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Toward Understanding EHR Use in Small Physician Practices

Toward Understanding EHR Use in Small Physician
Suzanne Felt-Lisk, M.P.A., Lorraine Johnson, Sc.D., M.P.H, Christopher Fleming, M.P.H.,
Rachel Shapiro, M.P.P., and Brenda Natzke
This article presents insights into the
use of electronic health records (EHRs)
by small physician practices participating
in a CMS pay-for-performance demonstra

tion. Site visits to four States reveal slow
movement toward improved EHR use.
Factors facilitating use of EHRs include
customization of EHR products and being
owned by a larger organization. Factors
limiting use of EHRs include system limi

tations, cost, and lack of strong incentives
to improve. Practices in one State were
moving more vigorously toward improved
EHR use than those in the other States.
Many practices also increased use of medical
assistants after implementing EHRs.
As part of the 2009 American Recovery
and Reinvestment Act, the Health Infor

mation Technology for Economic and Clin

ical Health (HITECH) Act involves a major
national commitment to implementing
health information technology (HIT). Spe

cifically, the HITECH Act promotes the
use of electronic health records (EHRs)
—including $30 billion in incentives for
Medicare and Medicaid providers—as
a means to improve quality, reduce cost
growth, and stimulate the economy in
the short term (Redhead, 2009; Congres

sional Budget Office, 2009). Implementers
face a number of challenges, however, one
Suzanne Felt-Lisk, Christopher Fleming, Rachel Shapiro, and
Brenda Natzke are with Mathematica Policy Research. Lorraine
Johnson is with the Centers for Medicare & Medicaid Services
(CMS). The statements expressed in this article are those of
the authors and do not necessarily reflect the views or policies of
Mathematica Policy Research or CMS.
of which is ensuring that small physician
practices are not left behind (Lohr, 2009).
While there has been some movement
toward consolidation, small practices
continue to provide a large proportion
of physician care in the U.S.; about one-
third of physicians still practice in solo
and two-physician practices (Liebhaber
and Grossman, 2007). At the same time,
they lag behind larger physician groups
in acquiring technology: in late 2007, only
9 percent of physicians in practices with
1 to 3 physicians had any electronic
medical record system, compared with
29 percent of practices with 11 to 50 phy

sicians and 50 percent of practices with
more than 50 physicians (DesRoches et
al., 2008). Adoption of HIT is occurring
more rapidly in medical groups than in
independent practice associations (IPAs),
and in medical groups the range of IT
capability is proportional to the size of
the organization (Robert Wood Johnson
Foundation, 2009).
The most authoritative evidence of the
impact of health IT and EHR systems on
quality of care is the systematic review of
the literature prepared by Chaudhry et
al. (2006). The authors found three major
benefits on quality: increased adherence
to guideline-based care, enhanced sur

veillance and monitoring, and decreased
medication errors. However, much of the
literature reviewed in the article came
from the four leading institutions design

ing and implementing health IT during
the last two decades, each of which
developed its own EHR system.
HealtH Care FinanCing review/Fall 2009/
Volume 31, Number 1
EHR system components, such as
reminders from guidelines to providers
and computerized physician order entry
(a process of electronic entry of physician
instructions for the treatment of patients,
that includes electronic prescribing as
well as other types of electronic ordering),
are thought to have the ability to improve
quality of care; however, literature on these
components finds mixed results (Keyhani
et al., 2008; Teich et al., 2000; Welch et al.,
2007; Kaushal, Shojania, and Bates, 2003;
Bizovi et al., 2002; and Bates et al., 1999).
The mixed results may in part reflect dif

ferences in how EHRs are used. Robert
Miller and colleagues (2005) conducted
case studies of 14 solo or small-group
practices with EHRs during 2004/2005.
Although the study reported the extent of
use of quality-related functions, its main
purpose was to quantify financial costs
and benefits, and to be eligible for case
study, practices had to be using one of
only two EHR vendors. Other studies have
used surveys to identify the prevalence of
use of various EHR features (DesRoches
et al., 2008; Menachemi et al., 2007), but
the categorical results do not leave the
reader with an understanding of EHR use
in practice. Other, larger-scale qualitative
work examining the dynamics of EHR
use and barriers to greater use in physi

cian practices dates back to the 2000-2002
timeframe, making it relatively dated in a
decade characterized by rapid evolution of
products and potentially the population of
EHR users (Miller and Sim, 2004).
In this article, we offer current insights
into the barriers and facilitators of EHR
use in small and medium-sized practices
based on site visits to 32 small-to medium-
sized physician practices in four States
selected by CMS. Effective use of EHRs is
widely believed to be a necessary means
of improving care quality and efficiency;
understanding barriers practices face and
facilitators they experience is the first
step to strengthening use. The selected
practices, located in Arkansas, California,
Massachusetts, and Utah, were among
those that are participating in the Medi

care Care Management Performance
Demonstration (MCMP), a pay-for

performance demonstration that encour

ages use of HIT to improve quality of care
to eligible chronically ill, fee-for-service
Medicare beneficiaries.
The site visits
were performed as part of the evaluation
of practices’ first year experience in the
demonstration (Felt-Lisk et al., 2009).
Demonstration Background
The 3-year MCMP demonstration was
mandated by the Medicare Prescription
Drug Improvement and Modernization
Act of 2003. Begun July 1, 2007, MCMP
provides an annual financial incentive
to approximately 640 practices in Arkan

sas, California, Massachusetts, and Utah
if they meet or exceed performance stan

dards established by CMS. The incen

tive payment is based on performance
on 26 clinical quality measures per

taining to diabetes, congestive heart
failure (CHF), coronary artery disease,
and the provision of preventive health
services, with an additional bonus if the
data are submitted through an EHR cer

tified by the Certification Commission
for Healthcare Information Technology.
A practice can earn up to $192,500 over
3 years ($38,500 per physician). In the
first year of the demonstration (prior to
the site visits), practices received a
maximum of $5,000 (depending on the
For more information on MCMP, see http://www.cms.hhs.
A second round of site visits is planned for 2010, and the
two rounds together will complement a quantitative analysis
of program impacts, helping us understand what produced the
impacts, or how the program logic intended to produce results
did not occur as expected.
HealtH Care FinanCing review/Fall 2009/
Volume 31, Number 1
A review (or “critique”) of a book or article is not primarily a summary. Rather, it
comments on
the work. As a course assignment, it situates the work in the light of
specific issues and theoretical concerns being di
scussed in the course. Your review should show
that you can recognize
and engage in
critical thinking
about the course content. Keep
questions like these in mind as you read, make notes, and then write the review or critique
1. What is the specific
of the book or article? What overall
does it seem to have?
For what
is it written? (Look in the preface, acknowledgements, reference list and
index for clues about where and how the piece was originally published, and about the
author’s background and position.)
2. Does the author state an explicit
? Does he or she noticeably have an axe to grind? What
are the
theoretical assumptions
? Are they discussed explicitly? (Again, look for statements
in the preface, etc. and follow them up in the rest of the work.)
3. What exactly does the work
to the overall topic of your course? What general
problems and concepts in your discipline and course does it engage with?
4. What
kinds of material
does the work present (e.g. primary documents or secondary material,
personal observations, literary analysis, quantitative data, biographical or historical accounts)?
is this material used to demonstrate and argue the thesis? (As well as indicating the
overall argumentative structure of the work, your review could quote or summarize specific
passages to describe the author’s presentation, including writing style and tone.)
6. Are there
alternative ways
of arguing from the same material? Does the author show
awareness of them? In what respects does
the author agree or disagree with them?
7. What theoretical issues and topics for
further discussion
does the work raise?
8. What are
your own reactions and considered opinions
regarding the work?

Browse in published scholarly book reviews to get a sense of the ways reviews function in
intellectual discourse. Look at journals in your discipline or general publications such as
University of Toronto Quarterly
London Review of Books
, or
New York Review of Books
(online at

Some book reviews summarize the book’s content briefly and then evaluate it; others
integrate these functions, commenting on the book and using summary only to give
examples. Choose the method that seems most suitable according to your professor’s

To keep your focus, remind yourself that your assignment is primarily to discuss the book’s
treatment of its topic, not the topic itself.
Your key sentences should therefore say “This
book shows…the author argues” rather than “This happened…this is the case.”
Prepared by Dr. Margaret Procter, Uni
versity of Toronto Coordinator, Writing Support
Over 50 other files giving advice on university writing are available at

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