers and hospitals, and the hospital calculation spreadsheet.
The Minnesota Department of Health’s Office of Rural Health and Primary Care (ORHPC) (www.health.state.mn.us/divs/orhpc/hit/index.html) supports efforts to increase the adoption and use of health information technology, including telehealth, for rural and safety-net providers. ORHPC provides resources, tools, and an EHR loan program for eligible recipients.
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being entirely paperless. There were 46 EHR vendors whose products were being used. Epic’s EHR system was the product most frequently used (245 of 750 clinics), followed by Allscripts (118 clinics), and Cerner (83 clinics) products.
Of the 371 clinics not using an EHR system, 101 have purchased and/or begun installation of one, and 270 have yet to buy a system. Of the clinics without an EHR system, 125 said they plan to implement one within the next year; 159 indicated that they plan to do so in the next three years. Thirty clinics said they have no plans to implement an EHR system in the next five years. Those clinics without an EHR system indicated the biggest obstacles to implementation are the cost, return-on-investment concerns, and limited access to knowledge or technical resources.
■ EHR Use
The survey asked a number of questions regarding how clinics use EHR systems. Respondents in 74% (555) of the clinics reported using computerized provider order entry (CPOE) for some or all provider orders including referrals, medication orders, and lab and diagnostic test orders (Table 2). Seventy-one percent of the clinics that use CPOE (393 of 555) said they use it for 80% to 100% of all provider orders. The most frequently identified barriers to using CPOE were the time required for staff training and the time it takes to build orders in the system. Less than 5% of the clinics without an EHR (18 of 371) use CPOE for providers’ orders.
Eighty-six percent of clinics (645 of 750) said they routinely use some type of clinical decision-support tool. Medication guides or alerts were regularly used by 76% (570 of 750) of clinics (Table 3). Other decision-support tools used were reminders of when preventive care services are due (52% or 391 clinics) and patient- or condition-specific reminders (41% or 305 clinics). The two most frequently identified obstacles to using clinical decision support at the point of care were the resources needed to build and implement the decision-support tools and the need to train staff and providers to use them.
Table 4 shows the prescribing practices of clinics with EHRs. Eighty-nine percent of clinics with EHRs (664 of 750) indicated that they order medication by entering prescriptions in the EHR. Sixty-seven clinics (9%) said they still use paper prescriptions. Some clinics (101 of 371) that do not have an EHR do e-prescribe. At clinics with EHRs, 60 percent (448 of 750) said they e-prescribe for more than 75% of prescriptions. Another 7% (56) use e-prescribing but for less than 75% of prescriptions. The remaining 167 clinics (22%) said their system either did not have an e-prescribing function or that function was turned off.
■ Health Information Exchange
The biggest benefit of EHRs will be realized when they are able to securely and meaningfully exchange information across the continuum of care. Several indicators were used to measure the interoperability of EHRs or the health information exchange activities of clinics.
Clinics report that routine electronic exchange of clinical information occurs most frequently with hospitals in the same system or that they are affiliated with and less frequently with nursing homes, home health providers, and providers in other settings (Table 5). Thirty-four percent of clinics (257 of 750) report providing an electronic summary of care record for 80% or more of patients who are referred to other providers or transitioned to other settings.
Almost 71% of clinics (530) electronically exchange clinical and patient data with the Minnesota Immunization Information Connection. Thirty-two percent (227) electronically share data about reportable diseases with the Minnesota Department of Health. A smaller percentage (17% or 131 clinics) indicate that they routinely send and receive electronic information to and from patients. The most significant challenges to securing information exchange with outside organizations are HIPAA requirements, other privacy or legal concerns, competing priorities, and access to technical support or expertise.
More than half of the clinics with EHRs (56% or 418) have an agreement to exchange information with at least one other clinic, hospital, or health system. Of the remaining clinics, 35% (260) subscribe to an outside service to facilitate health information exchange and 8% (61) use a nonprofit health information organization.
■ Application for CMS Meaningful Use Incentive
Meaningful use involves the exchange and use of health information to best inform clinical decisions at the point of care. More than half of all clinics surveyed (54% or 603 of 1,121) anticipate their providers will apply for CMS meaningful use incentives. Twenty-three percent (227) do not expect their providers will apply for the incentives. The remaining 26% (291) were unsure or did not respond.
The criteria for achieving meaningful use include accomplishing all of the core measures and five of the menu measures (Table 6). To estimate a clinic’s ability to achieve meaningful use, 14 of 15 core measures were assessed. Forty-three percent (325 of 750 clinics) were able to achieve five to nine core measures, another 45% (339) able to achieve 10 to 14. The remaining 11% (86) were able to achieve fewer than five core measures. The most challenging measures to meet were providing clinic summaries, collecting patient demographics, and providing the patient with their health information.
Discussion
The high rate of EHR adoption in Minnesota is the result of multiple factors including the commitment of providers and clinics to improve the quality of care they deliver and the work of the Minnesota e-Health Initiative, a public-private collaborative dedicated to supporting efforts to accelerate the adoption and use of HIT in the state.
The National Ambulatory Medical Care Survey, which included some Minnesota clinics in its sample, found that Minnesota had a significantly higher EHR adoption rate than the national average (50.7%).1 According to the survey, Minnesota’s EHR adoption rate of 80.2% is the highest in the nation. States bordering Minnesota also have high EHR adoption rates, with Wisconsin having a rate of 75.4% and North Dakota a rate of 74.9%.
The next step after adoption is incorporating the use of EHRs into the workflow and continuing to find ways to use the technology to improve care. One example of effective use is CPOE, which is associated with improved quality of care. It is encouraging to see not only a high percentage of clinics with EHRs using CPOE (74% of 750) but also to see that 70% of those clinics use it nearly all the time. Usage rates will grow as the EHR adoption rate increases and as clinics move toward achieving meaningful use, since CPOE use is a core measure of meaningful use.
Another meaningful use core measure is the implementation and use of clinical decision support tools other than medication alert. Sixty-four percent of clinics (480/750) are able to achieve this measure. As with CPOE use rates, the rates of clinical decision support use will increase as clinics make progress toward meaningful use.
When providers and facilities can exchange data through their EHR systems, information will follow the patient to wherever they access care and, therefore, enable providers to make the best possible clinical decisions. To make the most of this capability, clinics will not only need to continue exchanging data with other clinics and hospitals but also with other providers such as nursing homes, home health care agencies, state and local health departments, and others. As more of these other providers adopt and use EHRs, the opportunities for exchange will increase.
The barriers to adoption and use of EHRs and data exchange can be grouped into four categories: lack of funding, lack of technical assistance/knowledge, the need for ongoing maintenance, and the need for organizational change. Fortunately, Minnesota clinics have access to a number of resources and tools that can help them overcome these hurdles. They range from loans for rural providers that want to implement EHRs to tool kits to assist in implementation and data exchange (see “Resources for Clinics and Providers,” p. 35).
A number of clinics in Minnesota are interested in applying for federal incentives for meaningful use. As of last spring, more than half were anticipating their providers would apply for the incentives. Not only are the clinics expecting eligible providers to apply, but they also are close to achieving the core measures necessary to be eligible for incentive payments. The annual survey of EHR use among clinics in the state will continue to provide an updated picture of their intent and ability to achieve meaningful use.
Conclusion
The efforts of many have led to the high adoption rates and the increasing use of EHRs in Minnesota clinics. Although there are many more milestones to achieve, Minnesota clinics have made great progress in adopting and using EHRs effectively. As more clinics implement and take full advantage of the technology, it is likely that the quality of care and the health of all Minnesotans will improve accordingly. MM
Kari Guida is the HIT assessment and evaluation coordinator in the Minnesota Department of Health’s Office of Health Information Technology. Martin LaVenture is director of the Office of Health Information Technology.
The authors would like to thank MN Community Measurement and the Health Economics Program and Office of Health Information Technology at the Minnesota Department of Health, Division of Health Policy.
Reference
1. Hsiao CJ, Hing E, Socey TC, Cai B. Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates. CDC/NCHS, National Ambulatory Medical Care Survey. 2010.