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Study: External Incentives Accelerate Health IT Adoption among Small Primary Care Practices

January 26, 2017
by Heather Landi
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A recent study examining the adoption and use of health information technology by small primary care physician practices found that external incentives, such as those practices participating in pay-for-performance programs and participating in public reporting of clinical quality data, were associated with a greater adoption and use of health IT.

The study authors also found that practices with a larger proportion of revenue from Medicare were associated with a significant increase in meaningful use of health IT tools.

According to the study authors, implementation and meaningful use of health IT has been shown to facilitate delivery system transformation, “yet, despite major efforts to expand the adoption and use of HIT, uptake is far from universal,” the study authors wrote.

The study, titled “Increased Health Information Technology Adoption and Use Among Small Primary Care Physician Practices Over Time: A National Cohort Study" was published in the January/February issue of Annals of Family Medicine. The study was led by Diane Rittenhouse, M.D., from the department of family and community medicine, the University of California San Francisco, as well as researchers from the University of California, Berkeley, School of Public Health and Weill Cornell Medical College’s department of healthcare policy and research in New York City.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized nearly $30 billion to support the increased adoption and use of HIT throughout the US health care delivery system. In early 2010, the Office of the National Coordinator for Health Information Technology established a nationwide system of regional extension centers to support adoption and use, particularly among small primary care practices. Beginning in 2011, the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program offered financial rewards to practices for implementation and meaningful use of EHRs.

For the study, researchers surveyed 556 small primary care practices having eight or fewer physicians to investigate adoption and use of health IT. For their research, authors conducted two national surveys: the National Study of Small and Medium-Sized Physician Practices (2007-2010) and the Third National Study of Physician Organizations (2012-2013). The researchers studies 18 measures of health IT functionalities, including record keeping, clinical decision support, patient communication and health information exchange with hospitals and pharmacies. Additionally, the surveys focused on physician practices treating patients with 4 major chronic illnesses: asthma, coronary heart disease, depression, and diabetes.

The study authors noted that the majority of the practices were, at the start of the study period, small (1 to 2 physicians) and physician-owned, but trended over time to grow larger and/or come under hospital ownership. Specifically, between survey one (2007-2010) and survey two (2012-2013), physician-owned practices decreased from 90.6 percent to 86.8 percent and hospital-owned practices increased from 9.4 percent to 13.3 percent. Additionally, among the practices, pay-for-performance participation increased from 52.5 percent to 59 percent, and public reporting by practices increased from 40.8 percent to 54.6 percent.

According to the study, the results demonstrated an increase in 16 measures of health IT adoption and use by the small primary care practices participating in the study. “The proportion of practices that relied on paper records dropped precipitously during this period, and functionalities such as e-prescribing, e-mail with patients, and use of an EHR to collect clinical quality data increased substantially,” the study authors wrote.

More specifically, physician use of an EHR increased for the following functions:

  • electronic prescribing (from 25 percent to 70 percent),
  • notification of potential drug interactions (17 percent to 46 percent),
  • collecting data for quality measures (17 percent to 42 percent)
  • creating progress notes (26 percent to 51 percent)
  • creating a patient problem list (28 percent to 47 percent)
  • storing patient medication lists (29 percent to 51 percent),
  • enabling patients to view medical records online (1 percent to 19 percent)

Use of electronic registries within practices increased for all four chronic diseases, with the biggest increases occurring for asthma and diabetes (10 percent each).

The study authors wrote, “On the basis of prior research, we hypothesized that physician practices would be more likely to adopt and use HIT to the extent that they had both external incentives for change and internal capabilities to respond to those incentives. Controlling for other factors, participation in pay-for-performance incentives and participation in public reporting of clinical quality data were associated with greater adoption and use of health IT. A larger proportion of practice revenue from Medicare was also independently associated with greater health IT uptake.”

The study findings support the idea that practices serving a greater proportion of Medicare beneficiaries were more responsive to the CMS Medicare EHR Incentive Program.

Despite the substantial increases in adoption and use of health IT, the study authors also identified ample room for improvement “Fewer than 50 percent of practices used most EHR functionalities, and only 1 in 5 practices used e-mail with patients or allowed patients to see their medical record online. Maintenance of electronic registries for the management of chronic disease was also low for all practices. Chronic disease registries are complex care management tools that are useful for the patient-centered medical home model of primary care, but ones for which practices are typically not directly incentivized (eg, through the CMS Medicare EHR Incentive Program),” the study authors wrote.

The study authors noted that the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in April 2015 and is scheduled to go into effect in 2019. MACRA repealed the Sustainable Growth Rate payment method used by CMS, and will replace the CMS Medicare EHR Incentive Program with new systems of payment based in part on meaningful use of health IT and on clinical practice improvements. The law also allocates $100 million to support organizations (eg, quality improvement organizations, regional extension centers) that provide technical assistance to small practices participating in these new systems of payment. “Little is known about how exactly these new payment systems will shape up, but our study findings demonstrate that both practice characteristics and external incentives for change are important correlates of health IT adoption and use over time,” the study authors wrote.

And, based on the study findings, the study authors concluded, “The new MACRA will provide payment incentives and technical support to speed health IT adoption and use by small practices. We found that external incentives were, indeed, positively associated with greater adoption and use of HIT. Our findings also support a strategy of targeting assistance to smaller physician practices and those that are physician owned.”


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