Every silver lining has a black cloud

Two recent surveys of clinical IT use in the US offer some good news about increased use of clinical IT among physicians. The Center for Studying Health Systems Change, and the National Center for Health Statistics, have both recently issued reports on clinical IT penetration that shows steady growth among physicians over the past five years. Before you get too excited by this trend, however, you may want to take a quick look at some of the underlying data in these reports, because there may be more bad news than good.

I find two things particularly troubling. First, the digital divide is increasing. If you look at which physicians are increasing their use, you find that growth among large practices (especially those with over 50 physicians) is masking pathetically low growth among smaller practices (10 physicians or fewer). The CSHSC study found that while physicians in large practices increased their use of clinical IT systems by 18 percentage points between 2001 and 2005, those in smaller practices increased by only 7 percentage points over the same time. And even after all this growth, the NCHS data show that if you look at all of the physicians who don’t have an EHR, 90 percent of them are in small practices (10 physicians or fewer). Yet, those smaller practices account for the vast majority of the country’s ambulatory doctors (88 percent, according to NCHS), and outpatient visits (87 percent, according to the most recent data from the National Ambulatory Care Survey).

Since most patients go to the doctors who are least likely to have an EHR, less than 1 in 5 office visits (17 percent) are with doctors who use some type of clinical IT. Thus, as bad as the digital divide is among doctors, it's even worse for patients.

The second thing I find troubling is that those physicians who report using clinical IT are using only the most rudimentary types of systems, and those systems, in turn, offer only the most rudimentary types of benefits. The macro data from NCHS makes this abundantly clear. While almost 24 percent of physicians report using an EHR, only 9 percent are using what most of us in the field would really call an EHR (ie, one that has e-prescribing, ambulatory CPOE, electronic results, and electronic documentation). If you asked what fraction are using an EHR that would pass muster by either the CCHIT or the ISO standards, I suspect that we’d have way less than 9 percent.

As another example, take the CSHSC data noted above. While there was general increase in the use of clinical IT systems, most of that change was driven by increased electronic access to guidelines and use of electronic documentation of notes. Guidelines are great, but there isn’t much evidence that access to guidelines by itself does much to improve the quality, safety, or efficiency of care. Similarly, electronic documentation is only valuable when done in a qualified EHR system (for example, one that uses structured data to trigger decision support tools), and I suspect that most of what’s reported here is little more than word processing. Good for eliminating transcription costs, but doesn’t do much for the quality of care.

By contrast, the CSHSC report shows very little growth in the use of functions that have been shown to give value, such as reminders and e-prescribing. Among small physician practices, use of such systems grew at the glacial pace of about 1 percentage point per year between 2001 and 2005. And this growth is on a surprisingly low base of adoption – only 14 percent of physicians in small practices (9 or fewer) reported using e-prescribing in 2005. Reminder generation shows somewhat higher adoption (25 to 28 percent), but similarly slow growth (about 1 percentage point per year).

The bottom line for me on these studies is that growth isn’t happening when we want it to (now), where we want it to (in the practices that see the most patients), or how we want it to (in the functions that offer the greatest value in terms of quality and efficiency). There’s a more insidious aspect to this as well. If we hype clinical IT without guiding how it gets implemented, we run the risk of having large numbers of physicians getting locked into systems that offer relatively little real benefit to patient care. At MAeHC we've found that it's easier to move physicians from paper to a qualified EHR than it is to move them from half-measure electronic systems. If current national trends continue, the tyranny of avoiding “rip and replace” will become a bigger obstacle than it already is today.

Aside from these small quibbles, letting the market take care of this seems to be working out just fine……..