PART I: SYNTHESIS REPORT
D. Health IT Use
2. Use of EHR Functions
Most practices reported using their EHR systems to perform core functions—that is, those that are minimally required for scoring. These were: (1) having a certified EHR, (2) recording visit notes, (3) recording diagnostic test orders, (4) recording diagnostic test results, and (5) recording prescriptions. Of the practices that continued to participate in the demonstration through June 2010, completed an OSS, and had an EHR (N=237), 84 percent of them met all the minimum EHR requirements to receive a systems payment, including recording patient visit notes, recording diagnostic test orders and results, and recording prescriptions. However, the regular use of more advanced functions was not widespread, as discussed more below.
OSS summary scores. OSS summary scores measure EHR use overall and in each of five “domains” as described in Table II.6. EHR use varied considerably by domain. While the overall average summary score was 59 percent, the mean scores by domain ranged from 32 percent (use of system to increase patient engagement and adherence) to 80 percent (completeness of information). On average, practices also scored high in the medication safety domain (77 percent), and scored moderately in the communication of care outside practice and clinical decision support domains. Appendix A, Section 4 provides average OSS scores by domain by site.
Table II.6. EHR Functions Associated with the Five OSS Domains
Domain Functions
Completeness of Information
• Paper records transitioned to the EHR system
• Paper charts pulled for recent visits
• Method to transition paper records
• Clinical notes for individual patients
• Allergy lists for individual patients
• Problem/diagnosis lists for individual patients
• Patient demographics
• Patient medical histories
• Record that instructions/educational info were given to patients
• Record/enter new prescriptions and refills
• Record/enter lab orders
• Scan paper lab results
• Review lab results electronically
• Record/enter imaging orders
• Scan paper imaging results
• Review imaging results electronically
Communication about Care Outside the Practice
• Print/fax lab orders
• Fax lab orders electronically from system
• Transmit lab orders electronically directly from system to facility with capability to receive
• Print/fax imaging orders
• Fax imaging orders electronically from system
• Transmit imaging orders electronically directly from system to facility with capability to receive
• Transfer electronic lab results (received in non- machine-readable format) directly into system
• Enter electronic lab results manually
• Receive electronically transmitted lab results directly into system
• Transfer electronic imaging results (received in non-machine-readable format) directly into system
• Enter electronic imaging results manually into electronic system (whether received by fax, mail, or phone)
• Receive electronically transmitted imaging results directly into system
• Enter requests for referrals/consultation
• Transmit med lists/info
• Transmit lab results (machine-readable)
• Transmit imaging results (machine-readable)
• Receive electronically transmitted reports directly into system
• Print prescriptions, fax to pharmacy/hand to patient
• Fax prescription orders electronically from system
• Transmit prescription orders electronically directly from system to pharmacy with capability to receive Clinical Decision
Support
• Enter clinical notes into templates
• View graphs of height/weight data over time
• View graphs of vital signs data over time
• Flag incomplete/overdue test results
• Highlight out-of-range test levels
• View graphs of lab/test results over time
• Prompt clinicians to order tests/studies
• Review and act on reminders at the time of the patienta encounter
• Reference info on medications
• Reference guidelines when prescribing
• Search for or generate a list of patients: - requiring a specific intervention - on a specific medication
- who are due for a lab or other test - who fit a set of criteria (age, for example)
Use of the System to Increase Patient Engagement/ Adherence
• Manage telephone calls
• Exchange secure messages with patients
• Patients view records online
• Patients update info online
• Patients request appointments online (not scored)
• Patients request referrals online (not scored)
• Produce hard copy or electronic reminders for patientsa about needed tests, studies, or other services
• Generate written or electronic educational info to help patientsa understand their condition or medication
• Create written care plans to help guide patientsa in self-management
• Prompt provider to review patient self-management plan with patienta during a visit
• Modify self-management plan as needed following a patienta visit
• Identify generic or less expensive brand alternatives at time of prescription entry
• Reference drug formularies to recommend preferred drugs
Medication Safety
• Maintain medication list
• Generate new prescriptions
• Generate prescription refills
• Select medication (from a drop-down list, for example)
• Calculate appropriate dose/frequency
• Screen prescriptions for drug allergies, drug-drug interactions, drug-lab interactions, and drug- disease interactions
Source: Year 1 OSS (see Appendix A).
Influence of practice characteristics. OSS scores do not seem to be linked closely to the practice characteristics of size, location, and affiliation (Table II.7). The one characteristic that may play a role in helping practices fully implement EHRs is their participation in quality improvement initiatives. The mean score for practices that reported current participation in such a program is significantly higher overall and in three of the five domains, compared to those that reported no participation. This finding supports the common wisdom that EHRs can be and sometimes are being used as a key tool—by practices interested in improving quality—to support care management improvements.
Table II.7. Year 1 OSS Summary Scores by Practice Characteristics, for the 198 Treatment Group Practices that Met the Minimum Requirements to be Scored
Mean Weighted
OSS Summary
Scoreb
Mean Unweighted OSS Domain Scorea
Practice Characteristics Completeness of Information Communication of Care Outside Practice Clinical Decision Support Use of System to Increase Patient Engagement and Adherence Medication Safety
OSS score (all practices) 59 80 52 53 32 77
Practice Size (total number of providers) 1-2 physicians 59 80 52 51 31 77 3-5 physicians 58 77 50 52 32 75 6+ physicians 62 83 55 57 33 76 Whether in a Medically Underserved Areac Yes 60 79 50 53 32 79 No 59 80 53 53 32 75
Whether in a Rural Aread
Yes 61 81 51 56 31 80
No 59 80 52 53 32 76
Practice Affiliation
Affiliatedd 60 80 51 53 33 79
Not affiliated 59 80 53 54 31 74
Practice Currently Participating in Programs
Any programe 61* 82* 53 56* 34* 78
None or Don’t Know 55 75 49 45 27 73
*Significantly different p<.05.
Source: Year 1 OSS. Also, randomization data and data from the practice applications, where noted.
Notes: Minimum requirements for scoring were: (1) having a certified EHR, (2) recording of visit notes, (3) recording of diagnostic test orders, (4) recording of diagnostic test results, and (5) recording of prescriptions.
N= 198 practices that completed an OSS and met the minimum requirements to be scored. The number of responses varies by item.
a See Table II.6 for function-specific items covered in each domain, or reference the OSS instrument in Appendix A, Section 1 for additional detail).
b
The weighted OSS summary score reported here is a weighted total of the scores by domain (see Appendix A, Section 2 for weighting methodology). It does not include the additional 3 points that were awarded when practices were using a currently certified EHR.
c Source: Randomization information (done by linking geocoded addresses to data from HRSA’s website). d
Includes affiliation with IPA; PHO; community health center; academic medical center; owned by a hospital, hospital system, or integrated delivery system; owned by a larger medical group; or, has some other affiliation.
e
Includes PQRS; Bridges to Excellence; state or regional public reporting group; other private sector EHR demonstrations or initiatives; other federal quality improvement initiatives, including pay for performance; state or other publically funded quality improvement initiatives including pay for performance or Medicaid IT initiatives; private quality improvement initiatives, including pay for performance; or other similar programs.