Systematic Use of Health Information Technology: Are We There Yet ?

1. Systematic Use of Health Information Technology:Are We There Yet ? 2007 Annual Research Meeting June 5, 2007

2. 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

3. 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

5. 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

6. 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

7. 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

8. Questionnaire items • “For what % of your visits overall do you use any computer-based 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%

9. 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

10. 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

11. 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

12. PCP Characteristics

13. Data Review Documentation Communication Order Entry PCP self-reported use of HIT tools Note: Excludes missing (<4%)

14. PCP routine use (>80% of patient visits) of HIT tools by function groups • Data-Review: Viewing lab results, current list of medications, anddrug 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

15. PCP Self-reported perceptions on adequacy of HIT training Strongly Agree/Agree with “the amount of training for (HIT application) was adequate”: Note: Excludes missing (<4%) and no training received (<4%)

16. PCP Self-reported perceptions of HIT integration How much do you agree or disagree with the following statement: Note: Excludes missing (11%)

17. PCP Characteristics Associated with Self-Reported Systematic Use of HIT tools ‡ 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.

18. 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

19. 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

20. 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

22. Back-up

23. 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

24. PCP Characteristics Associated with Self-Reported Systematic Use (v2) of HIT tools ‡ 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.

25. PCP routine use (>80% of patient visits) of HIT tools by function groups • 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

26. Overview of available HIT tools

27. Self-reported perceptions on adequacy of HIT training by application PCP response to “the amount of training for (HIT application) was adequate”: Note: Excludes missing (<4%) and no training received (<4%)