Health IT Adoption: A cross-national comparison

Ashish K. Jha, MD, MPHAshish K. Jha, MD, MPH

Harvard School of Public HealthBrigham and Women’s HospitalVA Boston Healthcare System

June 26, 2006

Funded by: The Commonwealth Fund, New York, NY

Background

Healthcare costs rising in many nationsHealthcare costs rising in many nations

Quality of care variable, often inadequateQuality of care variable, often inadequate

The promise of health information technologyThe promise of health information technology

Will increase qualityWill increase quality

Will improve efficiencyWill improve efficiency

Will improve coordination of healthcareWill improve coordination of healthcare

Despite major policy focusDespite major policy focus

Level of HIT adoption in the U.S. unknownLevel of HIT adoption in the U.S. unknown

How U.S. compares to other nations also unknownHow U.S. compares to other nations also unknown

Research Questions

What is the level of HIT adoption in the U.S.?What is the level of HIT adoption in the U.S.?

How does it compare to other nations?How does it compare to other nations?

What are the major programs currently in What are the major programs currently in HIE?HIE?

Methods A comprehensive review of U.S. surveysA comprehensive review of U.S. surveys

Rating of surveys based on methodology, Rating of surveys based on methodology, contentcontent

Ratings criteria developed by group of Ratings criteria developed by group of experts:experts:

Sampling technique, response rateSampling technique, response rate

EHR contentEHR content

Reviews of surveys from other nationsReviews of surveys from other nations

Interviews from expertsInterviews from experts

Results Health IT in the U.S.Health IT in the U.S.

35 surveys of physicians and other providers35 surveys of physicians and other providers

21 surveys available for rating21 surveys available for rating

16 surveys of EHR adoption in ambulatory care16 surveys of EHR adoption in ambulatory care

5 surveys of EHR adoption in inpatient care5 surveys of EHR adoption in inpatient care

Few surveys of high qualityFew surveys of high quality

Nine high quality in methodologyNine high quality in methodology

Eight high quality in EHR contentEight high quality in EHR content

Four surveys high quality in both areasFour surveys high quality in both areas

Results – U.S. EHR adoptionRange: Medium or

High Quality SurveysBest Estimates:

High Quality Surveys

EHR: ambulatory 17% to 25% 17%

Solo practitioners 12.9% to 13% 13%

Large groups* 19% - 57% 39%

EHR: hospitals 16%† - 59%†† None

CPOE: hospitals 4% to 21% 5%

Cross-national comparisonPrimary Care Hospital Care

EMR CPOE EMR CPOE

USA 17-18% N/A 16% 5%

UK >90% >90% 8% 3%

Canada 19% 14% <10% 25%

Australia 90% 75% <10% <1%

New Zealand 72% 90% <10% <1%

Netherlands 95%95% 90%90% <5%<5% <5%<5%

Health Information ExchangeUSA Regional Health Information Organizations

7-10 RHIOs “functioning” 100+ in planning stages

England National Program for Health IT: Ambitious planNational Program for Health IT: Ambitious planNational backbone networkNational backbone networkNational sharing of data for imaging, prescriptions, National sharing of data for imaging, prescriptions, clinical dataclinical dataStill very early in deployment with some early hurdlesStill very early in deployment with some early hurdles

Canada Infoway: Imaging, labs, medications integrationInfoway: Imaging, labs, medications integration

Early stage: 8% to 27% completeEarly stage: 8% to 27% complete

Australia HealthConnect: $128M over 4 yearsHealthConnect: $128M over 4 yearsSlow efforts with small investments Slow efforts with small investments

mostly focused on broadband connectionmostly focused on broadband connection

Little data sharing occuringLittle data sharing occuring

New Zealand Little activity in data exchangeLittle activity in data exchange

Netherlands National pilot programs in fall, 2006 Two main features: electronic medication recordsTwo main features: electronic medication records Clinical data summaryClinical data summary 4000 Euros for GPs; 40,000 for pilot hospitals4000 Euros for GPs; 40,000 for pilot hospitals

Discussion

U.S. adoption rates of EHR lowU.S. adoption rates of EHR low Lack of good estimatesLack of good estimates Less than 1 in 5 ambulatory physicians using EHRLess than 1 in 5 ambulatory physicians using EHR Approximately 1 in 20 hospitals using CPOEApproximately 1 in 20 hospitals using CPOE

Other nations ahead on ambulatory EHROther nations ahead on ambulatory EHR U.S. has lowest rate of EHR use in ambulatory careU.S. has lowest rate of EHR use in ambulatory care Substantially behind Australia, UK, NZ and Substantially behind Australia, UK, NZ and

NetherlandsNetherlands

Lack of high quality data make other Lack of high quality data make other assessments difficultassessments difficult

Discussion

Poor adoption rates in hospitalsPoor adoption rates in hospitals No nation has moved substantially in this areaNo nation has moved substantially in this area

Different levels of activity on data Different levels of activity on data exchangeexchange

Major efforts in UK, Canada, and NetherlandsMajor efforts in UK, Canada, and Netherlands Slower efforts in US, Australia, and NZSlower efforts in US, Australia, and NZ Even well touted programs running into Even well touted programs running into

obstaclesobstacles

Limitations

Important caveats to adoption dataImportant caveats to adoption data U.S. estimates based on few high quality U.S. estimates based on few high quality

surveyssurveys Large confidence intervals when other surveys Large confidence intervals when other surveys

includedincluded Data from other nations not rigorously Data from other nations not rigorously

evaluatedevaluated Most surveys don’t distinguish “have” from Most surveys don’t distinguish “have” from

“use”“use”

Field rapidly changingField rapidly changing

Implications

Health IT adoption varies across nationsHealth IT adoption varies across nations U.S. behind in ambulatory EHR useU.S. behind in ambulatory EHR use

Likely will need greater access to capital to Likely will need greater access to capital to improveimprove

IT in hospitals widely neglectedIT in hospitals widely neglected Best evidence for improving careBest evidence for improving care New efforts to focus on hospital ITNew efforts to focus on hospital IT

HIE very early in deploymentHIE very early in deployment No single approach will work for all No single approach will work for all

nationsnations Adequate funding just part of the challengeAdequate funding just part of the challenge

Acknowledgement

HIT Adoption Initiative – funded by ONCHIT Adoption Initiative – funded by ONC Tim FerrisTim Ferris Karen DonelanKaren Donelan Alex ShieldsAlex Shields Cait DerRochesCait DerRoches Sara RosenbaumSara Rosenbaum

David BlumenthalDavid Blumenthal

Cross-country Initiative – funded by Cross-country Initiative – funded by CMWFCMWF

Doreen NevilleDoreen Neville Tim ClarkTim Clark David DoolanDavid Doolan David BatesDavid Bates