Impact of Health Information Technology on Primary Care Workflow and Financial Measures (Texas)

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Summary:

Several frequently cited barriers to the adoption of electronic health records (EHR) include potentially high implementation costs and uncertainty regarding its impact on workflow, productivity, and post-implementation revenue. The data in the literature on these barriers are based on expert opinion and the experience of academic centers using "home-grown" health information technology. "Real-world" data for commercial EHRs implemented in a relatively short time frame are not readily available. This research sought to estimate the cost and workflow impact of rapid implementation for 26 primary care practices within a fee-for-service ambulatory care physician network that adopted an EHR between July 2006 and December 2008.

The study identified "hidden" costs, i.e. resources and staff time, that provider practices and health care organizations must consider when planning for EHR implementation. The three main types of hidden costs are: the time spent by the corporate implementation team in guidance, planning, and overall support; time spent at the practice level in planning, training, and workflow redesign; and the time spent by end-users in activities such as pre-loading charts.

The main objectives of this study were to:

  1. Estimate the effect of the EHR on workflow outcome measures.
  2. Estimate the effect of the EHR on financial measures.
  3. Quantify financial and non-financial costs of implementation and maintenance, providing information on perceived barriers and facilitators in the adoption and implementation of the EHR.

Overall, the team estimated that the EHR and practice teams spent a total of 611 hours per practice for implementation. End-users spent 134 hours per physician. For a five physician practice, hardware and software implementation costs were estimated as $162,000, with $85,500 in maintenance expenses during the first year. The study found that a variety of people were needed for pre-implementation planning, including IT staff, management, clinicians, and leadership. There were short-term decreases found in productivity with substantial recovery in both work flow and financial measures 12 months after implementation. The results observed in this study compare to other reports in the literature suggesting that the effects a practice sees following EHR implementation may depend on the roles played by support staff (and how these can be redefined to reflect new workflow activities created by the EHR), and costs of ongoing EHR maintenance.

Impact of Health Information Technology on Primary Care Workflow and Financial Measures - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality through Health Information Technology (R03)
  • Grant Number: 
    R03 HS 018220
  • Project Period: 
    October 2009 - April 2011
  • AHRQ Funding Amount: 
    $99,955
  • PDF Version: 
    (PDF, 518.81 KB)

Summary: Little is known about the impact of commercial off-the-shelf electronic health record (EHR) systems on primary care workflow and financial measures, or about the financial and non-financial costs of implementation and maintenance of these systems. Given the goal of universal EHR use in the United States, such knowledge is of immediate and critical importance for the multiple stakeholders in the health care delivery arena.

The HealthTexas Provider Network (HTPN), a large fee-for-service ambulatory care physician network affiliated with an integrated health care delivery system in North Texas, began a staggered 3.5-year roll-out of GE Centricity, an ambulatory EHR system, in mid-2006. Using billing and administrative data, the investigators prospectively examined the impact of the implementation and maintenance of the ambulatory EHR on 26 primary care practices' workflow and financial measures. Investigators also examined the financial resources consumed and the non-financial time and effort costs of the HTPN implementation team and practice physicians, nurses, and office staff preparing for implementation.

The study aimed to better understand frequently-cited perceived barriers to ambulatory EHR adoption, including uncertainty regarding financial and non-financial costs of implementation, loss of productivity during implementation, interference with workflow, and return on investment. Reducing uncertainty in these areas should inform real-world health information technology (IT) implementation decisions and stimulate more comprehensive health IT implementation research in ambulatory care settings.

Specific Aims:

  • Estimate the effect of the EHR on workflow outcome measures. (Achieved)
  • Estimate the effect of the EHR on financial measures. (Achieved)
  • Quantify financial and non-financial costs of implementation and maintenance, providing information regarding perceived barriers and facilitators to adoption and implementation of the EHR. (Achieved)

2011 Activities: The majority of the work on this grant was completed in 2010, including the completion of the last aim. Dr. Fleming and his team used a 3-month no-cost extension to complete the analysis for the first two aims, as well as manuscript and final report preparation. This project was completed April 2011.

Preliminary Impact and Findings: Results for the third aim were published in the March 2011 volume of Health Affairs, "Financial and Non-financial Costs Associated with Electronic Health Record Implementation in the Primary Care Setting." The analysis takes into account both hardware and software purchases and the time and effort invested in implementation. They estimate the EHR and practice teams spent 611 hours per practice for implementation, and end-users spent 134 hours per physician. For a fivephysician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. These results highlight the often hidden costs of EHR implementation, in terms of the time and effort required by individuals at both the leadership and practice level.

Another major concern creating a barrier to EHR adoption is the fear that it is a risky investment that decreases provider productivity and increases practice expenses. In order to assess the impact of the EHRs on productivity, the team examined relative value units (RVUs) and visits per physician fulltime equivalent (FTE). RVUs are used to compare the amount of resources required to perform various services between or within an organization's departments. Work RVUs per-physician FTE did decrease after EHR implementation, representing a drop in productivity. RVUs were 8 percent lower during the first 6 months following implementation, but rebounded to 4 percent lower than pre-implementation levels by 12 months post-implementation. Visits per-physician FTE followed a similar pattern, dropping 8 percent from pre-implementation levels during the first 6 months after EHR implementation, recovering to 4.5 percent lower than pre-implementation after 12 months.

Net income also decreased initially, but after 12 months was not different than pre-EHR levels. Physician expense increased to about $1,650 per-physician FTE per month, which is approximately the per-physician monthly cost of EHR maintenance costs. While fears of increased expenses and decreased productivity during the initial period after EHR implementation are justified, they are not as large or persistent as thought, with a return to pre-implementation baseline levels after 12 months.

Target Population: Adults, Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Impact of Health Information Technology on Primary Care Workflow and Financial Measures - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality through Health Information Technology (R03)
  • Grant Number: 
    R03 HS 018220
  • Project Period: 
    October 2009 – April 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $99,955
  • PDF Version: 
    (PDF, 1 MB)


Target Population: Adults, Pediatric*

Summary: Little is known about the impact of commercial off-the-shelf electronic health record (EHR) systems on primary care workflow and financial measures, or about the financial and non-financial costs of implementation and maintenance of these systems. Given the goal of universal EHR use in the United States, such knowledge is of immediate and critical importance for the multiple stakeholders in the health care delivery arena.

The HealthTexas Provider Network (HTPN), a large fee-for-service ambulatory care physician network affiliated with an integrated health care delivery system in North Texas, began a staggered 3.5 year roll-out of GE Centricity, an “off-the-shelf” Certification Commission for Health Information Technology-certified ambulatory EHR system, in mid-2006. Using billing and administrative data, the investigators are prospectively examining the impact of the implementation and maintenance of the ambulatory EHR on 26 primary care practices’ workflow and financial measures. Investigators are also examining the financial resources consumed and the non-financial time and effort costs of the HTPN implementation team and practice physicians, nurses, and office staff preparing for implementation. Due to the staggering of the EHR implementation, comparisons will be both cross-sectional (between EHR and non-EHR practices at set points) and longitudinal (between measures collected at the same practice pre- and post-EHR implementation).

The study will contribute to knowledge regarding frequently-cited perceived barriers to ambulatory EHR adoption, including uncertainty regarding financial and non-financial costs of implementation, loss of productivity during implementation, interference with workflow, and return on investment. Reducing uncertainty in these areas should inform real-world health information technology (IT) implementation decisions and stimulate more comprehensive health IT implementation research in ambulatory care settings. Understanding the workflow and financial impacts, as well as financial and non-financial costs related to implementation of health IT, is important for stakeholders at all stages in the ambulatory EHR decision process, including adoption and implementation.

Specific Aims:
  • Estimate the effect of the EHR on workflow outcome measures. (Ongoing)
  • Estimate the effect of the EHR on financial measures. (Ongoing)
  • Quantify financial and non-financial costs of implementation and maintenance, providing information regarding perceived barriers and facilitators to adoption and implementation of the EHR. (Achieved)

2010 Activities: Dr. Fleming and his team completed the work for the third aim, quantifying the financial and non-financial costs of implementing the ambulatory EHR. Financial costs included those pertaining to purchases of hardware, software, and system resources. Non-financial costs related to time and effort of the HealthTexas EHR implementation team; time the physician champions, nurse superusers, and office managers spent overseeing EHR implementation tasks (e.g., planning, workflow reengineering, and training); and time spent by individual physicians, medical staff, and office staff preparing for EHR use (e.g. pre-loading charts, training). As part of this work, the project team engaged in key informant interviews with operational leadership, including the vice president of informatics and the manager of training and workflow, to understand and quantify the implementation and maintenance costs for activities during the 120 days pre- and 60 days post-“Go Live” from three perspectives: 1) the physician network's implementation team; 2) the individual practice implementation teams consisting of the physician champion, EHR practice manager, and both clinical and non-clinical staff; and 3) the end-users.

Dr. Fleming and his team made considerable progress in preparing the dataset for the first two aims, including the collection of administrative data containing the covariates and outcome variables for the statistical models. Their covariates will reflect summarized practice characteristics including average number of years with HTPN, specialty, average patient age, and percentage of female patients. The analytic dataset is complete and the team has begun to design and construct the data analytical platform in MS-SQL Server, MS-Access, and SAS that will be used to test the impact of the EHR implementation through comparisons of pre- and post-implementation data. The patient level visit-related data from the administrative system have been coupled with the individual physician and practice-level data. The analytic variables have been constructed regarding the implementation (2006-2007 versus 2008) and time in relation to implementation (prior to implementation, 1 to 6 months, 7 to 12 months, and greater than 12 months post-implementation). The Non-physician Staff per Physician Full time Equivalent is the last variable to be constructed with attention being made to the consideration of primary care effort. The outcome data are now being reviewed for potential outliers.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is reported as on track in some respects but not others and budgeted funds are somewhat underspent, by approximately 5 to 20 percent. However, Dr. Fleming and his team received a 3 month no-cost extension and the project is on target to complete within the new grant time frame. Slippage occurred due to the difficult nature of modeling the complex inter-relationships within these data. As the relationships between the independent variables of interest and the outcome variables are non-linear, it has taken more time than anticipated to estimate these relationships.

Preliminary Impact and Findings: The project team completed the work for the third aim and results were published in the March Health Affairs,Financial and Non-financial Costs Associated with Electronic Health Record Implementation in the Primary Care Setting”. The analysis takes into account both hardware and software purchases and the time and effort invested in implementation. They estimate the EHR and practice teams spent 611 hours per practice for implementation, and end-users spent 134 hours per physician. For a five physician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. These results highlight the often hidden costs of EHR implementation, in terms of the time and effort required by individuals at both the leadership and practice level.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

Impact of Health Information Technology on Primary Care Workflow and Financial Measures - Final Report

Citation:
Fleming N. Impact of Health Information Technology on Primary Care Workflow and Financial Measures - Final Report. (Prepared by Baylor Research Institute under Grant No. R03 HS018220). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 393.97 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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