Implementation and use of
HIT in primary care settings
Jesse Crosson, PhD, Pamela Ohman-Strickland, PhD
John Scott, MD, PhD, Elizabeth Clark, MD, MPH
Benjamin Crabtree, PhD, Nicole Isaacson, PhD
Deborah Cohen, PhD, Douglas Bell, MD, PhD
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Introduction
• HIT recommended for error reduction,
quality improvement, and cost reduction
• Translation to typical primary care
practices is needed
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Funders
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Methods
• Synthesis of findings from five multimethod studies of implementation and use
of HIT in primary care
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Multiple Methods
• Qualitative data collection and analysis
– Participant observation in 69 primary care practices
– Key informant interviews
– In-depth interviews with over 128 primary care physicians and
their staff
– Template organizing and grounded theory analysis of text data
• Medical record review
– 927 patient records across 50 practices
– Hierarchical logistic regression
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Findings – comparative case
study
• Successful practices (n=5)
– Anticipated workflow change and disruption
– Had informed and prepared support staff
– Physicians expected practice-level efficiency gains
• Less successful practices (n=7)
– Had little or no advance knowledge
– Expected only minimal disruption: “anything you start
new, it’s going to cause problems up front, but, I’m
sure … within two weeks that will all be sorted out.”
– Physicians thought e-prescribing would be faster
JC Crosson, N Isaacson, et.al. Variation in electronic prescribing implementation
among twelve ambulatory practices. JGIM, 2008, 4:364-71
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Findings – case study
• Reminders were disabled because lab
values were scanned into the record.
• “Our clinicians know what to do.”
• High levels of interpersonal conflicts
negatively affected communication
• The practice was described by the senior
owner as a “dictatorship”
JC Crosson, C Stroebel, et. al. Implementing an electronic medical record in a family medicine
practice: communication, decision-making, and conflict. AnnFamMed, 2005; 3:307-311.
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Quantitative assessment of
care quality and EMR use
• Chart audits of 927 randomly selected
patients with diabetes in 50 family
medicine practices in 2003-2004
• Hierarchical logistic regression to examine
adherence to guidelines
JC Crosson, PA Ohman-Strickland, et. al. Use of electronic medical records and diabetes quality of
care: results from a sample of family medicine practices. AnnFamMed, 2007; 5: 209-215.
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Results
• Mean practice-level rates of adherence to
clinical guidelines were higher in non-EHR
practices
• The odds of patients in non-EHR practices
meeting three targets (A1c, LDL, BP) was
2.68 times that of patients in EHR
practices.
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Medication Adherence
Alerting
• Alert sent after 60 day gap between prescription
and fill
– 1918 messages sent, May – Nov 2008
• Qualitative evaluation in 6 primary care practices
– Pre: no awareness of ability to track fill status
– Post: no reported usage of messages
– Discontinuation of e-prescribing
• Quantitative assessment
– Analysis of prescribing and claims data – ongoing
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Developing an e-Prescribing
Implementation Toolset
• Develop a strong pharmacy relationship
• Delegate work through protocols
• E-prescribing eliminates some errors but
creates the opportunity for new ones
• Pay attention to staff turnover issues
• Accessible IT support
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School
Policy Implications
• Primary care practices need:
– Ongoing technical support for both implementation
and effective use of HIT
– Training in population health concepts in order to
realize HIT benefits
– Quality incentives to reward the results of appropriate
use
• Regulations needed to ensure
– Technologies are capable of achieving health quality
improvements
Research Division, Department of Family Medicine, Robert Wood Johnson Medical School