BACKGROUND AND OBJECTIVE: There are limited national data on pediatric health information technology adoption rates. Our objective was to determine pediatricians’ adoption rates of electronic health record systems (EHRs), barriers to adoption, and features of the systems adopted.
METHODS: A survey of 1620 randomly selected US members of the American Academy of Pediatrics from February to July 2009 addressed use of EHRs and barriers to adoption. Bivariate analysis and logistic regression were used to determine associations between EHR use and various physician and practice characteristics.
RESULTS: Six hundred forty-six postresidency pediatric clinicians practicing in office- or clinic-based settings responded (57.2%). Self-reported electronic medical record/EHR use was 54%/41%, but far fewer used systems that met the definition of a basic (25%) or fully functional (6%) EHR. Only 3% used a system that was fully functional and pediatric-supportive. Pediatricians practicing in multispecialty practices and those in hospital-based practices were more likely to use basic or fully functional EHRs than those in solo/2-physician practices. More than half of respondents reported financial barriers to implementing EHRs, and more than one-third were concerned about whether systems could meet their needs and whether an EHR would affect productivity.
CONCLUSIONS: Pediatric adoption of fully functional EHRs lags general adoption. Barriers to adoption include financial and productivity concerns, but pediatricians are also concerned about finding systems that meet their needs. Few pediatricians use a system that is pediatric-supportive. To help identify pediatric-supportive systems, EHR certification efforts should include these requirements.
- AAP —
- American Academy of Pediatrics
- EHR —
- electronic health record
- EMR —
- electronic medical record
- IT —
- information technology
- OR —
- odds ratio
What’s Known on This Subject:
Information is limited on adoption of fully functional electronic health records (EHRs) in office-based pediatric practices, such as rates of adoption, barriers to adoption, and features that pediatricians choose.
What This Study Adds:
A nationwide survey of members of the AAP in 2009 found that pediatric adoption of fully functional EHRs lags general adoption. Barriers include financial and productivity concerns, but pediatricians are also concerned about finding systems that meet their specific needs.
In 2009, ∼48.3% of US office-based physicians reported using any electronic medical record (EMR)/electronic health record (EHR) system, with 21.8% having a basic EHR system and 6.9% a fully functional EHR system, increasing to 50.7%, 24.9%, and 10.1%, respectively, by 2010.1 There is little recent information on pediatric health information technology (IT) adoption rates.2 One study from 2006 suggested that the EHR adoption rate of ambulatory child health providers in Florida was 16%.3 Pediatrics is one of the least well reimbursed specialties,4 and practice health IT needs are different from those in corresponding adult practices. Pediatric-supportive EHR systems should support additional features, including tracking of well-child visits, anthropometric support (such as growth charts or percentile calculations), tracking of immunizations, immunization forecasting (calculating catch-up immunizations), and prescription support for weight-based dosing.5 There are no recent published national data on pediatric health IT adoption rates nor is there an accurate estimate of adoption of pediatric-supportive EHR systems.
The objective of our study was to quantify the percentage of pediatricians using a basic, fully functional (as defined by the National Ambulatory Medical Care Survey),6 and pediatric-supportive EHR system (as defined above). Our study also assessed barriers to the adoption of EHR systems.
It is estimated that ∼69% of board-certified pediatricians were members of the American Academy of Pediatrics (AAP) at the time of the survey.7 This survey was the 74th Periodic Survey of AAP members. It was an 8-page self-administered questionnaire sent to 1620 nonretired US members. An introductory letter from the executive director of the AAP, a business-reply return envelope, and a flyer describing the Periodic Survey and its uses accompanied each questionnaire. Two dollars was included in the first mailing as a token of appreciation. Up to 7 contacts were made between February and July 2009.
The survey was developed by AAP staff and AAP members with expertise in health information technology. Questions addressed the use of EHR systems and their specific capabilities, including documentation of care, clinical decision support, and other advanced features critical to improve health care quality. For purposes of this survey, EHRs were defined as records of health-related information on an individual that are edited and accessed by clinicians and staff across >1 health care organization (ie, information is exchanged between multiple sources involved in an individual’s care over time).8 Respondents were asked to answer all questions as they applied to their main practice site (ie, the location at which they see the most ambulatory patients).
Tasks identified in respondents’ computerized system were grouped by using definitions from the literature.6,9 “Basic” EHRs include 7 features: patient demographics, problem lists, prescription orders, ability to view laboratory results and images, medication lists, and clinical notes. “Fully functional” EHRs include “basic” features plus display of out-of-range laboratory results, medical history, laboratory orders, drug interaction warnings, radiology orders, electronic prescriptions to pharmacy, electronic images returned, laboratory orders sent electronically, radiology orders sent electronically, and guideline reminders. Pediatric-supportive EHRs were defined as “fully functional” EHRs that also support 5 fundamental features: tracking of well-child visits, anthropometric support (such as growth charts or percentile calculations), tracking of immunizations, immunization forecasting (in the form of calculating catch-up immunizations), and prescription support for weight-based dosing. Questions on barriers to EHR use were also included, as well as physician and practice characteristics. The study was approved by the AAP Institutional Review Board.
χ2 analyses were used to assess differences in response to use of “basic” or “fully functional” EHR systems by pediatrician and practice characteristics including gender, age (dichotomized by mean age of 48 years), member type (self-defined as ≥50% time spent in general pediatrics vs a subspecialty area), payment mix (<20% patients covered by Medicaid/ State Children’s Health Insurance Program vs ≥20%), practice setting (self-defined as urban inner city, urban not inner city, suburban, or rural), practice type (for analysis 14 original answer categories were collapsed into pediatric group practices of 1 or 2, 3 to 5, and ≥6 pediatricians, multispecialty group practice/health maintenance organization, and hospital/clinic practice) and practice location (self-defined as Northeast, Midwest, South, and West, classifications used by the National Center for Health Statistics). Patient race and ethnicity categories included white, Hispanic, African American, Asian/Pacific Islander, American Indian, and Other; for analysis, the latter 5 categories were collapsed into 1 group labeled “nonwhite” because of the small numbers of respondents within each of these categories. Multiple logistic regression was used to examine the likelihood of having a basic or fully functional EHR system as a function of pediatrician and practice characteristics. Logistic regressions were performed for whether basic, fully functional, or pediatric-supportive EHR systems were used. Analyses were conducted by using SPSS statistical software, version 18.0 (IBM SPSS, Inc, Chicago, IL).
We received 927 completed questionnaires for a response rate of 57.2%. Analyses are based on responses from the 646 postresidency pediatricians providing patient care in an office- or clinic-based setting. Respondents were predominantly white (78.1%) general pediatricians (72.8%); 54.2% were women (Table 1).
In response to the question “Does your main practice use an electronic medical record (EMR), not including billing records?” 54% of pediatricians reported using either all electronic or part electronic EMR system. In response to the question “Does your main practice use an electronic health record (EHR), not including billing records?” 41% of pediatricians reported using either all or part electronic EHR system. However, when asked about current or potential use of formal criteria for EHR systems, we found roughly 1 in 4 pediatricians used a basic system or planned to adopt one within 12 months of completing the survey. Within this 25%, only 6% of all respondents used or planned to adopt a fully functional system. Included in this 6%, only 3% of all respondents used or planned to adopt a fully functional system with pediatric-supportive features. Usage of individual features varied (Table 2).
Usage of basic EHR systems was further analyzed (Table 3). The odds of adopting a basic EHR system was more than 5 times greater among pediatricians in multispecialty group practice (odds ratio [OR] 5.06, confidence interval [CI] 2.39–10.71) and hospital/clinic practice (OR 5.89, CI 2.65–13.07) than those in solo/2-physician practices. General pediatricians and male pediatricians are approximately twice as likely to use a basic EHR system than subspecialist (OR 2.07, CI 1.09–3.96) and female (OR 2.29, CI 1.40–3.74) pediatricians. Logistic regression analysis of fully functional and pediatric-supportive EHR systems was conducted but was not revealing because too few respondents reported using these more comprehensive systems.
Barriers to EHR Adoption
More than half of pediatricians said the amount of money needed to implement an EHR was a major barrier to adoption. Other perceived barriers to adoption named by more than one-third of respondents were finding an EHR that meets their needs, concern about loss of productivity during transition, uncertainty about return on investment, and concerns that the system they purchased will become obsolete (Table 4).
Based on National Ambulatory Medical Care Survey estimates of EHR use1 our findings indicate that pediatricians are ∼1 to 2 years behind the national average in terms of implementing fully functional EHR systems, and because pediatric practices were included in these national surveys, our estimates of this lag may be underestimates. Multispecialty group practices and hospital/clinic ambulatory practices were 5 and 6 times more likely, respectively, to use EHRs. Similar to other studies, pediatrician practice characteristics (especially practice size) have an effect on EHR adoption.9 Our study found generalists reported greater uptake of EHRs than subspecialists, which was consistent with some studies9,10 but not others.3
The barriers to adoption of health IT in pediatric practice are similar to those described in other studies. Financial barriers are the leading concern regarding acquiring and implementing EHR systems.9,11–14 As part of the effort to reform the health system, the American Recovery and Reinvestment Act of 2009 allocated more than $19 billion toward incentive payments through Medicare and Medicaid to encourage the adoption and “meaningful use” of EHRs. The initial requirements for physicians to qualify for these incentive payments include the use of a “certified EHR.” Additional “Testing and Certification Bodies” accredited through the Office of the National Coordinator for Health Information Technology are required to certify EHRs against a set of criteria for the Medicare and Medicaid incentive programs. Regional Extension Centers have also been created to provide consultation services for providers transitioning to EHRs.
It is widely anticipated that the availability of financial incentive payments, and, ultimately, a Medicare penalty for failure to implement a certified EHR by 2015, will spur rapid acceleration of EHR implementation in the United States. Insurance companies and other third-party payers should be encouraged to follow the lead of the Medicare and Medicaid programs in providing incentives to pediatricians who implement EHRs. Pediatricians face several additional barriers when considering the conversion from paper records to EHRs. Most pediatricians will not qualify for incentive payments through the Medicare program. To qualify for incentive payments through Medicaid, pediatricians must serve a patient population of ≥20% Medicaid beneficiaries. In our study, 68% of pediatricians reported a Medicaid patient population of ≥20% (and 75% of these pediatricians currently do not have either a basic or fully functional EHR system). However, in many areas of the country, caring for such a significant Medicaid population is not feasible, and practices that care for fewer Medicaid patients are less likely to have an EHR. Although states have some flexibility to modify the requirements for their own Medicaid incentive programs, pediatricians in states with more complex requirements or that do not offer incentive programs will not have the opportunity to receive the same financial support for EHR implementation that physicians in other specialties receive through the Medicare program.
The AAP has advocated for the inclusion of pediatric-supportive functionalities in any EHR system that may be used in a setting where children receive care and has funded a Child Health Informatics Center (www2.aap.org/informatics/chic.html) to coordinate federal, state, and local efforts to support EHR adoption as identified by the Academy. However, there is great variation in whether Regional Extension Centers have expertise in or capacity for addressing issues specific to child health. Although the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services are supporting development of a model EHR format for children, there must still be a strong emphasis placed on ensuring that vendors create pediatric-supportive systems to maximize the impact of these efforts.
This study finds that few pediatricians are using pediatric-supportive EHR systems, and that many pediatricians (40%) are concerned that existing EHR systems do not provide the functionality necessary to care for pediatric patients. With the redefinition of certification criteria, the new US Department of Health and Human Services 2011/2012 requirements do not include criteria related to pediatrics, so current certification efforts do not reinforce the importance of implementing pediatric-supportive systems.
It seems likely that EHR vendors will devote their resources to becoming certified for incentive programs and may not pursue additional child health certifications because it is a challenge to convince vendors to implement pediatric-supportive features when they have customers who do not appreciate the need for these features. It will be important either to provide a rationale to vendors to prioritize these features, either by adding certification criteria or creating development toolkits to make it easier for vendors to integrate these features.
Pediatricians in the United States are lagging in implementation of EHR systems, especially in smaller pediatric group practices and rural or inner-city areas. New policy initiatives are needed to help remove barriers to pediatric-supportive EHR implementation. Delays in implementing pediatric-supportive features may lead pediatricians to delay EHR implementations, with the implication that US health care for children may lag that seen in other countries where clinical practice is supported with more uniform health IT implementations.15
There are several limitations to our study. The survey included only members of the AAP, so the findings may not be generalizable beyond this group. Also, it is possible that pediatricians who responded to our survey tended to be EHR users or had a greater interest in the subject of EHRs, thus our data may overestimate the adoption of EHRs among pediatricians. However, our response rate of 57% is similar to other national surveys of pediatricians and has been shown to have minimal response bias.16
We thank the American Academy of Pediatrics for fielding this study. We also acknowledge Drs Mark Del Beccaro, George Kim, Elizabeth Goodman, Lynn Olson, and William Cull for their thoughtful reviews.
- Accepted July 27, 2012.
- Address correspondence to Michael G. Leu, MD, MS, MHS, Clinical Effectiveness, M1-7, 4800 Sand Point Wy NE, Seattle, WA 98105. E-mail:
Drs Leu, Klein, and Ms O’Connor have had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Preliminary analysis from this research was presented at the 2010 Pediatric Academic Societies’ meeting in Vancouver, Canada, and the 26th International Pediatric Association Congress of Pediatrics in Johannesburg, South Africa.
The Periodic Survey is a program of the American Academy of Pediatrics (AAP; www.aap.org/research/periodicsurvey); however, the views expressed in this article are those of the authors and do not necessarily represent those of the AAP.
FINANCIAL DISCLOSURE: Dr Leu owns intellectual property in libraries for computing BMI and blood pressure percentiles that have been made available at no cost to researchers and patient registry vendors; the other authors have indicated they have no other financial relationships relevant to this article to disclose.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found on page e1674, and online at www.pediatics.org/cgi/doi/10.1542/peds.2012-2724.
- ↵Hsiao CJ, Hing E, Socey TC, Cai B. Electronic medical record/electronic health record systems of office-based physicians: United States, 2009 and preliminary 2010 state estimates. Dec 2010. Available at: www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf. Accessed August 23, 2011
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- ↵National Ambulatory Medical Care Survey (NAMCS) Electronic Medical Records Supplement 2008. Available at: www.cdc.gov/nchs/data/ahcd/EMR-NAMCS-011608webversion.pdf Accessed August 23, 2011
- ↵American Academy of Pediatrics, Department of Membership. ABP board certified pediatricians market share report. Unpublished data, 2011
- ↵The National Alliance for Health Information Technology. Defining Key Health Information Technology Terms. April 2008. Available at: http://healthit.hhs.gov/defining_key_hit_terms Accessed June 14, 2012
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- Copyright © 2012 by the American Academy of Pediatrics