Karen Donelan

Use of electronic health records in U.S. hospitals.

BACKGROUND Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals. METHODS We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption. RESULTS On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems. CONCLUSIONS The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

Electronic Health Records’ Limited Successes Suggest More Targeted Uses

Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated

When the Caregiver Needs Care: The Plight of Vulnerable Caregivers

20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.

Perspectives of Physicians and Nurse Practitioners on Primary Care Practice

OBJECTIVES This study examined the characteristics, activities, and challenges of high-risk informal caregivers. METHODS Telephone interviews were conducted with a nationally representative cross-section of 1002 informal caregivers. Vulnerable caregivers with poor health or a serious health condition were compared with nonvulnerable caregivers. RESULTS Thirty-six percent of caregivers were vulnerable. Compared with nonvulnerable caregivers, vulnerable caregivers were more likely to have difficulty providing care, to provide higher-intensity care, to report that their physical health had suffered since becoming a caregiver, to be aged 65 years or older, to be married, and to have less than 12 years of education. CONCLUSIONS Reliance on informal caregivers without considering the caregivers ability to provide care can create a stressful and potentially unsafe environment for the caregiver and the care recipient.

Electronic health records in small physician practices: availability, use, and perceived benefits

BACKGROUND The U.S. health care system is at a critical juncture in health care workforce planning. The nation has a shortage of primary care physicians. Policy analysts have proposed expanding the supply and scope of practice of nurse practitioners to address increased demand for primary care providers. These proposals are controversial. METHODS From November 23, 2011, to April 9, 2012, we conducted a national postal-mail survey of 972 clinicians (505 physicians and 467 nurse practitioners) in primary care practice. Questionnaire domains included scope of work, practice characteristics, and attitudes about the effect of expanding the role of nurse practitioners in primary care. The response rate was 61.2%. RESULTS Physicians reported working longer hours, seeing more patients, and earning higher incomes than did nurse practitioners. A total of 80.9% of nurse practitioners reported working in a practice with a physician, as compared with 41.4% of physicians who reported working with a nurse practitioner. Nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed. CONCLUSIONS Current policy recommendations that are aimed at expanding the supply and scope of practice of primary care nurse practitioners are controversial. Physicians and nurse practitioners do not agree about their respective roles in the delivery of primary care. (Funded by the Gordon and Betty Moore Foundation and others.).

Health insurance markets and income inequality: findings from an international health policy survey

OBJECTIVE To examine variation in the adoption of electronic health record (EHR) functionalities and their use patterns, barriers to adoption, and perceived benefits by physician practice size. DESIGN Mailed survey of a nationally representative random sample of practicing physicians identified from the Physician Masterfile of the American Medical Association. Measurements We measured, stratified by practice size: (1) availability of EHR functionalities, (2) functionality use, (3) barriers to the adoption and use of EHR, and (4) impact of the EHR on the practice and quality of patient care. RESULTS With a response rate of 62%, we found that < 2% of physicians in solo or two-physician (small) practices reported a fully functional EHR and 5% reported a basic EHR compared with 13% of physicians from 11+ group (largest group) practices with a fully functional system and 26% with a basic system. Between groups, a 21-46% difference in specific functionalities available was reported. Among adopters there were moderate to large differences in the use of the EHR systems. Financial barriers were more likely to be reported by smaller practices, along with concerns about future obsolescence. These differences were sizable (13-16%) and statistically significant (p < 0.001). All adopters reported similar benefits. Limitations Although we have adjusted for response bias, influences may still exist. CONCLUSION Our study found that physicians in small practices have lower levels of EHR adoption and that these providers were less likely to use these systems. Ensuring that unique barriers are addressed will be critical to the widespread meaningful use of EHR systems among small practices.

Pediatrician identification of Latino children at risk for autism spectrum disorder

OBJECTIVE To assess disparities in access to health care, financial burden of medical bills and perceived quality of care between those with above average incomes and those with below average incomes in five nations and to examine the relationship inequities in care experiences to health insurance coverage. DESIGN Cross-sectional analysis of a random survey of adults in 1998. SUBJECTS 5059 adults ages 18 and over in five English-speaking countries: Australia, Britain, Canada, New Zealand and the United States (approximately 1000 per country). MAIN OUTCOME MEASURES Failure to receive needed care, difficulty getting care, waiting for elective surgery, problems paying medical bills, failure to fill prescriptions due to cost, perceived quality of medical care received and of most recent doctor visit. RESULTS There were two to three-fold differences between those with above and below average incomes on measures of access to care in the US, Australia and New Zealand. In Britain and Canada indicators of access of to care were similar for the two income groups. Problems paying medical bills were most prevalent in the US, yet significant differences by income also existed in Australia, Canada and New Zealand. Those with below average incomes were more likely to have not filled a prescription due to cost in Australia, Canada, New Zealand and the US, with gaps by income most severe in the US. Ratings of quality of doctor visit were significantly different for the two income groups in the US, but not other countries. CONCLUSIONS The analysis finds striking differences among countries in the relative equity of health care experiences. In general, care experiences are more unequal in three countries such as the US, Australia and New Zealand where systems have relatively greater reliance on private health insurance and markets. Greater inequality in care experiences is also associated with more divided public opinion regarding the need for system reform and the direction of recent policy changes. In Canada and Britain where care experiences are more equal of the health system are similar across income groups. Reliance on private insurance and patient user fees appears to lead to more divided views of the overall health system as well as inequity in access to care.

Percutaneous Breast Biopsy: Effect on Short-term Quality of Life

BACKGROUND AND OBJECTIVES: Latino–white disparities in age at autism spectrum disorder (ASD) diagnosis may be modified by primary care pediatrician (PCP) practices and beliefs. The objectives of this study were to assess ASD and developmental screening practices, attitudes toward ASD identification in Latino children, and barriers to ASD identification for Latino children, in a sample of 267 California PCPs. METHODS: In mail-based PCP survey, we assessed rates of bilingual general developmental and ASD screening, perceptions of parent ASD knowledge in Latino and white families, reports of difficulty assessing for ASDs in Latino and white children, and perceptions of barriers to early ASD identification for Latinos. RESULTS: Although 81% of PCPs offered some form of developmental screening, 29% of PCPs offered Spanish ASD screening per American Academy of Pediatrics guidelines, and only 10% offered both Spanish general developmental and Spanish ASD screening per American Academy of Pediatrics guidelines. Most PCPs thought that Latino (English and Spanish primary family language) parents were less knowledgeable about ASDs than white parents. PCPs had more difficulty assessing ASD risk for Latino children with Spanish primary family language than for white children, even when the PCP conducted recommended ASD screening or had >25% Latino patients. The most frequent barrier to ASD identification in Latinos was access to developmental specialists. CONCLUSIONS: Multiple factors in the primary care setting may contribute to delayed ASD identification for Latinos. Promoting language-appropriate screening, disseminating culturally appropriate ASD materials to Latino families, improving the specialist workforce, and providing PCP support in screening and referral of Latino children may be important ways to reduce racial and ethnic differences in care.

Caregiving: challenges and implications for women's health.

PURPOSE To examine the effects of percutaneous breast biopsy on short-term quality of life. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant prospective study. From December 1, 2007, through February 28, 2010, women undergoing percutaneous breast biopsy in an academic medical center were recruited to participate in a mixed-mode survey 2-4 days after biopsy. Patients described their biopsy experience by using the Testing Morbidities Index (TMI), a validated instrument for assessing short-term quality of life related to diagnostic testing. The scale ranged from 0 (worst possible experience) to 100 (no adverse effects). Seven attributes were assessed: pain or discomfort before and during testing, fear or anxiety before and during testing, embarrassment during testing, and physical and mental function after testing. Demographic and clinical information were also collected. Univariate and multivariate linear regression analyses were performed to identify significant predictors of TMI score. RESULTS In 188 women (mean age, 51.4 years; range, 22-80 years), the mean TMI score (±standard deviation) was 82 ± 12. Univariate analysis revealed age and race as significant predictors of the TMI score (P < .05). In the multivariate model, only patient age remained a significant independent predictor (P = .001). TMI scores decreased by approximately three points for every decade decrease in patient age, which suggests that younger women were more adversely affected by the biopsy experience. CONCLUSION Younger patient age is a significant predictor of decreased short-term quality of life related to percutaneous breast biopsy procedures. Tailored prebiopsy counseling may better prepare women for percutaneous biopsy procedures and improve their experience.

Childhood Cancer Survivor Study participants' perceptions and knowledge of health insurance coverage: implications for the Affordable Care Act.

Informal and unpaid care is an integral feature of the U.S. health care system for the nations sick, disabled, frail, and terminally ill. Much of what we know about caregiving is based on interviews with caregivers and, in some cases, care recipients. Prior studies have either not been based on a nationally representative sample or have collected very little information about non-caregivers. This study, using the Commonwealth Fund 1998 Survey of Womens Health, uses a nationally representative sample of caregivers and non-caregivers to examine the health impact of providing informal and unpaid care, focusing primarily on women. Our findings indicate that caregivers experience double jeopardy. They are significantly more likely to be in poor health and to have experienced problems getting needed care. These findings suggest that it is time to explore alternative or complements to informal caregiving. They underscore the need to find more equitable ways to share caregiving costs and risk, and provide support to assist those who currently provide care.