ABSTRACT
Aims: The interplay between rising doctor follow fashions and using well being info change (HIE) stays understudied. We examined associations between using rising follow fashions and using HIE. We additionally examined obstacles to HIE adoption amongst physicians who weren’t using HIE.
Examine Design: Survey knowledge got here from a 2019-2021 statewide census of all physicians in Arizona collected on the time of license renewal (n = 3312, or 17.9% of all practising physicians).
Strategies: Major outcomes had been physician-reported HIE use for affected person care summaries and for laboratory outcomes. Secondary outcomes had been 5 widespread HIE obstacles amongst non-HIE customers. The first predictor was doctor follow mannequin: accountable care group (ACO), clinically built-in community (CIN), or built-in supply community (IDN) vs conventional care supply mannequin. Covariates included doctor specialty, age, gender, and county of follow.
Outcomes: In contrast with physicians in conventional care supply fashions, physicians in ACOs, CINs, or IDNs had considerably greater odds of utilizing HIE to share each affected person care summaries (P < .01) and laboratory outcomes (P < .05 for ACOs), though associations different throughout supplier and follow traits. ACO suppliers not utilizing HIE had been extra prone to cite an absence of connectivity and lack of awareness as HIE obstacles.
Conclusions: Suppliers in an rising follow mannequin are extra doubtless to make use of HIE than these in a conventional care supply mannequin. Nonetheless, nuances in these associations counsel a persistence of beforehand recognized HIE gaps, and the obstacles cited present steerage for rising HIE use amongst completely different follow sorts.
Am J Manag Care. 2023;29(1):27-34. https://doi.org/10.37765/ajmc.2023.89301
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Takeaway Factors
- We leverage a wealthy knowledge set of a number of thousand physicians to analyze the interaction between participation in rising supplier follow fashions equivalent to accountable care organizations (ACOs), clinically built-in networks (CINs), or built-in supply networks (IDNs) and use of well being info change (HIE).
- We discover a robust however not deterministic relationship between ACO/CIN/IDN participation and HIE use. We determine notable areas for future research and coverage consideration the place suppliers are collaborating in both HIE or ACO/CIN/IDN fashions however not each. We additionally discover notable patterns in obstacles to make use of of HIE between ACO/CIN/IDN-participating suppliers and nonparticipating suppliers, together with demographic and follow traits and differential self-reported obstacles to future adoption and use of HIE.
- Nuances in associations between ACO/CIN/IDN participation and use of HIE counsel a persistence of beforehand recognized HIE gaps, and the obstacles cited present steerage for rising HIE use amongst completely different follow sorts.
- Recognizing and figuring out co-occurrence of ACO/CIN/IDN participation and HIE in at present’s well being care supply atmosphere is particularly essential on condition that reaching the complete theoretical advantages of rising follow fashions might necessitate wider use of HIE.
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Rising doctor follow fashions search to enhance well being care worth in contrast with conventional well being care supply fashions, together with higher high quality and decrease prices.1,2 These new follow fashions can take many types,3 together with accountable care organizations (ACOs), clinically built-in networks (CINs), and built-in supply networks (IDNs), amongst others.
Rising doctor follow fashions have develop into more and more widespread in recent times. For instance, the primary nationwide survey of ACOs was carried out in 2012-2013 and recognized roughly 260 ACOs in america.4 By 2017-2018, the variety of ACOs in america had elevated to 862.5 Greater than 30 million Individuals now obtain care by way of an ACO.6 CMS has set a goal that almost all of well being care in america be delivered underneath some rising follow mannequin as of 2018, a big shift from the roughly 20% of care delivered underneath these fashions in 2014.7 Though there was a considerably combined historical past of success in reaching elevated worth by way of these new follow fashions,8 these care supply approaches represent a rising and more and more essential portion of the US care supply panorama.9,10
At roughly the identical time as new fashions for well being care supply have develop into extra prevalent, a major shift towards using digital well being data (EHRs) and well being info change (HIE) has occurred. In 2007, previous to CMS’ rollout of adoption incentive funds for EHRs, roughly 35% of office-based physicians reported utilizing any EHR.11 By 2017, that determine had elevated to 86%, with 80% of physicians reporting utilizing an EHR system that meets federal significant use requirements for selling interoperability.12 Together with the fast enlargement of EHR use pushed by the Well being Info Expertise for Financial and Scientific Well being Act,13 physicians and hospitals are additionally exchanging digital well being knowledge by way of purpose-built HIE platforms and organizations. The enlargement of HIE has been much less fast than that of EHRs, however within the roughly 10 years for the reason that emergence of the primary financially viable HIE round 2009, greater than 40 financially viable HIE organizations have emerged.14 Substantial obstacles to HIE adoption stay, nevertheless, together with monetary, technological, organizational, and environmental elements.15
From a conceptual standpoint, it’s cheap to suspect that the concurrent progress of doctor follow fashions and HIE has been mutually reinforcing and mutually helpful. A constant goal throughout all types of rising follow fashions is to incentivize care coordination throughout care supply settings.16 Coordinated care can promote supply of well timed well being companies and follow-up, doubtlessly leading to fewer pointless or repeated companies. Nonetheless, relational, managerial, and informational obstacles exist. Well being info know-how is a vital software for combating widespread informational obstacles.17 HIE might assist to facilitate interprovider and interorganization communications in well being care and yield extra productive well being care encounters for sufferers.16,18,19 This may be seen empirically as communities with established HIEs are related to decrease per capita Medicare prices.20 Moreover, by way of the Medicare Entry and CHIP Reauthorization Act, suppliers might be eligible to obtain cost incentives for HIE participation in an effort to advertise higher care coordination.
But the proof base relating to the intersection of rising follow fashions and using HIE stays considerably restricted, partly on account of methodological and knowledge challenges.21 For instance, knowledge on doctor follow mannequin proliferation come partly from the ACOs themselves, equivalent to Dartmouth’s Nationwide Survey of ACOs. That survey just isn’t particularly geared toward figuring out EHR or HIE utilization patterns and due to this fact has a considerably slender set of EHR and HIE knowledge parts as of its present (fourth) wave.6 Equally, the perfect out there knowledge on progress and traits of HIEs come from a survey of HIE organizations, however that survey doesn’t concurrently study using an rising follow mannequin. Information reported in an appendix to a 2021 reporting of HIE survey knowledge by Adler-Milstein et al counsel that solely about one-third of HIEs can generate high quality measures essential for participation in an rising follow mannequin, equivalent to an ACO; roughly one-half of HIEs report offering knowledge ample for finally producing high quality measures.14 Briefly, comparisons of adoption and use of each an rising follow mannequin and HIE could also be restricted by the shortage of particular person provider-level knowledge and could also be topic to the ecological fallacy. Subsequently, comparatively little is understood concerning the sorts of suppliers who’re and are usually not using an rising follow mannequin and concurrently utilizing HIE to share well being care knowledge.
The first function of this research was to look at the affiliation between rising doctor follow fashions, equivalent to ACOs and built-in settings, and using HIE on the stage of the person supplier. The secondary function of this research was to look at whether or not there’s an affiliation between using an rising follow mannequin and obstacles to HIE use among the many physicians who weren’t exchanging info electronically.
METHODS
Conceptual Framework
In analyzing associations between rising doctor follow fashions and the digital change of well being care info, we centered particularly on 3 follow fashions—ACOs, CINs, and IDNs—and a pair of sorts of well being care knowledge—affected person care summaries and laboratory outcomes. We centered on these 2 sorts of well being care knowledge as a result of we hypothesized that these are important knowledge sorts shared in settings equivalent to ACOs, CINs, and IDNs. Use of HIE can have completely different advantages relying on the particular sorts of well being care companies used. In emergency departments, for instance, HIE may end up in sooner entry to info from exterior sources.22 Within the case of ACOs, CINs, and IDNs, nevertheless, it’s particularly related that main care suppliers obtain well timed and full summaries of sufferers’ visits with specialist suppliers.23 Likewise, laboratory outcomes which might be unavailable on the time of a affected person’s go to may end up in the necessity for extra affected person visits or repeat exams,19 each of which might be disincentivized underneath a value-based cost care supply mannequin. We due to this fact hypothesized that participation in an ACO, CIN, or IDN can be positively related to the probability of HIE use relative to physicians practising in conventional care supply fashions equivalent to charge for service.
Information
Information for this research come from the Arizona State College Heart for Well being Info and Analysis’s ongoing survey on physicians’ use of digital medical data and change of digital well being knowledge. Further info on this survey is contained within the eAppendix (out there at ajmc.com). Briefly, the survey’s pattern body is all licensed Arizona physicians. Survey responses are voluntarily accomplished on-line following completion of the license renewal software. As of 2020, roughly 95% of Arizona physicians report utilizing EHRs, greater than 900 organizations take part within the state’s HIE, and roughly 18 ACOs exist within the state.24,25
In 2019-2021, 18,485 physicians renewed their medical licenses and acquired an invite to finish this survey. A complete of 3312 full responses had been acquired, for an general response price of 18%. This represents roughly 18% of all physicians practising within the state of Arizona, because the survey doesn’t use a fractional sampling body or multistage sampling design. As proven in eAppendix Desk 1, respondents and nonrespondents differed on some however not all observable dimensions. Survey weights had been used to account for observable variations in supplier age, gender, diploma sort, and Medicaid acceptance standing between suppliers who did and didn’t full the survey.
Our main outcomes of curiosity had been 2 separate dichotomous measures of utilizing HIE to share (1) affected person care summaries and (2) laboratory outcomes. “Sure” signifies {that a} doctor reported exchanging that sort of knowledge electronically by way of HIE. “No” signifies that the respondent exchanged that sort of knowledge by way of fax, didn’t change, or didn’t know. Our secondary outcomes of curiosity had been 5 separate dichotomous measures for the sorts of obstacles (if any) reported by physicians who reported that they didn’t electronically change both affected person care summaries or laboratory outcomes. The 5 barrier sorts had been knowledgeable by earlier studies14,15,19 and had been (1) lack of an HIE, (2) issues about affected person confidentiality, (3) lack of technological help for issues, (4) lack of connectivity between EHR and different techniques, and (5) lack of awareness from different suppliers.
Our foremost predictors of curiosity had been 2 dichotomous variables that recognized whether or not a doctor (1) self-identified participation in an ACO or (2) self-identified participation in an built-in care mannequin (a part of both a CIN or IDN), the place the reference group was participation in a conventional care supply mannequin (eg, conventional fee-for-service personal follow or different sorts of fashions). Roughly 1% of physicians responded that they practiced “concierge” drugs and had been excluded from these analyses.
We additionally included a number of covariates in multivariable fashions: (1) follow sort (solo personal follow, group personal follow, hospital-based, group clinic); (2) specialty (main care, pediatric, medical-surgical); (3) gender (feminine, male); (4) diploma sort (MD, DO); (5) Medicaid supplier (sure, no); (6) age (25-34, 35-44, 45-54, 55-64, ≥ 65 years); and (7) county of follow (Maricopa [Phoenix area], Pima [Tucson area], different). Though not an ideal match, county of follow can function a tough proxy for rurality. Maricopa and Pima counties are the two largest and extra urbanized counties in Arizona. The remaining 13 counties are, with some exceptions, rural in nature.
Statistical Analyses
We calculated univariate abstract statistics on our pattern together with rely and proportion for all variables. We in contrast knowledge on survey respondents with full knowledge (n = 3312) vs these with incomplete knowledge; outcomes are proven in eAppendix Desk 1. We calculated multivariable logistic regression fashions of our main outcomes of curiosity on our main predictors of curiosity plus iteratively added units of management variables. All fashions managed for demographics together with doctor’s gender, age, county, and Medicaid standing. A further mannequin was run that additionally managed for follow sort. Our last “full” mannequin managed for demographics, follow sort, and supplier specialty. Separate fashions had been estimated for supplier’s use of HIE to change affected person care summaries and using HIE to change laboratory outcomes. We additionally ran separate fashions for every of the 4 doctor follow sorts to look at relationships between variables of curiosity which might be particular to a given follow sort. To look at our research’s secondary function, we ran separate regression fashions of every of the 5 sorts of obstacles to HIE use on the complete set of predictors and covariates. All analyses had been carried out utilizing Stata/MP model 16.1 (StataCorp LLC), and all fashions had been estimated utilizing heteroscedasticity-robust SEs. Moral approval for this research was obtained from the Arizona State College Institutional Evaluation Board.
RESULTS
Full knowledge on HIE use, doctor follow mannequin, and doctor demographic knowledge had been out there for 3312 physicians in Arizona. As proven in Desk 1, 75% of respondents reported utilizing HIE to change affected person care summaries and 82% reported utilizing HIE to change laboratory outcomes. Roughly half (49%) of physicians reported practising in a conventional care supply modality whereas 27% practiced in an ACO and 24% practiced in an built-in care mannequin (CIN or IDN).
There was a major affiliation between doctor follow mannequin and use of HIE to change affected person care summaries. In contrast with physicians in conventional care supply fashions, physicians in rising follow settings (ACOs, CINs, or IDNs) had considerably greater odds of utilizing HIE to share affected person care summaries (Desk 2, mannequin 1). Estimates from the complete mannequin (Desk 2, mannequin 3) present that physicians in ACOs had 1.948 instances higher odds of utilizing HIE to share affected person care summaries in contrast with physicians in conventional care supply fashions (P < .001). Physicians in built-in care fashions had 2.172 instances higher odds of utilizing HIE to share affected person care summaries in contrast with physicians in conventional care supply fashions (P < .001). These patterns are constant when individually estimating the associations with HIE use amongst ACO practices which might be and are usually not additionally in a CIN or IDN (eAppendix).
Equally, there was a major affiliation between doctor follow mannequin and using HIE to change laboratory outcomes (Desk 3). Physicians in ACOs had 2.079 instances greater odds of utilizing HIE to share laboratory outcomes in contrast with physicians in conventional care supply fashions (P = .039). Physicians in built-in care fashions had 1.981 instances greater odds of utilizing HIE to share laboratory outcomes in contrast with physicians in conventional care supply fashions, however this was not important (P = .055).
The affiliation between follow mannequin and HIE use different considerably throughout the 4 follow sorts assessed (Desk 4). There was a powerful and optimistic affiliation between ACO standing and using HIE to change affected person care summaries for solo personal practitioners (odds ratio [OR], 2.311; P = .035), group personal practitioners (OR, 1.996; P = .008), and hospital-based practitioners (OR, 1.594; P = .046), however there was no important affiliation between these variables for practitioners at group clinics (P = .057). In built-in care fashions, there was no important relationship between built-in care mannequin and HIE use amongst solo personal practitioners (P = .371) or group clinics (P = .340). There was a major optimistic affiliation between built-in care mannequin and HIE use in group personal follow (OR, 4.760; P = .001) and hospital-based practices (OR, 2.082; P = .002).
Regardless of having greater odds of utilizing HIE, Desk 5 exhibits that ACO physicians had been considerably extra prone to report an absence of connectivity with different suppliers and a lack of awareness from different suppliers as obstacles to utilizing HIE than had been physicians in conventional care supply fashions (OR, 1.426; P < .05; and OR, 1.649; P < .001, respectively). Variations in self-reported obstacles to utilizing HIE additionally emerged throughout different follow or doctor traits included within the regression fashions. For instance, physicians in group or personal follow had been considerably extra prone to report issues over confidentiality (OR, 1.883; P < .01) than had been physicians in group clinics. Moreover, physicians in Maricopa County (which accommodates Phoenix and is essentially an city county) had been much less prone to report an absence of connectivity as a barrier to HIE (OR, 0.649; P < .01).
DISCUSSION
Our research leveraged a wealthy physician-level knowledge supply to evaluate the affiliation between rising doctor follow fashions and using HIE. We had been in a position to account for practice- and physician-level elements utilizing a big, statewide census of physicians in a comparatively giant and various state. To our data, this research presents one of many largest samples of physician-reported knowledge on the associations between rising follow mannequin participation and HIE use. We discovered that suppliers in ACOs and built-in fashions equivalent to CINs and IDNs had been extra prone to report utilizing HIE to change affected person care summaries and laboratory outcomes than had been their friends in conventional care supply fashions.
A optimistic relationship between ACO or built-in care fashions and using HIE is in line with our research’s speculation and with some,19,22,23 though not all,26,27 prior literature. There could also be synergistic advantages to ACO or built-in care modalities and HIE use.28 Odds of HIE use for affected person summaries or laboratory outcomes elevated by roughly 50% to 100% for suppliers in ACOs or built-in care fashions (Tables 2 and three), a substantively giant relationship. But the connection was not absolute, that means that though many ACO and built-in care mannequin suppliers used HIE, some didn’t. Purposive exploration of the workflow and technological capacities in these settings might profit from additional research.
Moreover, we noticed essential nuances in relationships between rising follow fashions and HIE use in keeping with supplier follow sort. Particularly, the optimistic relationships between rising follow mannequin participation and use of HIE was primarily pushed by suppliers in group and hospital-based practices. Neighborhood clinics didn’t see important associations between an rising follow mannequin and HIE use, whereas solo practitioners noticed heterogeneous associations between particular follow sorts (ACO vs built-in care mannequin) and HIE use. It has been beforehand proven that suppliers in small practices and in underserved settings face substantial obstacles to HIE adoption.7 Nonetheless, earlier proof on this subject didn’t differentiate the normal fee-for-service care mannequin from these rising doctor follow fashions. Current proof means that technical and different obstacles to small-practice participation in knowledge change persist.29 Our research gives new proof that HIE obstacles particular to small practices and group clinics might manifest even in rising follow fashions equivalent to ACOs and built-in care fashions.
Among the many physicians who weren’t utilizing HIE to change info, obstacles tended to differ by a supplier’s follow sort. Suppliers in ACOs had been extra prone to report numerous obstacles, together with an absence of connectivity and knowledge from different suppliers. These findings assist to elucidate why one prior research discovered that rising follow mannequin participation was related to a decrease general probability of HIE participation.26 Our outcomes present that rising follow participation is related to a better use of HIE amongst physicians in Arizona, however a number of the physicians who adopted an rising follow mannequin are confronting obstacles to utilizing Arizona’s HIE. This implies that some physicians and/or well being practices might profit from help with establishing connections to different suppliers when adopting an rising follow mannequin. Enhancements to HIE connectivity might also must be focused.
Limitations
Our research’s findings needs to be seen in gentle of a number of limitations. First, our knowledge are cross-sectional, and we don’t have knowledge on the timing of HIE adoption or doctor follow; endogeneity could also be current and findings needs to be seen as associative solely. Second, our measure of HIE use is self-reported and doesn’t measure depth of use; additional research of frequency of use or validation of precise utilization patterns might shed further gentle on the relationships noticed, together with the seemingly counterintuitive discovering that ACO members reported each comparatively excessive ranges of change and comparatively excessive prevalence of obstacles to change. Third, our knowledge come from a statewide survey of all licensed physicians and are topic to potential response bias; nevertheless, we utilized pattern weights based mostly on the inhabitants of physicians’ gender, age, diploma (MD/DO), and Medicaid acceptance. The survey is deployed as a part of the biannual license renewal course of and encompasses numerous subject areas, and we aren’t conscious of any particular the explanation why sure follow fashions or HIE members can be kind of prone to reply. Fourth, as a result of our survey didn’t determine the doctor’s particular person follow, ACO, or CIN/IDN itself, we aren’t in a position to incorporate statistical adjustment for potential clustering of SEs on the follow or group ranges. This may occasionally doubtlessly end in SEs which might be narrower than they might in any other case be and, if that had been the case, may result in potential for sort 1 error. Fifth, our findings are associative, and causality can’t essentially be inferred; there are a selection of things—considered one of which is monetary—that will promote or inhibit use of HIE in sure follow fashions.19
CONCLUSIONS
Our research leveraged a big and complete pattern of physicians to evaluate the affiliation between rising doctor follow fashions and using HIE. We discovered a powerful optimistic relationship indicating that suppliers in rising follow fashions are extra doubtless to make use of HIE for affected person care summaries and laboratory outcomes. Vital nuances exist on this relationship, nevertheless. Not all rising follow mannequin physicians are utilizing HIE, and the affiliation is comparatively weaker—or nonexistent—in settings which have beforehand been discovered to face distinctive HIE obstacles. The sorts of obstacles to HIE use cited by physicians different by follow mannequin and kind, doubtlessly offering steerage for future initiatives geared toward rising use of HIE throughout completely different doctor practices. Attaining the complete theoretical advantages of rising follow fashions might necessitate widespread use of HIE. Likewise, using HIE might allow profitable pursuit of well being care supply modalities equivalent to ACOs and built-in care fashions. Our research’s physician-level proof gives info on the complicated relationships occurring at this essential follow mannequin–HIE nexus.
Acknowledgments
The authors gratefully acknowledge contributions from the Arizona State College Heart for Well being Info & Analysis, particularly Tameka Sama and Sruthi Kommareddy. The authors additionally acknowledge the Arizona Well being Care Price Containment System for its help of this research and ongoing doctor workforce survey knowledge assortment/evaluation. The authors acknowledge the Arizona Medical Board and the Arizona Board of Osteopathic Examiners in Medication and Surgical procedure for his or her help of ongoing doctor workforce survey knowledge assortment in Arizona. Lastly, the authors gratefully acknowledge the people who participated and responded to the survey.
Writer Affiliations: College of Public and Inhabitants Well being, Boise State College (JMM), Boise, ID; Faculty of Well being Options, Arizona State College (CS), Phoenix, AZ.
Supply of Funding: Funding for this research was acquired from Arizona Well being Care Price Containment System (AHCCCS) (contract #YH14-0039). Findings don’t essentially replicate this company’s views. The company was not concerned in knowledge evaluation, interpretation of findings, or determination to publish.
Writer Disclosures: Drs McCullough and Stecher acquired grant funding from AHCCCS.
Authorship Info: Idea and design (JMM, CS); acquisition of knowledge (JMM); evaluation and interpretation of knowledge (JMM, CS); drafting of the manuscript (JMM, CS); important revision of the manuscript for essential mental content material (JMM, CS); statistical evaluation (JMM, CS); provision of sufferers or research supplies (JMM, CS); acquiring funding (JMM); administrative, technical, or logistic help (JMM, CS); and supervision (JMM).
Tackle Correspondence to: J. Mac McCullough, PhD, MPH, College of Public and Inhabitants Well being, Boise State College, 1910 College Dr, Boise, ID 83725. E-mail: [email protected].
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