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					                                                  Original Contributions

  EHR and Other IT Adoption
      among Physicians:
    Results of a Large-Scale
      Statewide Analysis
                            Nir Menachemi, PhD, MPH; and Robert G. Brooks, MD

                                                    A B S T R A C T
 Despite a national push toward the adoption of health information technologies, much is
    still unknown about the use of IT in physician’s offices.We surveyed all primary care
physicians and a 25 percent stratified random sample of other specialists (total n= 14,921)
  in Florida to better understand current trends and factors related to the use of IT in the
  ambulatory setting. Data was analyzed using logistic regression modeling techniques to
 compute adjusted odds ratios. Covariates included practice size, medical training, practice
 type, age, race, and gender. Routine office computer use (80 percent) was found to be very
  common for administrative functions. The use of quality enhancing technologies such as
PDAs (37.5 percent), use of e-mail with patients (16.6 percent) and EHR (23.7 percent) was
 less common. Overall, large practice size, specialty practice, physician age and gender, and
multi-specialty practice affiliation were significantly related to the use of many, but not all,
                      of these IT applications in the ambulatory setting.

                                                  K E Y W O R D S
     ■   Ambulatory physician office practice             ■   Information technology         ■   Electronic health records

   Adoption of health information technologies (IT) has             would accrue through a variety of mechanisms, which
been heralded as a critical goal of a 21st-century healthcare       include ready access to medical records, more efficient test
system. Toward that goal, a national strategic plan for             and drug ordering, fewer errors, and improved communica-
accomplishing broad IT adoption has been recently                   tion between providers. However, before the maximum
outlined.1                                                          benefits can be realized, electronic data will need to be
   The goal of broad-scale IT adoption is partly based on           pervasively available in all healthcare settings representing
evidence that suggests that IT in healthcare can improve            the full continuum of care.
quality2,3,4,5,6 and potentially save money.7,8,9 These benefits       Numerous studies in the scholarly literature have

                                                                            Journal of Healthcare Information Management — Vol. 20, No. 3   79
                                                            Original Contributions

     examined IT utilization in healthcare. These studies,                    for clarity and readability.
     however, have typically focused on the inpatient                            The most recent list of all physicians (allopathic and
     setting,3,10,11,12 where IT has been generally adopted more              osteopathic) with a clear and active medical license in
     rapidly. Fewer academic studies exist of the ambulatory                  Florida was obtained from the State Department of Health
     setting, where most healthcare is delivered.13,14 Studies of IT          for 2004. Those physicians with a practice address outside
     use in ambulatory settings that do exist tend to be limited              of Florida were excluded.
     by relatively small sample sizes,15,16,17,18,19,20,21,22 have a narrow      A cover letter and questionnaire was mailed to every
     scope,23 for example, by focusing on only one application                primary care physician—family medicine, internal medicine,
     or technology,15,17,24,25,26,27,28,29 or have a focus on a limited       pediatrics, and obstetrics and gynecology—as well as a 25
     population, such as physician preceptors,30 members of                   percent stratified random sample of other specialists.
     research networks20 or physicians in a managed care                      Because the focus of this study was the ambulatory setting,
     environment.21 One notable exception is a recent study31                 physicians that do not traditionally practice in this setting,
     that examined a national representative sample of physi-                 such as radiologists, pathologists, anesthesiologists, and
     cians and their use of IT in 2003, before the recent                     emergency physicians, were excluded. The cover letter
     increased national attention on health IT.1                              indicated the purpose of the study and encouraged
        While research has identified many trends worth                       individual physicians to participate. After the first mailing,
     monitoring, much is still not understood about the factors               surveys that were returned as undeliverable, primarily
     that are associated with the use of IT in the ambulatory
     setting. To better understand current trends in IT use and
     specifically EHR adoption, we conducted a large-scale study
                                                                                 “…much is still not understood
     of physicians in Florida. In particular, the study focused on
     practice-related computer use, available Internet access, use             about the factors that are associated
     of personal digital assistants (PDAs), use of e-mail to
     communicate with patients, and the use of electronic health                     with the use of IT in the
     records (EHRs). It is believed that this study represents the
                                                                                       ambulatory setting.”
     largest study of U.S. physician IT use of its kind.
        Unlike smaller-scale national studies, the study enabled
     an in-depth look at the use of ambulatory IT in a single                 because of unknown or changed addresses or incorrect
     state where regulatory, reimbursement, and medico-legal                  practice locations, were re-mailed if updated information
     issues do not vary. Research identified pertinent                        was obtained. New addresses could not be obtained for 7.2
     demographic and practice characteristics of physicians that              percent of the sample, and these individuals were excluded
     are related to use of these IT applications. Specifically,               from participating in the survey.
     building on the previous literature,31,32,33,34 researchers                 Each questionnaire was tracked by a six digit identifying
     examined typical categories of practice configurations                   code. After four weeks, non-responders were mailed a
     (practice size, type, specialty, and so on) and physician                second cover letter and questionnaire. A small number of
     characteristics (age, race, and gender) that may influence               physicians—fewer than one percent—who indicated that
     the adoption of IT. Moreover, researchers examined the                   they were no longer actively treating patients were
     relationships between IT adoption and satisfaction with the              excluded. Data from completed questionnaires were
     level of computerization and with the status of medical                  entered into a computer database and was subjected to
     practice among responding physicians.                                    data verification and cross-check methodologies. The appro-
                                                                              priate institutional review board approved the protocol that
     Methods                                                                  was used.
         A survey instrument was developed and administered to
     a large sample of 14,921 physicians in Florida. The survey               Statistical Analysis
     instrument was developed using multiple methods. First, a                   Analyses included standard descriptive statistics and
     comprehensive literature review identified gaps in                       binary logistic regression models to compute adjusted odds
     published data regarding IT use in the ambulatory setting.               ratios. Dependent variables included in the regression
     Then, a list of questions was crafted to build on previously             models included routine office computer use, routine PDA
     published work. Next, content and face validity were estab-              use, use of e-mail with patients and routine EHR use.
     lished by soliciting expert advice. Individuals with expertise           Covariates included practice size, medical training, practice
     in health policy or medical informatics were asked to advise             type, age, race, and gender. All analyses were computed in
     and recommend additional content areas to include in the                 SPSS version 13.0 and significance was considered at the
     survey. Numerous iterations resulted in a first draft instru-            P<.05 level.
     ment that was cognitively tested with a panel of physicians                 To examine practice size, categories were based on the

80     Journal of Healthcare Information Management — Vol. 20, No. 3
                                               Original Contributions

number of physicians practicing at a given practice location.   with respect to attributes of the survey that would likely
Medical training was dichotomized to facilitate comparison      influence participation.
between primary care physicians with other specialists. For
the purpose of this analysis, primary care included family      Results
physicians, general practitioners, pediatricians, and general      A total of 4,203 surveys were returned, representing a
internists. Physician age was categorized by decade and         28.2 percent participation rate. Demographic and practice
included categories of those younger than 40 years, 41 to       characteristics of the respondents are shown in Table 1.
50, 51 to 60, and 61 and older.                                 Briefly, the average age of respondents was 50.6 years with
   Lastly, as recommended by survey research experts,35 the     a total age range of 30 to 86. Most of the responding physi-
potential for response bias was studied by comparing            cians were Caucasian (68.4 percent), male (75.9 percent),
respondents and non-respondents with respect to known           and worked in a single specialty practice (66.3 percent). A
demographics and compared early and late respondents            great number of respondents were in either solo practice

                                                                          Journal of Healthcare Information Management — Vol. 20, No. 3   81
                                                            Original Contributions

     (30.9 percent) or had two to nine physicians in their group        computer functions most commonly reported by respon-
     (54.2 percent). An additional 9.7 percent and 5.2 percent          dents included billing and charge capacity (80.6 percent),
     were in groups of 10 to 49 physicians, or in groups with           scheduling of patients appointments (78.6 percent), claims
     more than 50 physicians, respectively.                             submission (65.6 percent), and patient registration (64.2
        Access to a computer (96 percent) and Internet access           percent).
     (96.4 percent) were almost universally available in the               Routine office computer use among physicians was
     physician office practices surveyed. Of those with available       related to practice size, medical training, practice type, age,
     Internet access, roughly three-quarters (74.5 percent)             and gender (see Table 2). For example, respondents from
     indicated the availability of high-speed connections. Only         practices with 50 or more physicians were significantly
     10.6 percent indicated currently using a connection via            more likely to indicate routine use of the office computer
     dial-up service. Additionally, almost one in 10 physicians         (compared with those in solo practice, OR=4.18, p=.021), as
     (9.7 percent) indicated the availability of wireless               were specialist physicians (compared with primary care,
     networking capability in tandem with Internet access in            OR=1.47, p<.001) and those working in a multi-specialty
     their medical practice.                                            practice (OR=1.64, p=.012).
        Among those with a computer available, almost all (97.4            Approximately half (50.8 percent) of respondent physi-
     percent) indicated the computer was used within the scope          cians indicated that they own a PDA. Of those, 68 percent
     of their practice. However, non-physician staff (92.6              reported that they routinely using a PDA in their office
     percent) typically used the available computer more often          practice. The most common PDA functions included drug
     than physicians (81.1 percent). Specific office-based              referencing (83.7 percent), calendar and organizer functions

82     Journal of Healthcare Information Management — Vol. 20, No. 3
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(75.4 percent), and checking for medication interactions         68 physicians (1.6 percent) suggested that their office
(73.3 percent).                                                  practice location currently had an EHR available but that
   Overall, routine use of PDAs among physicians was             they did not personally use the system.
systematically related to practice size, age, race, and gender      Overall, routine EHR use was significantly related to
(see Table 2). For example, physicians who were older than       practice size, medical training, practice type, and age of the
61 were significantly less likely to routinely use a PDA than    physician (see Table 2). Specifically, practices with 50 or
their younger counterparts who were younger than 40              more physicians (OR=19.6, p<.001), those with 10 to 49
(OR=0.43, p<.001). Furthermore, females were less likely         physicians (OR=4.44, p<.001), and those with two to nine
to use PDAs (OR= 0.60, p<.001), while African American           physicians (OR=1.40, p<.011) were more likely than solo
(OR=2.28, p=.002) and Hispanic (OR=1.46, p=.004) physi-          practices to have physicians who routinely use an EHR.
cians were more likely than Caucasian to indicate routine        Additionally, specialist physicians were significantly more
PDA use.                                                         likely to use EHRs than primary care physicians (OR=1.27,
   Of the 4,015 physicians who indicated having an office-       p=.037) and those in a multi-specialty group were more
based computer, 17.2 percent suggested personally using          likely than those in a single specialty practice (OR= 1.47,
email to communicate with patients. Physicians who               p=.021) to routinely use EHRs.
personally used email with patients (n=683) reported doing          When asked to indicate how satisfied they were with the
so rarely (45.1 percent) or occasionally (37.5 percent). Only    level of computerization in their current office practice,
117 physicians (17.4 percent) reported using email with          most physicians indicated being satisfied (67.2 percent). The
their patients often.                                            remaining physicians were either dissatisfied (16.5 percent)
   Respondents from the largest practices (50 or greater         or neutral (16.3 percent). Being satisfied with the level of
physicians) were significantly more likely than those in solo    computerization in their office was significantly and
practice to use email to communicate with patients               positively associated with routine computer use, routine
(OR=1.94, p=.05) (see Table 2). Moreover, only Asian physi-      EHR use and email use with patients, but negatively corre-
cians reported using email with patients significantly less      lated with routine PDA use (Table 3).
frequently than their Caucasian counterparts (OR=0.26,              Physicians also were asked to respond on a Likert scale
p<.001).                                                         to how computer-savvy they considered themselves and
   For the current study, an EHR was defined as a paperless      overall how satisfied they were with the current medical
form of the medical record that requires the provider to         practice. Findings indicated that sophisticated computer
enter patient information, such as clinical notes, into a        users were significantly more likely to be using all
computer system instead of doing so on paper. Among              examined IT applications when compared with their
responding physicians, 995 (23.7 percent) reported personal      “neutral” or “unsophisticated” counterparts (Table 3).
routine use of an EHR in their office practice. An additional    Additionally, overall satisfaction with the status of one’s

                                                                         Journal of Healthcare Information Management — Vol. 20, No. 3   83
                                                            Original Contributions

     medical practice was positively and significantly associated       all other confounding factors in statistical models. This trend
     with routine use of an EHR (Table 3).                              is influenced by the fact that worthy EHR software is more
                                                                        complex to develop for the variety of clinical situations
     Comment                                                            encountered by primary care physicians.42,43 As the products
         The Institute of Medicine36,37,38 and others7,39,40 have       in this market segment mature, additional features will
     described the important clinical and financial benefits            hopefully encourage adoption of EHRs among primary care
     associated with the use of IT, particularly in the ambulatory      practices. Alternatively, if this trend continues, the digital
     setting. The extent to which physicians have been using            divide between primary care and other specialty physicians
     key IT applications, including general computer use, PDAs,         may widen.
     and EHRs, as well as patient email has been previously
         However, existing understanding of adoption of IT appli-
                                                                           “Primary care physicians were less
     cations has been limited by small or narrowly focused                  likely than others to be utilizing
     studies. In light of the patient safety and healthcare quality
     implications associated with the use of IT, updated informa-           computer and EHR technologies.”
     tion on adoption will need to be continually evaluated in
     all healthcare settings, especially the ambulatory care                The literature has mixed results regarding the relation-
     environment.                                                       ship of age and IT adoption among ambulatory care physi-
         The current study found a large percentage of physicians       cians. Some studies find no relationship between IT
     in Florida who are routinely using office-based computers          adoption and physician age31,34,44 while others report a
     to support administrative functions of their medical               positive45 but not necessarily linear30,46 relationship. Most of
     practices. However, fewer physicians have embraced                 these previous studies were limited to a specific specialty or
     clinical and quality-enhancing technologies such as EHRs,          other narrowly defined group. Furthermore, all of these
     PDAs, and patient email. When compared with other indus-           previous studies relied on univariate statistical methods that
     trialized nations studied in a recent Harris Interactive poll,41   failed to control for potential confounders. In the current
     this study’s data suggests that EHR and other IT use among         study after using multivariate methods, younger age is
     physicians in Florida lags considerably behind Sweden, The         significantly associated with higher routine use of EHR
     Netherlands, Denmark, Great Britain, Finland, and Austria.         systems. The same is true for routine office computer use
         In Florida, the decision to adopt some of these technolo-      and, to some degree, PDA use, but not for physician-patient
     gies appears to be related to both practice and individual         email. While these trends are important, they are likely to
     characteristics. For example, physicians who practice in           weaken over time as younger physicians, and those
     larger groups were significantly more likely than those in         currently in the education pipeline, begin replacing older
     solo practice to indicate routine office computer use, PDA         physicians who retire.
     and EHR use, and use of patient email.                                 With respect to gender and race, the current study found,
         With respect to EHRs, this relationship was not only the       with a few caveats, that race does not seem to be systemati-
     strongest but also had a significant dose-response relation-       cally related to ambulatory IT adoption in Florida. For
     ship. That is, the larger the group practice in Florida, the       example, both African American and Hispanic physicians
     more likely it is to routinely use EHRs. This trend, also          are more likely to report routine PDA use, a trend that may
     noted elsewhere,31 is probably attributable to the economies       be the result of a project in Florida that equipped
     of scale that larger practices have in terms of increased          thousands of high-volume Medicaid physicians with hot-
     access to both financial and human resources. Likewise,            synching PDAs to help improve quality outcomes and
     membership in a multi-specialty practice is potentially            decrease rising state Medicaid costs. If African American
     associated with similarly available resources. In addition, it     and Hispanic physicians disproportionately participated in
     may be more important to foster enhanced communication             that Florida Medicaid project, this specific trend may not be
     between physicians of differing specialties seeing common          generalizable outside of Florida.
     patients within a group. As such, physicians in multi-                 Additionally, only physicians of Asian descent, when
     specialty groups were significantly more likely to indicate        compared with their colleagues, were less likely to report
     routine use of an office-based computer and a greater likeli-      using email with patients. One potential explanation may
     hood of using an EHR.                                              be that perhaps these Florida physicians, many of whom
         Primary care physicians were less likely than others to be     are international medical graduates,47 find it challenging to
     utilizing computer and EHR technologies. This seems to             communicate via email in a language other than their
     confirm a previous study comparing primary care providers          native tongue.
     and specialists.31 The current study in Florida found that             Lastly, current study findings seem to conflict with
     these relationships were still significant after controlling for   previous work31,34,44 that suggested no differences exist

84     Journal of Healthcare Information Management — Vol. 20, No. 3
                                                        Original Contributions

among the genders with respect to IT adoption in health-                     tions associated with survey research. This includes, but is
care. The current study found that males were proportion-                    not limited to, participants’ willingness and ability to partici-
ally more likely to routinely use a PDA in the scope of their                pate, and be accurate with their responses. The response
practice. These findings were statistically significant even                 rate, while adequate,49,50 may be a limiting factor because
after controlling for other factors. It is yet uncertain if these            bias is always a possibility. Nevertheless, no significant
different findings are attributable to more sophisticated                    evidence of bias was detected even after employing
statistical methods employed in the current study or if                      common techniques51,52,53,54,55 used to identify response bias.
Florida physicians truly differ from their colleagues                           Finally, the current study depicts health IT applications
elsewhere in the country.                                                    used at a single point in time and in one state. Thus, gener-
   Lastly, physicians who indicated that they were satisfied                 alizability to other locales and time periods must be done
with the level of computerization in their practice were                     with caution.
significantly more likely to have indicated using an EHR,                       In spite of these limitations, the present study represents
office-based computer, or email with their patients. This                    the largest evaluation of physician IT usage to date and
suggests that those who are using available technologies to                  demonstrates an overall positive trend in adoption of
enhance the safety and quality of the care they give tend to                 important IT applications in the outpatient practice of
be satisfied with the products they have chosen to use.                      medicine. As such, it offers hope that the vision of a
Moreover, those using an EHR system also were signifi-                       healthcare system wired for quality care is continuing to
cantly more likely to be satisfied with the overall state of                 materialize in tangible and measurable ways in the ambula-
their medical practice. This suggests that EHR systems may                   tory marketplace.
improve physician satisfaction in a variety of ways, in
addition to the clinical and organizational benefits they may                About the Authors
provide. This may be important in light of the increasing                       Nir Menachemi, PhD, MPH, is an assistant professor and
number of physicians reporting dissatisfaction with                          director of the Center on Patient Safety at the Florida State
practicing medicine.48 More research may be required to                      University College of Medicine.
understand how IT can be used to increase satisfaction                          Robert G. Brooks, MD, is professor and associate dean
among physicians.                                                            for health affairs at the Florida State University College
   The current study was susceptible to the common limita-                   of Medicine.

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