Transcript IMPACT: Analyses of Pre-HealthConnect Self

Systematic Use of Health
Information Technology:
Are We There Yet ?
2007 Annual Research Meeting
June 5, 2007
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Study team
Ilana Graetz
Joe Kim, MD
Mary Reed, DrPH
Richard Brand, PhD
Tom Rundall, PhD
Jie Huang, PhD
John Hsu, MD MBA MSCE
Kaiser Permanente - Division of Research
University of California, Berkeley
University of California, Los Angeles
University of California, San Francisco
Funding Support: Agency for Health Care Research and Quality
No other relevant financial relationships to disclose
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Background
• Health Information Technology (HIT)
– Great potential to improve clinical care
– Actual effects less clear
• HIT Use is critical to realizing potential benefits
– Range of HIT components/functions
– Routine and systematic use of HIT tools & resulting information
• Limited information
– Actual levels of HIT use
– Types of HIT used
– Patterns of HIT use during clinical care
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Objective
•
Within a large integrated delivery system
(IDS), we examined:
–
Providers’ self-reported levels of use of available
Health Information Technology (HIT) functions
–
Factors associated with systematic use of HIT
functions
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Setting
• Large, prepaid integrated delivery system (IDS)
– 18 Medical Centers & 110 Primary Care Teams
– 1130 Adult Primary Care Providers (PCP)
• 1010 Physicians
• 120 Nurse practitioners or physician assistants
• Four HIT applications:
– Introduced in 1995 (one) and in 2004 (three)
– Paper-based chart still available
– Applications not integrated
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Survey Design
•
•
•
•
Data collection between July and December 2005
Setting: Ambulatory care
Population: Adult primary care providers (PCP)
Response Rate: 43%
• Cross-sectional self-administered questionnaire
– Levels of use of HIT for specific clinical functions
– Adequacy of HIT training
– Perception of HIT integration
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Questionnaire items
• “For what % of your visits overall do you use any computerbased HIT tools for:”
– Data-Review
• “Viewing lab results”
• “Viewing the current medication list for patients”
• “Viewing the current drug allergies for patients”
– Order-Entry
• “Entering orders for new prescriptions or refills”
– Communication
• “Sending messages to other providers or staff”
• “Requesting referrals or consultations”
– Documentation
• “Writing free-text notes for electronic charting”
• “Using standard note templates for electronic charting”
Response categories: N/A, None, 1-20%, 21-40%, 41-60%, 61-80%, 81-100%
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Questionnaire items
• HIT Integration
– How much do you agree with the following statement:
• “Our team incorporated HIT tools into our clinical
workflow, i.e., regularly used as part of our clinical
practice”
• “These HIT tools are fully integrated allowing the provider
to use and share information across multiple functions
seamlessly, e.g., no need to switch applications for labs
and notes or to cut and paste lab results into a progress
note.”
• HIT Training
– How much do you agree with the following statement:
• “The amount of training I received for (application) was
adequate.”
Response categories: None, Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree
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Definitions of HIT Use
• Any Use
– Some Use: Use of HIT for 1-80% of visits
– Routine Use: Use of HIT for over 80% of
visits
•
•
•
•
Data-Review
Order-Entry
Communication
Documentation
• Systematic Use: Use of HIT for all four function
groups for over 80% of visits
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Analysis
• Outcome: Systematic use
• Model: Multivariate logistic regression
• Covariates:
– Age, gender, race/ethnicity, job title
– PCP panel size, self-reported hours worked per week
– Perceived level of HIT integration and incorporation into
workflow
– Perceived adequacy of HIT training
• Sensitivity Analyses: Different definitions of systematic use
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PCP Characteristics
Respondents
Total
n = 483
Gender: Female
(%)
Non-Respondents
n = 647
(%)
263
(54.4)
277
(42.8)
220
(45.6)
370
(57.2)
243
(50.3)
294
(45.4)
239
(49.4)
352
(54.4)
Job Title: MD/DO
405
(83.9)
605
(93.5)
NP/PA
78
(16.1)
42
(6.5)
≤ 40
173
(35.8)
226
(34.9)
41-50
147
(30.4)
212
(32.8)
51+
163
(33.8)
209
(32.3)
55
(11.4)
100
(15.5)
501-1000
63
(13.0)
55
(8.5)
1000-1500
126
(26.1)
132
(20.4)
1500-2000
132
(27.3)
198
(30.6)
2000+
107
(22.2)
162
(25.0)
Male
Race/Ethnicity: White
Non-white
Age:
Panel Size: ≤ 500
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PCP self-reported use of HIT tools
89.3
10.5
View Rx list
89.5
10.5
Data
Review
View lab results
72.5
Order Rx
26.0
83.7
Messaging other providers
15.9
42.9
Requesting consults/referrals
Documentation
Communication
Order
Entry
View Rx allergies
54.1
67.6
Free-text notes
32.4
38.7
Note templates
19.5
0%
40.7
39.4
20%
40%
20.7
41.1
60%
80%
100%
% of Respondents
Routine Use (over 80% of visits)
Note: Excludes missing (<4%)
Some Use (1-80% of visits)
No Use
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PCP routine use (>80% of patient visits) of HIT
tools by function groups
100
% of Respondents
83.7
80
66.7
66.1
60
39.3
40
21.3
20
0
Data Review
Order-Entry
Communication Documentation Systematic Use
Data-Review: Viewing lab results, current list of medications, and drug allergies
Order-Entry: Computerized physician order-entry for medications
Documentation: Inputting visit notes using either free text or templates
Communication: Sending messages to other providers or requesting referrals/consultations
Systematic Use: Use of HIT for all four function groups for over 80% of visits
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PCP Self-reported perceptions on adequacy of HIT
training
Strongly Agree/Agree with “the amount of training for (HIT application) was
adequate”:
Adequacy of
Training
0%
19.9
55.5
24.6
20%
40%
60%
80%
100%
% of Respondents
All: Adequate training for all four applications
Partial: Training adequate for some applications (1 to 3)
None: Training not adequate for any application (0)
Note: Excludes missing (<4%) and no training received (<4%)
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PCP Self-reported perceptions of HIT integration
How much do you agree or disagree with the following statement:
Team incorporated HIT
into work flow
HIT fully integrated
12.4
5.1
0%
33.7
13.8
25.3
19.0
20%
33.3
40%
17.6
11.0
28.8
60%
80%
100%
% of Respondents
Strongly Agree
Note: Excludes missing (11%)
Agree
Neutral
Disagree
Strongly Disagree
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PCP Characteristics Associated with Self-Reported
Systematic Use of HIT tools
PCP Characteristics
OR
95% CI
Gender: Female vs. male
1.05
0.60,
1.84
Panel Size: 1000-1500 vs. <1000
0.87
0.40,
1.90
1500-2000 vs. <1000
1.04
0.54,
2.01
2000+ vs. <1000
0.95
0.46,
1.97
41-50 vs. <40
0.67
0.39,
1.15
51+ vs. <40
1.11
0.60,
2.06
Race/Ethnicity: Not white vs. white
1.03
0.56,
1.88
Job Title: MD vs. NP/PA
0.87
0.48,
1.56
Hours worked per week: ≥40hrs vs. <40 hrs/week
1.83 ‡
1.13,
2.94
Training: Agrees training adequate for all application vs. partial
3.04 †
1.71,
5.40
1.66
0.78,
3.51
1.09
0.47,
2.53
1.27
0.76,
2.11
2.79 ‡
1.37,
5.70
1.73
0.85,
3.50
Age:
Does not agree training adequate for any app. vs. partial
HIT Integration: Agrees HIT integrated vs. Neutral
Disagrees HIT integrated vs. Neutral
Team incorporation of HIT: Agrees team incorporates HIT vs. Neutral
Disagrees team incorporates HIT vs. Neutral
‡
p<0.05 † p<0.01
Model: Logistic regression with clustering at the medical center level. The odds ratios for the small missing categories
were omitted from the table.
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Limitations
• Single, integrated delivery system
• Self-reported levels of use
• No objective measure of clinical need for the
appropriateness of HIT use
• Modest response rate
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Conclusion
• High levels of basic HIT use
– Nearly all clinicians reported some use of HIT tools
– Less than 1 in 5 clinicians used an advanced HIT
function routinely (charting templates)
• Limited amount of systematic HIT use
– Less than a quarter of clinicians systematically used
all HIT tools
– Factors significantly associated with systematic use
were:
• Adequacy of training
• Incorporation of HIT tools into workflow
• Hours worked per week
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Implications
• HIT use not yet systematic
– Incomplete capture of clinical
information
– Limited potential for clinical HIT benefits
– Unlikely to see care transformation yet
• Need to improve HIT use
– Approaches to improve training
– Approaches to improve workflow
integration
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Back-up
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Definitions of HIT Use (v2)
• Any Use
– Some Use: Use of HIT tool for 1-80% of visits
– Routine Use: Use of HIT for over 80% of visits
•
•
•
•
Data-Review
Documentation
Order-Entry
Communication
• Systematic Use (v2): Routine use of HIT for
documentation and data-review & any use of HIT for
communication and order-entry
– Model: Multivariate logistic regression
– Covariates: Age, gender, race/ethnicity, job title, PCP panel
size, self-reported hours worked per week, perceived level of HIT
integration and incorporation into workflow, and perceived
adequacy of HIT training
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PCP Characteristics Associated with Self-Reported
Systematic Use (v2) of HIT tools
PCP Characteristics
OR
95% CI
Gender: Female vs. male
0.82
0.50
1.34
Panel Size: 1000-1500 vs. < 1000
1.03
0.42
2.55
1500-2000 vs. < 1000
1.12
0.89
2.57
2000+ vs. < 1000
1.24
0.53
2.88
41-50 vs. ≤ 40
0.43‡
0.26
0.73
> 50 vs. ≤ 40
0.80
0.44
1.46
Race/Ethnicity: Not white vs. white
0.90
0.57
1.41
Job Title: MD vs. NP/PA
0.70
0.36
1.36
Hours worked per week: ≥ 40hrs vs. < 40 hrs/week
1.79 ‡
1.08
2.98
Training: Agrees training adequate for all application vs. partial
3.18 †
1.83
5.53
1.32
0.71
2.45
0.72
0.40
1.29
1.13
0.66
1.95
3.35 ‡
2.12
5.29
2.13
0.95
4.80
Age:
Does not agree training adequate for any app. vs. partial
HIT Integration: Agrees HIT integrated vs. Neutral
Disagrees HIT integrated vs. Neutral
Team incorporation of HIT: Agrees team incorporates HIT vs. Neutral
Disagrees team incorporates HIT vs. Neutral
‡
p<0.05 † p<0.01
Model: Logistic regression with clustering at the medical center level. The odds ratios for the small missing categories
were omitted from the table.
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PCP routine use (>80% of patient visits) of HIT
tools by function groups
100
% of Respondents
80.8
80
66.7
66.1
60
39.3
40
28.2
20
0
Data Review
Documentation
Order-Entry
Communication Systematic Use
(v2)
Data-Review: Viewing lab results, current list of medications, and drug allergies
Documentation: Inputting visit notes using either free text or templates
Order-Entry: Computerized physician order-entry for medications
Communication: Sending messages to other providers or requesting referrals/consultations
Systematic Use: Use of HIT for all four function groups for over 80% of visits
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Overview of available HIT tools
CIPS
First Available:
eChart
1995
eRx/eRefill
eConsult
March 2004
Functions:
Data-Review




Documentation

Order-Entry

Communication
Paper-based
alternative:
Integrated:
Description:
Yes
Yes
Yes
Yes
Not integrated with each other (i.e., need to log onto each application separately)
• Viewing lab
results
• Viewing
medication list
• Writing free-text
visit notes
• Using standard
note templates
• Viewing medication
allergies
• Viewing medication
list
• Viewing medication
list
• Viewing medication
allergies
• Entering orders for
new prescription or
refills
• Requesting
referrals or
consultations
• Sending messages
to other providers
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Self-reported perceptions on adequacy of HIT
training by application
PCP response to “the amount of training for (HIT application) was adequate”:
CIPS
54.9
e-Rx/e-Refill
22.4
67.5
e-Consult
14.3
60.2
e-Chart
28.9
0%
17.6
17.9
20%
Strongly Agree
28.2
40%
60%
% of Respondents
Agree
14.0
Neutral
Note: Excludes missing (<4%) and no training received (<4%)
Disagree
4.7
12.4
11.8
16.1
3.9
4.0 1.9
5.8
4.5
8.9
80%
100%
Strongly Disagree
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