Only 4% of physicians have comprehensive EHR systems.

About 17% of U.S. physicians have electronic health records in their offices, but only 4% of those doctors have comprehensive systems, according to a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% reported that their practice had purchased a system that had yet to be implemented. And 26% said that their practice was planning to purchase an EHR system in the next 2 years, according to a survey (N. Engl. J. Med. 2008; 359:50-60).

"If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3-5 years." Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing to release the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at the Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of whom 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. "We're not surprised by that, given their worries about the cost of the system," Dr. DesRoches said. Physicians are also seeking legal protection from personal liability if the record is tampered with by an outside party.

"This suggests that we might be able to significantly increase the rate of adoption by easing the financial burden on office-based providers. I think this is particularly true for providers in smaller one- and two- physician practices," Dr. DesRoches said.

These types of incentives will be critical to increasing adoption, said Dr. Richard J. Baron, an internist in a five-physician community-based practice in Philadelphia that implemented an EHR in July 2004. While the use of the EHR has changed his practice for the better, Dr. Baron said the process of implementing the system was both disruptive and costly.

Not only did the practice spend more than $40,000 per physician to purchase their EHR system, but they are also spending $60,000 annually for technical support. The practice also experienced a 2.5% absolute decrease in revenue in the year they implemented the system, said Dr. Baron, who recently became chair of the American Board of Internal Medicine.

In the current reimbursement system, a primary care physician is much more likely to get a return on investment with the purchase of a new scanner than for adopting an EHR, he said. It would be helpful to find a mechanism to aggregate funding from the stakeholders who benefit financially when physicians adopt EHRs, Dr. Baron said.

"I really think new financing strategies are desperately needed," he said.

BY MARY ELLEN SCHNEIDER

New York Bureau