EHR Adoption Efforts Should Focus on Small Practices

Nearly half of all physicians in Massachusetts use electronic health records, but the majority of EHR adopters are concentrated in large, financially stable, multispecialty groups, according to a study published in the current Journal of the American Medical Informatics Association. The statewide survey of 1,345 physicians, which was conducted in spring 2005, sought to assess where Massachusetts stands in terms of EHR adoption and to measure the factors that influence adoption.

While the survey found that 45% of physicians use an EHR, only 23% of practices have adopted the technology. Practice size and EHR adoption were strongly related, as 52% of practices with seven or more physicians reported using an EHR, compared with just 14% of solo practices. Hospital-based practices and teaching practices also were more likely to use EHRs, the survey found.

Massachusetts’ EHR adoption rate for individual physicians is much higher than the national average based on recent surveys, according to Dr. Steven Simon, lead author of the study and assistant professor of ambulatory care and prevention at Harvard Medical School and Harvard Pilgrim Health Care.

In addition, he said the state’s overall high EHR adoption rate can be attributed partially to the fact that it has a lot of large, multispecialty practices and academic health centers. He added, “I think there’s been an intense focus in Boston in particular on health information technology, and I’d like to think that that has driven it to some degree as well.”

He also mentioned the impact of Massachusetts’ big health systems “that for a decade or more [have] been pushing to improve quality of care and recognized early on that one mechanism to get there would be using electronic health records.”


As other surveys have found, financial concerns were the top barrier to EHR adoption for physicians in Massachusetts. However, the JAMIA survey found that both EHR adopters and non-adopters also were concerned about ongoing costs and a loss of productivity.

Further, about half of all physicians surveyed cited privacy and security concerns as barriers to EHR adoption.

“I think it is sort of an underscore or wake-up call that physicians are telling us that, ‘Okay, even if you are going to give me financial support, even if you are going to pay for it for me or give me low-interest or no-interest loans, my concerns will remain about privacy and security,'” Simon said. He added that he thinks physicians are worried about how EHRs will affect their practice activity and workflow, though the survey did not explicitly address that issue.

While the survey is not representative of the U.S. as a whole, Simon expects that a national survey would find similar barriers. He said that on a national level, “financial concerns are going to persist,” as are “concerns about privacy and security.” He added, “I’d be surprised if there was anything but concurrence with what the physicians in Massachusetts said.”

Targeting the Right Physicians

The study concludes that programs and initiatives aimed at increasing EHR adoption should focus on small physician practices.

“I think our survey and others have made it clear that the large groups have it figured out,” Simon said. Large physician practices have the financial, IT infrastructure and staff resources needed to adopt EHR systems, he said.

Policymakers and organizations looking to “push EHR adoption forward” should “hone their focus on small office practices, and they’re doing that,” Simon said. The Massachusetts eHealth Collaborative and CMS’ Doctor’s Office Quality – Information Technology program are efforts that already are targeting the correct physicians, Simon said.

The survey also found that physicians were most influenced by their own practice in their decision to adopt EHRs. One-third to one-half of physicians said local or regional organizations influence their EHR adoption, and fewer than 30% of physicians said state or national groups influenced their decision.

Simon said that he expects such organizations as the Leapfrog Group, the Massachusetts Medical Society or managed care plans would be surprised to learn that “their influence isn’t perceived to be as high as they might hope it would be.”

In order to be effective, these groups should localize their efforts and encourage physicians to participate in their program development and be a part of their leadership, according to Simon.

Future Research

Simon and his co-authors in 2007 plan to do a follow-up survey in order to examine change over time.

“In particular, we’ll look to see if small offices are making any headway,” Simon said. “We’d like to know if the barriers change, and it’s entirely possible that as people get to know more and as people use EHRs more, the perceptions of barriers can change.”

In addition to looking at change over time, the researchers plan to tackle other issues, such as asking more in-depth questions about physicians’ privacy and security concerns, Simon said.

The findings of the follow-up study might “influence how policymakers tailor new interventions,” he said.

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