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Most Medicare Outpatient Visits are to Physicians with Limited Clinical Information Technology

Data Bulletin No. 30
July 2005
Joy M. Grossman, Marie C. Reed

doption of clinical information technology (IT) in physicians’ practices has the potential to improve quality and reduce the cost of care for people with complex health problems, including many Medicare patients. Monitoring adoption trends and assessing gaps in Medicare patients’ access to physicians with clinical IT are important as policy makers try to speed IT adoption. A majority of Medicare fee-for-service outpatient visits in 2001 were to physicians without significant IT support for patient care, according to a new baseline analysis of Medicare claims data linked to the Community Tracking Study (CTS) Physician Survey. At the same time, more vulnerable beneficiaries, including those who were sicker, living in low-income or rural areas, or who were black, did not have significant differences in access to physicians with clinical IT.

More than half of Medicare outpatient visits (57%) were to physicians in practices that used IT for no more than one of the following five clinical functions: obtaining treatment guidelines, exchanging clinical data with other physicians, accessing patient notes, generating preventive treatment reminders for the physician’s use, and writing prescriptions. Access rates across individual clinical functions varied considerably. While half of Medicare outpatient visits were to practices using IT to obtain treatment guidelines, the proportion of visits to practices with IT support for other patient care functions was much lower, falling to 9 percent of visits to practices with electronic prescribing (see Table 1). Medicare beneficiaries’ limited access to physicians with clinical IT mirrors the general population, since it reflects physicians’ slow rate of IT adoption.1


Table 1
Medicare Outpatient Visits to Physicians in Practices with Information Technology (IT) Support for Specific Patient Care Functions in 2001, by Patient Health Status1

 
Access Treatment Guidelines
Exchange Clinical Data with Other Physicians
Access Patient Notes
Generate Preventive Care Reminders
Electronic Prescribing
All
49%
33%
30%
23%
9%
  Healthiest Third2
52
34
30
22
9
  Middle Third
78*
33
30
23
9
  Sickest Third
48*
32*
29
24*
9
1 Patient health status as measured by the Klabunde index of relative comorbidity. For details see endnote 2.

2 Reference group.

* Comparison with reference group is statistically significant at p <.05.

Source: Linked data from the Centers for Medicare and Medicaid Services 2001 5 Percent Carrier File and 2001 CTS Physician Survey


No Disadvantage for More Vulnerable Beneficiaries

he sickest Medicare patients are likely to benefit the most from seeing physicians using clinical IT because of the complexity of their cases and the need for care coordination. While access to physicians using IT was low for all beneficiaries, there were few differences in access between sicker and healthier beneficiaries. For example, across the five clinical functions, there were only small differences in the percentage of outpatient visits to physicians using IT between the sickest third of Medicare patients—as measured by a comorbidity index2—and the healthiest third. Similar results were found for outpatient visits by the frail elderly—those 85 and older—and by beneficiaries eligible for Medicare because of disability. However, there were substantial differences for patients with end-stage renal disease that vary by clinical IT function (see Supplementary Table 1).

Some policy makers are concerned that patients in rural areas or underserved low-income urban areas are less likely to have access to physicians with clinical IT because these providers may be slower to adopt IT. However, outpatient visits by Medicare patients living in rural or lowincome areas were as likely as or, in a few instances, more likely than those in urban or more affluent areas to be with physicians in practices using IT (see Table 2). And, visits by black patients were as likely to be to physicians in practices with IT as visits by white patients.


Table 2
Medicare Outpatient Visits to Physicians in Practices with Information Technology (IT) Support for Specific Patient Care Functions in 2001, by Patient Demographics

 
Access Treatment Guidelines
Exchange Clinical Data with Other Physicians
Access Patient Notes
Generate Preventive Care Reminders
Electronic Prescribing
Location of Patient Residence1
  Urban2
48%
34%
28%
22%
9%
  Rural
52
32
35*
26*
10
Neighborhood Income in 20001
  Wealthiest Quartile2
47
33
26
23
9
  3rd Quartile
48
33
30*
23
9
  2nd Quartile
52
36
32*
24
9
  Poorest Quartile
50
31
30*
23
9
Race
  White2
49
33
29
23
9
  Black
48
33
32
21
9
  Other
48
34
31
27
10
1 Patient zip code of residence was used to determine urban/rural location and neighborhood income. Urban refers to metropolitan areas defined by the Office of Management and Budget. Income data are from the U.S. Bureau of the Census.

2 Reference group.

* Comparison with reference group is statistically significant at p <.05.

Source: Linked data from the Centers for Medicare and Medicaid Services 2001 5 Percent Carrier File and 2001 CTS Physician Survey



Policy Implications

hile patient characteristics are only loosely associated with the likelihood that Medicare outpatient visits will be to physicians in practices using clinical IT, multivariate analysis suggests that physician characteristics are far more important. In particular, practice setting—especially practice size—and, to a lesser extent, physician specialty played far more important roles in predicting whether outpatient visits were to physicians with clinical IT (see Supplementary Table 2). More than three-fourths of Medicare outpatient visits were to physicians in practices with fewer than 50 physicians, the practices that are least likely to adopt clinical IT. Currently, Medicare is targeting some efforts to speed IT adoption at smaller practices, including technical assistance and a chronic-care payfor- performance demonstration. Broader policy efforts—including financial incentives—may be needed, however, to substantially improve patient access. Policy makers also will need to monitor trends to assure that patients who can benefit most from clinical IT have access to physicians using these tools.




Notes

1. Reed, Marie C., and Joy M. Grossman, Limited Information Technology for Patient Care in Physician Offices, Issue Brief No. 89, Center for Studying Health System Change, Washington, D.C. (September 2004).
2. Comorbidity is a measure of the relative number and severity of health conditions, such as diabetes and hypertension, that may cause or aggravate other conditions. The Klabunde relative comorbidity index was calculated from all claims in the 2001 5 Percent Carrier File. See Klabunde, Carrie N., et al., “Development of a Comorbidity Index Using Physician Claims Data,” Journal of Clinical Epidemiology, Vol. 53, No. 12, (December 2000).



Supplemental Tables

Supplemental Table 1 - Medicare Outpatient Visits to Physicians in Practices with IT Support for Specific Patient Care Functions in 2001, by Patient Age and Medicare Eligibility

Supplemental Table 2 - Adjusted Odds Ratios for Likelihood of Medicare Outpatient Visits to Physicians in Practices with IT to Support Specific Patient Care Functions in 2001

 

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