How many physicians use information tools and performance data to improve the quality of care they deliver?

Only about one-quarter to one-half of U.S. physicians surveyed in 2003 used valuable patient data and information technologies to manage patient care. Only one-quarter or fewer received performance feedback on the quality of care they deliver, and only one-third participated in collaborative or redesign efforts to improve patient care.

Why is this important?

Patients receive the majority of their health care through physician office visits. The degree to which physicians use information tools and performance data can greatly determine their ability to engage in systematic quality improvement. For example:

• Effective use of electronic medical records and electronic prescribing can help improve the quality and safety of care and the efficiency of clinical operations (Johnston et al. 2004; Miller and Sim 2003, 2004).
• Patient registries and appointment reminders facilitate tracking and follow-up of those in need of preventive services or care for a chronic illness, promoting improved outcomes (Fahey et al. 2006; Griffin and Kinmonth 2000; Jacobson and Szilagyi 2005; Stone et al. 2002).
• Physician prompts and alerts increase the delivery of recommended services at patient visits and can improve medication management (Balas et al. 2000; Bennett and Glasziou 2003; Walton et al. 2001).
• Performance feedback can help physicians identify gaps and motivate improvements in practice (Fidler et al. 1999; Jamtvedt et al. 2003).

Findings

Only a minority of U.S. physicians involved in the ongoing care of adult patients reported in 2003 that they had incorporated key clinical information management and quality improvement tools and techniques into everyday practice (Audet et al. 2005).

• Although more than one-third (37%) of physicians routinely accessed electronic laboratory results, less than one of five (18%) routinely used an electronic medical record or electronic prescribing (17%). More than one-half reported no plans to use the latter two information technologies in the near future.
• More than one-half (54%) of physicians reported sending patient reminders for preventive or follow-up care, but only about two of five (38%–41%) had a system that provided alerts or prompts about drug prescribing problems or abnormal test results requiring follow-up. Only a minority had automated these processes. One-third or more (34%–44%) reported no immediate plans to use these tools in any form.
• Physicians' ability to generate patient-panel data was generally low. Less than one-half could easily identify patents by age group (49%) or by diagnosis or health risk (44%), and fewer than one of six could easily identify patients with abnormal laboratory results (16%) or using high-risk medications (15%).
• Only one of five physicians received performance feedback on clinical care (20%) or outcomes (18%), such as the percentage of their patients who received preventive care or achieved control over their disease. Only one-quarter (25%) received survey data on patients' experiences. Most relied on external sources such as health plans for such information (not shown).
• Only about one-third of physicians had participated in collaborative efforts (32%) to improve quality, or in redesign efforts (34%) to improve patient care systems in their own practice or at a hospital in the past two years.
• Only one of five physicians (19%) always or often had objective information on the quality of care provided by physicians to whom they refer patients; almost two-thirds (64%) never or rarely had such information.

Implications

Physicians may be hesitant to embrace quality improvement techniques because of skepticism about their effectiveness, perceived financial disincentives (more than one-half said that providing the best quality care can reduce their revenues), insufficient organizational support, and lack of public visibility of quality problems (Audet et al. 2005; Blumenthal and Epstein 1996; Milstein and Adler 2003).

Universal physician use of advanced electronic health records systems equipped with electronic prescribing, laboratory ordering, and clinical decision support tools might save up to $44 billion nationally by preventing many adverse drug events and hospitalizations (Johnston et al. 2004). Yet more than one-half of physicians cite start-up costs as a major barrier to the adoption of information technologies.

Use of potentially quality-enhancing information tools and performance data was lowest among solo physicians and those working in small practices (less than 10 physicians)—the settings in which most physicians practice and hence in which most patients receive their care. Even among those using electronic medical records, many are not making routine use of advanced clinical decision support features that can be important to improved patient care.

Improvement Ideas and Resources

Achieving widespread use of information technology (IT) will require enhanced federal leadership and public–private partnerships to lower the cost of adoption by assuring access to capital, promoting standards for interoperability, and providing technical support for implementation. This goal is being addressed in part by an August 2006 Executive Order Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. In addition, IT systems must be further developed to better support quality measurement and improvement.

Making quality improvement a common element of practice in physician offices will require changes in medical education, professionalism, and reimbursement. Continuing efforts are needed to incorporate quality improvement principles in medical school curricula, support specialty board maintenance of certification requirements, spread pay-for-performance programs that effectively reward quality improvement, and advance ambulatory care quality measurement.

One example is the ABIM (American Board of Internal Medicine) Foundation's Putting Quality into Practice initiative, which aims to 1) foster physicians' use of data to improve clinical performance, and 2) guide development of standards for evaluating physicians by certifying boards and accrediting organizations. The foundation is distributing a free DVD in which physicians share their experiences with quality measurement and improvement.

Measure:

The denominator for the charts includes a sample of 1,837 respondents from a sample of 3,598 physicians randomly selected from the American Medical Association master file who were involved in the direct care of adult patients and in practice for at least three years post-residency. Specialists (radiologists, anesthesiologists, pathologists, and dermatologists) unlikely to be involved in ongoing patient care were excluded. Data were weighted by gender, age, and practice setting to reflect the national distribution of physicians in the American Medical Association master file (Audet et al. 2005).

Limitations:

The survey response rate was 53 percent. There were no differences between respondents and non-respondents by gender, age, practice size, specialty, or years in practice.

Source:

Data were compiled by researchers at The Commonwealth Fund based on responses to the National Survey of Physicians and Quality of Care, a nationally representative self-administered mail and online survey of U.S. physicians conducted by Harris Interactive between March 17, 2003, and May 30, 2003 (Audet et al. 2005).

References:

* Indicates source of data used in the chart(s).* Audet, A.-M. J., M. M. Doty, J. Shamasdin, and S. Schoenbaum. 2005. Physicians' Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care. New York: The Commonwealth Fund.

Balas, E. A., S. Weingarten, C. T. Garb et al. 2000. Improving Preventive Care by Prompting Physicians. Archives of Internal Medicine 160 (3): 301–8.

Bennett, J. W., and P. P. Glasziou. 2003. Computerised Reminders and Feedback in Medication Management: A Systematic Review of Randomised Controlled Trials. Medical Journal of Australia 178 (5): 217–22.

Blumenthal, D., and A. M. Epstein. 1996. Quality of Health Care. Part 6: The Role of Physicians in the Future of Quality Management. New England Journal of Medicine 335 (17): 1328–31.

Fahey, T., K. Schroeder, and S. Ebrahim. 2006. Interventions Used to Improve Control of Blood Pressure in Patients with Hypertension. Cochrane Database of Systematic Reviews (2): CD005182.

Fidler, H., J. M. Lockyer, J. Toews et al. 1999. Changing Physicians' Practices: The Effect of Individual Feedback. Academic Medicine 74 (6): 702–14.

Griffin, S., and A. L. Kinmonth. 2000. Diabetes Care: The Effectiveness of Systems for Routine Surveillance for People with Diabetes. Cochrane Database of Systematic Reviews (2): CD000541.

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Jamtvedt, G., J. M. Young, D. T. Kristoffersen et al. 2003. Audit and Feedback: Effects on Professional Practice and Health Care Outcomes. Cochrane Database of Systematic Reviews (3): CD000259.

Johnston, D., E. Pan, J. Walker et al. 2004. The Value of Computerized Order Entry in Ambulatory Settings. Wellesley, Mass.: Center for Information Technology Leadership.

Miller, R. H., and I. Sim. 2003. Electronic Medical Records: Lessons from Small Physician Practices. Oakland, Calif.: California HealthCare Foundation.

Miller, R. H., and I. Sim. 2004. Physicians' Use of Electronic Medical Records: Barriers and Solutions. Health Affairs (Millwood) 23 (2): 116–26.

Milstein, A., and N. E. Adler. 2003. Out of Sight, Out of Mind: Why Doesn't Widespread Clinical Quality Failure Command our Attention? Health Affairs (Millwood) 22 (2): 119–27.

Stone, E. G., S. C. Morton, M. E. Hulscher et al. 2002. Interventions that Increase Use of Adult Immunization and Cancer Screening Services: A Meta-Analysis. Annals of Internal Medicine 136 (9): 641–51.

Walton, R. T., E. Harvey, S. Dovey et al. 2001. Computerised Advice on Drug Dosage to Improve Prescribing Practice. Cochrane Database of Systematic Reviews (1): CD002894.