PHYSICIANS’ VIEWS ON QUALITY OF CARE: FINDINGS FROM THE COMMONWEALTH FUND NATIONAL SURVEY OF PHYSICIANS AND QUALITY OF CARE Anne-Marie J. Audet, Michelle M. Doty, Jamil Shamasdin, and Stephen C. Schoenbaum May 2005 Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff. Additional copies of this and other Commonwealth Fund publications are available online at www.cmwf.org. To learn more about new Fund publications when they appear, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 823. CONTENTS About the Authors.......................................................................................................... iv Acknowledgments ........................................................................................................... v Executive Summary........................................................................................................ vi I. Information Technologies: Current Use, Future Plans, and Perceived Barriers............ 1 II. Practice-Level and Performance Data: Availability, Sources, and Willingness to Share .................................................................................... 11 III. Physicians’ Involvement in Quality Improvement Activities ..................................... 19 IV. Coordination of Care and Referrals ......................................................................... 23 V. Strategies to Improve Quality of Care ...................................................................... 32 VI. Incentives and Disincentives to Providing Quality Care and Physicians’ Satisfaction with Current Practice ..................................................... 36 Appendix A. Physician and Practice Characteristics ........................................................ 40 Appendix B. Survey Methodology................................................................................. 42 Appendix C. Tables ....................................................................................................... 43 Notes............................................................................................................................. 95 iii ABOUT THE AUTHORS Anne-Marie J. Audet, M.D., assistant vice president for quality improvement, joined The Commonwealth Fund in November 2000 and is responsible for the Fund’s program to improve the quality of health care services. Dr. Audet has worked in the field of quality improvement for over a decade and brings to the Fund a deep understanding of the science of quality improvement, as well as an appreciation of the barriers and enablers that come into play when having to translate knowledge into real-world situations. At the national level, Dr. Audet worked in policy analysis at the American College of Physicians. At the state level, she led the implementation of the Medicare Health Care Quality Improvement Program in Massachusetts while working at the Massachusetts Peer Review Organization. More recently, she worked at the level of a health care institution and an integrated network of care with CareGroup. Prior to joining the Fund, Dr. Audet served as director of the Office for Clinical Effectiveness/Process Improvement at Beth Israel Deaconess Medical Center in Boston, where she was responsible for development of quality measurement systems, educational programs, and institution-wide medication safety initiatives. She was coeditor of Clinical Crossroads, a series published monthly in JAMA. Dr. Audet holds a B.Sc. in cell and molecular biology and an MDCM and M.Sc. from McGill University and an S.M. in health policy and management from Harvard University. She was assistant professor in Medicine at Harvard University. Michelle M. Doty, Ph.D., is a senior analyst for health policy, research, and evaluation at The Commonwealth Fund, where she conducts research on health care access and quality among vulnerable populations and on the extent to which the lack of health insurance contributes to barriers to care and inequities in quality of care. Prior to joining the Fund, Dr. Doty worked at the University of California at Los Angeles School of Public Health as senior data manager and programmer on a National Institutes of Health– funded multisite research project that examined the contexts of Hispanic adolescent sexual behavior. She also worked for the Pacific Institute for Women’s Health in Los Angeles as research manager of a Center for Disease Control–funded research and demonstration project focusing on community reproductive health services for low-income Hispanic adults. Dr. Doty holds a B.A. in anthropology from Barnard College and an M.P.H. and Ph.D. in public health from the University of California, Los Angeles. Jamil Shamasdin, program associate, joined The Commonwealth Fund in August 2002 and works in the Fund’s program to improve the quality of health care services. Mr. Shamasdin holds a B.A. from Harvard University, with a concentration in health care policy. iv Stephen C. Schoenbaum, M.D., is senior vice president with responsibility for coordinating the development and management of The Commonwealth Fund’s quality improvement programs. He is also a member of the Fund’s executive management team. Prior to joining the Fund in February 2000, he was president of Harvard Pilgrim Health Care of New England and senior vice president of Harvard Pilgrim Health Care, where he was responsible for delivery system operations in a mixed staff and network model HMO with approximately 150,000 members. Prior to joining Harvard Community Health Plan in 1981, Dr. Schoenbaum was a member of the Department of Medicine at Brigham and Women’s Hospital and did epidemiologic research in obstetrics and infectious diseases. From 1967 to 1969, he was an Epidemic Intelligence Service (EIS) officer at the Centers for Disease Control. He is an associate professor in the Department of Ambulatory Care and Prevention, Harvard Medical School, the author of more than 100 scientific articles and papers, and the editor of a book on measuring clinical care. Dr. Schoenbaum received an A.B. from Swarthmore College with honors, an M.D. from Harvard Medical School (cum laude), and an M.P.H. from Harvard School of Public Health. He also completed the Program for Management Development at Harvard Business School. ACKNOWLEDGMENTS The Harris team responsible for the design and analysis of the questionnaire included Kinga Zapert and Jordon Peugh. In addition to the authors, The Commonwealth Fund team included Cathy Schoen and Sara Collins. v EXECUTIVE SUMMARY Although the concept of quality improvement is not new,1 very little is known about physicians’ views on and experiences with quality improvement tools and principles. In 2003, The Commonwealth Fund conducted a National Survey of Physicians and Quality of Care to explore physicians’ use of quality improvement tools, including information technology (IT) tools; future plans to initiate quality improvement activities; and views of potential solutions, as well as barriers. Because information is at the core of quality improvement, the survey explored physicians’ access to data on their practices and performance, as well as their willingness to share such data. In its 2001 landmark report, Crossing the Quality Chasm, the Institute of Medicine (IOM) stressed the importance of care coordination to providing high-quality care. To examine the issue from a physician-level perspective, The Commonwealth Fund survey asked physicians about the problems that patients encounter as a result of poor coordination, as well as the problems that physicians themselves experience, like the timeliness or availability of referral information. While research has demonstrated that hospitals and health systems may take financial risks by making quality improvement a priority,2 little is known about similar risks physicians might face. To address this gap, the survey asked physicians about the role quality plays in determining compensation and about other financial factors they may have experienced in striving to improve quality. Finally, the survey explored physicians’ opinions about various solutions and approaches to improving quality. Information Technology: Current Use, Future Plans, and Perceived Barriers Results from the survey indicate physicians’ use of information technology (IT) is growing, albeit slowly. Electronic billing is the IT tools used most routinely, despite the reported benefit of other IT applications. For example, providers who use electronic medical records (EMRs) reported more efficient clinical operations, due to better accessibility and organization of information. EMR use may also increase billing revenue as a result of more accurate tracking of service provided, more accurate coding,3 and more timely collection of payments. By reducing the need for transcription, data entry, reception, and medical record management, EMRs may also reduce physicians’ office operating costs.4,5 Despite these benefits, only 27 percent of surveyed physicians reported using EMRs either routinely or occasionally, with an additional 20 percent saying they plan to use them in the next two years. Another innovation—electronic access of diagnostic test information—allows results to be viewed earlier, facilitates more timely vi intervention, decreases the ordering of unnecessary tests by 10 to 15 percent,6 and decreases the amount of time spent charting. Although 58 percent of surveyed physicians say they routinely or occasionally access test results electronically, only 37 percent say they do so routinely. Similarly, more than one-half of the physicians surveyed generate patient reminders, but only 21 percent have automated the process. Clinical decision support systems (CDSS) have also been shown to improve clinical practice and patient outcomes. Such a benefit was demonstrated in 43 percent of the studies reviewed by Dereck Hunt and colleagues.7 Yet less than one-quarter of surveyed physicians say they use CDSS routinely or occasionally. The most significant barrier to IT use is cost, with financial burdens greatest for solo and small-group practices—the settings where most U.S. physicians practice.8 The initial costs of acquiring EMR capability have been estimated at $15,000 to $50,000 per physician, excluding the cost of decreased productivity that can occur in early stages of implementation. Studies have found that IT can have financial benefits. However, these benefits vary by practice, from no reported gains to gains of more than $20,000 per year.9 Practice-Level and Performance Data: Availability, Sources, and Willingness to Share According to the survey’s findings, physicians are not using data about their practices in a comprehensive way. More than one-half of physicians find it difficult or impossible to get basic profile data on their patients. An even greater percentage (85%) are unable to identify or have difficulty identifying patients who may require closer attention because of abnormal laboratory results or medications that need to be monitored or changed. Physicians who can easily access such information are more likely to practice in larger groups and work full-time in clinical care. Collecting and analyzing data requires knowledge, special technical tools, staff, and time. Large physician groups, due to their financial flexibility and organizational culture, are more likely to engage in these kinds of activities. Physicians also do not routinely use data to monitor the quality of their clinical practice. Thirty-three percent of surveyed physicians say they have access to performance data, most relying on external sources of information. One-quarter of surveyed physicians identified insurers and health plans as the most common source of quality-of-care data. Only 14 percent said they generated performance measures themselves. Salaried physicians and those who work in larger groups are more likely to generate performance data internally. vii Although nearly three-quarters (71%) of physicians agreed that performance data should be shared with their medical leadership, only slightly more than one-half (55%) agreed this information should be shared with patients. Twenty-nine percent agreed that this information definitely or probably should be shared with the public. However, despite physicians’ discomfort, there is evidence that sharing medical records with patients may improve adherence to medical advice.10 Peer comparison and mentoring can lead to improvements in care,11 and information sharing could help physicians refer patients to the most appropriate specialists. Physicians’ Involvement in Quality Improvement Activities Only one-third of all surveyed physicians report participating in activities designed to change and improve their practices, with the type of practice setting affecting the degree of involvement. Those more likely to be engaged in improvement activities include physicians who work in larger groups, physicians who work in hospital-based or staff models, and salaried physicians. Similarly, a greater percentage of physicians who work full-time (more than 40 hours) are active in redesign, compared with those working part- time (20 hours or fewer) (37% vs. 22%) and a greater percentage of primary care physicians (PCPs) are involved, compared with specialists (42% vs. 31%). Collaborative activities that involve public agencies or community groups working together to improve outcomes for patients with specific conditions present another strategy to create system-wide change. However, two-thirds of the surveyed physicians report never having participated in collaboratives. Providers who have used quality improvement collaboratives are more likely to be primary care, salaried physicians in larger group practices. Coordination of Care and Referrals The most commonly reported quality problems for physicians are issues of care coordination. These issues include disruptions in the process of transferring important patient information and patients receiving conflicting information. Most physicians (72%) reported that patients’ medical records, test results, or other relevant information were sometimes or often not available at the time of a scheduled visit. One-third often or sometimes observed that tests or procedures had to be repeated because findings were not available or were inadequate for interpretation, and 28 percent reported that care was compromised due to conflicting information from different health professionals. One- quarter (26%) observed that patients experienced problems following hospital discharge due to information not being released in a timely manner. In some cases (15%), physicians viii reported that patients often or sometimes did not receive appropriate follow-up, despite test results that indicate the need for such treatment. The frequency of coordination problems differs somewhat by practice setting and size, with physicians who practice in groups of more than 50 more likely than solo practitioners to report such problems. In addition, PCPs mainly observe issues around follow-up and hand-off (e.g., hospital discharge process), while specialists more often experience test results that are unavailable and need to be repeated. One-third of physicians said they had problems receiving information and feedback regarding referral in a timely manner. These problems are more frequently experienced by specialists and physicians in larger group practices. In addition, most physicians (64%) say they rarely or never have objective information about the quality of care provided by physicians to whom they refer patients. Quality-of-care data appears to have little impact on referral decisions, with most physicians using other information, such as patients’ experiences with physicians or professional reputation among peers. Quality Improvement Strategies The survey explored physicians’ opinions on the effectiveness of seven potential strategies to improve quality of care. These include: appropriate time spent with patients; patient access to preventive care and health education; treatment guidelines or protocols; information technologies; information about specialists and specialty centers for referrals; team work and communication. Most physicians (52%) cited time spent with patients as an effective strategy in improving quality of care. They also cited access to preventive care (41%) and teamwork and increased communication among health care professionals (35%). Other approaches such as guidelines, electronic medical records and e-prescribing, and performance data, received only limited support from physicians. While most physicians believe that team care results in better decisions, some remain skeptical. One-third (32%) agree or strongly agree that teamwork makes care more cumbersome, while one-quarter (24%) agree or strongly agree that a team approach can increase the likelihood of medical errors. Physicians in solo practice are less supportive of team care than those in larger groups or in hospital settings. Specialty and gender are also significant factors. Forty-one percent of primary care physicians said that teamwork would be very effective in improving care, compared with 33 percent of specialists. Thirty-two of male physicians said that teamwork would be very effective, compared with 45 percent of female physicians. ix Incentives and Disincentives for Providing Quality Care For most of the surveyed physicians, productivity remains the major factor determining compensation. Thirty-nine percent of physicians reported that board recertification status is a factor in compensation, while less than one-third (27%) cited clinical quality as a factor. Under current payment policies, physicians are rarely compensated for providing certain patient-centered services, like e-mail or phone consultations. None of the surveyed physicians were reimbursed for e-mail consultations and very few received reimbursements for phone consultations (4%) or group patient visits (5%). There is no system in place to financially reward physicians for providing high-quality care. In fact, there appear to be financial disincentives. Altogether, one-half of physicians said that providing the best quality of care often (23%) or sometimes (28%) translates into lower revenues. Physicians in solo practice are more likely than physicians in larger group practices to hold this opinion (58% vs. 46%, respectively). Implications for Policy and Practice The survey confirms that physicians have not yet fully embraced quality improvement, with a striking gap between physicians in solo practice and those in larger group settings. Although the majority of U.S. physicians work in solo practice or small group (2–9 physicians) practice settings,12 quality improvement methods have been least adopted in such environments. Quality improvement appears to be institutionalized within organizations that have the infrastructure to support it, but not fully disseminated throughout the profession. Accelerating adoption of quality improvement principles and tools by physicians will require policies that address the following three areas: 1) capacity and infrastructure; 2) education to build knowledge and skills, and 3) professionalism. It is unlikely that a robust IT infrastructure will be established, and even more unlikely that tools will be adopted by physicians, without federal leadership.13 Some recent progress has been made on this front. For instance, in May 2004, the Department of Health and Human Services (HHS) appointed a new national health information technology coordinator, David Brailer, M.D. In addition, the Bush Administration set forth a goal for most Americans to have electronic health records by 2014. In Congress, several bills were proposed that address IT, from Senators Judd Gregg (R-N.H.), Hillary Rodham Clinton (D-N.Y.), John Kerry (D-Mass.), and Representative Nancy Johnson (R-Conn.), and most recently, on May 11th 2005, Rep Tim Murphy (R-Pa.) and Rep Patrick Kennedy (D-R.I.) introduced the 21st Century Health Information Act as a bipartisan legislation to address the systemic obstacles and misaligned incentives that have hindered health information technology adoption. In 2005, the President’s budget for IT initiatives x includes $50 million to AHRQ.14 In addition, the 2006 budget includes $75 million to the Office of the National Coordinator for Health Information Technology to foster collaboration and develop an interoperable health information technology network.15 Although this represents a great step forward, more funding and attention will be required in the future. In the United Kingdom for instance, the government invested $10 to $16 billion toward the National Health Information Infrastructure. Future policy options should include federal grants, annexes to the Medicare diagnosis-related group physician reimbursement, and revolving loans (which have been particularly successful in transportation and environmental protection).16,17 In the United Kingdom and Sweden, for example, physicians who invest in EMRs receive government subsidies. Fifty-eight percent of physicians in the United Kingdom and 90 percent of physicians in Sweden report using them.18 To support the spread of IT, it will be necessary to create and support standardization. The Health Informatics Initiative of May 2004 led to the adoption of 15 standards by HHS and 20 federal agencies. The implementation of local or regional standards using “community-based interconnectivity” models are under way on the state-wide and city- wide levels, as well as in local, hospital-based and integrated health care delivery settings (e.g. Massachusetts, Rhode Island, Santa Barbara, Regenstrief Institute in Indianapolis). These systems allow connections to be made and information shared among various providers, including physicians, emergency room staff, and pharmacists. By spreading the cost of the IT infrastructure over a greater number of people, such models may significantly decrease the cost of investment and make it feasible for individual or small groups of physicians to acquire these technologies.19,20 Other IT business models will likely require private and public sector partnering to invest in the necessary infrastructure to support and sustain quality. Quality measurement has not yet been fully embraced by the medical profession, despite its important role in improvement activities. The task of monitoring one’s practice and using that information to make improvements should not only be a required skill, but a professional responsibility. In 1999, the American Council of Graduate Medical Education approved a new set of residency program training requirements, under which residents must reach competency in six areas, including practice-based learning and improvement and systems-based practice.21 The recognition of these competencies is an essential first step in training the next generation of physicians to evaluate and improve their own care. The 2001 IOM report, Crossing the Quality Chasm, recognized that necessity of aligning payment policies with quality improvement.22 The IOM called for public and private xi purchasers to reexamine their payment policies to remove barriers that impede quality improvement and build stronger incentives for quality enhancement. Currently, quality of care determines compensation for less than 10 percent of physicians. Instead, productivity is the main determinant for most physicians. To understand and determine how financial incentives can best foster quality, pay-for-performance programs are currently being tested and evaluated—at Pacificare and the Integrated Healthcare Association in California, among other locations.23 Physicians are still cautious about making the quality of their care transparent, but if quality is to be rewarded, data must be measured and shared. Ultimately, the medical profession must take the lead to make care more transparent, with physicians balancing issues of ethics, fairness, accountability, and confidentiality. The public is becoming increasingly worried that doctors are secretive and wary of making full disclosure. Physicians should work to enhance trust between the public and the profession by allowing greater openness about the quality of the care they provide. xii I. INFORMATION TECHNOLOGY: CURRENT USE, FUTURE PLANS, AND PERCEIVED BARRIERS The diffusion of information technology (IT) in health care has been modest, at best, despite its ability to improve health care’s efficiency and quality.24 Electronic medical records (EMRs), for instance, have become sophisticated and powerful tools, but few health care organizations use them.25 The situation is similar for related technologies, like clinical decision support systems (CDSS) and computerized prescribing and order entry systems. This survey explored physicians’ current use of quality improvement tools, future plans to initiate quality improvement activities, and barriers they perceive in adopting IT tools.26 Use of Information Technologies in Clinical Practice The most common use of IT is for administrative purposes. • Over three-quarters of respondents use IT for electronic billing either routinely or occasionally. (Chart I-1) IT is less commonly used to improve practice efficiency and quality or to communicate with other physicians or patients. IT tools are used by a greater percentage of physicians in large-group practices and by a greater percentage of salaried physicians. Electronic access to test results • Fifty-eight percent of all respondents reported using electronic access to patients’ test results either routinely (37%) or occasionally (21%). • Eighty-seven percent of large-group-practice physicians have access to test results electronically routinely or occasionally, compared with 36 percent of solo-practice physicians. (Chart I-2) Use of EMR and electronic ordering • About one-quarter (27%) of physicians use EMRs routinely or occasionally. Less than one in five use them routinely. (Chart I-1) • One-quarter (27%) of physicians order tests, procedures, or drugs electronically either routinely or occasionally, but only 17% do so routinely. • Fifty-seven percent of physicians who practice in groups of more than 50 use EMRs routinely or occasionally, compared with 13 percent of solo physicians. (Chart I-2) 1 • Thirty-six percent of salaried physicians use EMRs routinely or occasionally compared with 21 percent of non-salaried physicians. (Table I-2) Clinical decision support systems • One-quarter of physicians use electronic CDSS routinely or occasionally (24%), but most of this group only use it occasionally (18%). (Chart I-1) • Forty percent of physicians who practice in groups of more than 50 use CDSS routinely or occasionally, but only19 percent of solo practice physicians do so. (Chart I-3) E-mail communication • Twenty-eight percent of physicians use e-mail either routinely or occasionally to communicate with other doctors; but only 7 percent do so routinely. (Chart I-1) • Eighteen percent of physicians communicate with patients either routinely or occasionally via e-mail; but only 3 percent communicate this way routinely. • Only 17 percent of solo physicians communicate routinely or occasionally with other doctors via e-mail compared with 61 percent of those who practice in groups of more than 50. (Chart I-3) • Twice the number of salaried than non-salaried physicians use e-mail to communicate with other physicians (39% vs. 20%). (Table I-2) • E-mail communication between doctors and patients is more likely among physicians in large groups than among those in solo practice (33% vs. 16%). (Chart I-3) Electronic alerts and reminders • Although 38 percent of physicians receive alerts about drug prescribing problems, only 12 percent of this group said these alerts are electronically generated. (Chart I-4) • Forty-one percent of physicians receive alerts for abnormal test results requiring special follow-up, but only 10 percent said these alerts are electronically generated. • Fifty-four percent of respondents send reminders to their patients regarding routine preventive care. Only 21 percent have computerized this task. 2 • Among solo physicians, 6 percent receive electronic drug alerts, compared with 27 percent of physicians who practice in groups of more than 50. (Chart I-5) • One-third of physicians who practice in groups of more than 50 generate patient reminders electronically (31%), compared with 13 percent of solo practice physicians. For the most part, primary care physicians and specialists do not differ in their use of IT. Some differences exist in use of reminder systems and e-mail communication. • Specialists are more likely than primary care physicians to generate patient reminders electronically (24% vs. 14%). (Table I-2) • Specialists are more likely than primary care physicians to communicate with other doctors using e-mail (30% vs. 22%). Future Use of IT Physicians were surveyed regarding their future plans (within the next year) to adopt new IT tools. EMRs, electronic ordering and prescribing, CDSS, and electronic access to test results are expected to be the most widely adopted in the next year. In general, it is expected that IT will grow slowly and the rate of adoption will vary according to the type of technology. • Twenty percent of respondents who are not yet using EMRs plan to use them within the next year. (Chart I-6) Including current users, this would bring the total percentage of users to 47 percent. • Nineteen percent of respondents plan to adopt electronic ordering and prescribing. Including current users, this would bring the total percentage of users to 47 percent. • Seventeen percent of physicians plan to adopt CDSS in the next year, leaving a 58 percent share of physicians who will not use or adopt the tool within the next year. • Fourteen percent of physicians plan to adopt computer access to test results, bringing total users to 73 percent. The use of e-mail between physicians is likely to grow faster than such use between physicians and patients. • Twelve percent of physicians plan to start using e-mail to communicate with other physicians, but 57 percent of physicians are not currently using e-mail to 3 communicate with other physicians nor do they have plans to do so within the next year. • Eleven percent of physicians plan to start using e-mail to communicate with their patients. Seventy-one percent of respondents do not currently use e-mail to communicate with their patients and have no plans to do so within the next year. Use of alert systems and patient reminders (electronic or manual) is expected to grow more slowly. • Less than two of 10 physicians plan to implement systems to receive alerts about potential drug prescribing problems (16%) or abnormal test results that require follow-up (13%). (Chart I-7) • Ten percent of physicians are planning to adopt reminder systems. About one- third of physicians (34%) do not have such systems and have no plans to implement them. Practice size affects the expected speed and extent of adoption. • Nearly twice as many physicians in large group practices as solo practitioners (22% vs. 13%) plan to adopt EMRs within the next year. (Chart I-8) • A similar percentage of salaried as non-salaried physicians who are not currently using EMRs plan to adopt them (21% vs.19%). Non-salaried physicians are more likely to say they have no plans to use EMRs within the next year, as compared with salaried physicians (60% vs. 43%). (Table I-2) Perceived Barriers to IT Adoption The top three reported barriers to IT adoption are: • cost of system start-up and maintenance (56%), • lack of local, regional, and national standards (44%), and • lack of time to consider acquiring, implementing, and using a new system (39%). (Chart I-9) Practice size is the main factor affecting the degree of importance of these barriers. The financial barriers are greatest for solo and small-group practices. 4 • Sixty-two percent of physicians in solo practice and 59 percent of those in small groups say start-up costs are a major barrier, compared with 43 percent of physicians in groups larger than 50. (Chart I-10) • Solo practitioners and small group practice physicians are more skeptical about the effectiveness of such technologies than are physicians in large groups. Forty percent of solo-practice physicians and 24 percent of physicians in small groups say that lack of scientific evidence is a concern, compared with 11 percent of physicians in large groups. (Table I-1) • Physicians in solo practice are more likely (30%) than physicians in larger practices (15% to 19%) to cite privacy concerns as a barrier to adoption. 5 Chart I-1. Use of Information Technologies Percent indicating “routine” or “occasional” use 100 Yes, used occasionally 79 Yes, used routinely 80 6 60 58 21 40 73 27 27 28 24 9 9 18 20 37 21 18 18 17 14 6 7 3 0 Electronic Access Electronic Electronic Clinical E-mail E-mail Billing to Test Medical Ordering * Decision with with Results Records Support Doctors Patients * Electronic ordering of tests, procedures, or drugs. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart I-2. Electronic Access to Patient Test Results, Electronic Medical Records, and Electronic Ordering, by Practice Size Percent who currently “routinely/occasionally” use the following 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 87 75 66 61 57 50 46 36 35 37 23 25 25 13 14 0 Electronic Access to Electronic Medical Electronic Ordering * Test Results Records * Electronic ordering of tests, procedures, or drugs. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 6 Chart I-3. Use of Clinical Decision Support, E-mail with Doctors, and E-mail with Patients, by Practice Size Percent who currently “routinely/occasionally” use the following 100 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 75 61 50 40 35 33 29 25 19 21 21 19 17 16 13 0 Clinical Decision Support E-mail with Doctors E-mail with Patients Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart I-4. Use of Reminders or Alerts Percent indicating following tasks currently performed in their office practice 100 Yes, using a manual system Yes, using a computerized system 54 50 38 41 33 26 31 12 10 21 0 Drug Alerts Follow-Up Alerts Reminders Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 7 Chart I-5. Use of Electronic Drug Alerts, Follow-Up Alerts, and Reminders, by Practice Size Percent who currently use a “computerized system” for the following 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 75 50 31 27 21 25 22 23 17 10 11 13 9 6 5 0 Drug Alerts Follow-Up Alerts Reminders Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart I-6. Planned Future Use of IT Percent expecting use Not used, NO plan to use within next year Not used, PLAN to use within next year 100 82 80 73 72 75 69 60 41 53 53 58 71 40 57 21 27 20 15 20 19 17 14 12 11 6 0 Electronic Access Electronic Electronic Clinical E-mail with E-mail with Billing to Test Medical Ordering * Decision Doctors Patients Results Records Support * Electronic ordering of tests, procedures, or drugs. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 8 Chart I-7. Planned Future Use of Reminders or Alerts Percent expecting future use of the following 100 Not done, NO plan to in next year Not done, PLAN to in next year 60 56 50 44 44 43 34 16 13 10 0 Drug Alerts Follow-Up Alerts Reminders Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart I-8. Planned Future Use of Electronic Medical Records, by Practice Size Percent expecting use Not used, NO plan to use within next year Not used, PLAN to use within next year 100 86 77 73 65 50 73 44 53 56 37 22 28 22 20 13 21 0 Total 1 Physician 2–9 10–49 50+ Physicians Physicians Physicians Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 9 Chart I-9. Barriers to Adoption Major Barrier Minor Barrier Not a Barrier Start-up costs 56% 28% 15% Lack of uniform standards 44% 40% 14% Lack of time 39% 44% 16% Maintenance costs 37% 46% 15% Lack of evidence of effectiveness 26% 38% 35% Privacy concerns 21% 49% 29% Lack training/knowledge 16% 47% 36% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart I-10. Barriers to Adoption of Information Technologies, by Practice Size Percent indicating start-up costs, scientific evidence, or privacy concerns as a “major barrier” to greater use of information technologies 100 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 75 62 59 49 50 43 40 30 24 25 19 15 17 11 17 0 Start-Up Costs Scientific Evidence Privacy Concerns Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 10 II. PRACTICE-LEVEL AND PERFORMANCE DATA: AVAILABILITY, SOURCES, AND WILLINGNESS TO SHARE Payers, regulatory agencies, and oversight organizations have shown interest in using quality improvement principles and physician performance measures to improve health care. But little is known about how physicians themselves use data to monitor and improve the care they deliver. The survey explored physicians’ access to data about their patient panel, performance data (e.g., percentage of women over age 50 who have had mammograms), outcomes (e.g., percentage of diabetics with HgA1c under control), and data from patient surveys. Physicians were also asked about their views on sharing performance data and medical records. Access to Patient Panel Data Most physicians are not making full use of data on their practices, and find it difficult or impossible to get basic profile data of their patient panel. • One-half or more find it difficult or impossible to generate lists of patients by diagnoses or age group. (Chart II-1) • Eighty-four percent find it difficult or impossible to generate lists of patients by laboratory results or drugs prescribed. Lack of access to such data makes it more difficult to follow patients who may require closer follow-up given abnormal lab results or high-risk drugs. Physicians who work full-time and those who work in large group practices are more likely to have access to data on their patient panel. • Fifty percent of solo physicians can easily generate lists of patients using any criteria (e.g., diagnoses, age, test results, medications), compared with 61 percent of physicians in large groups. (Chart II-2) • Twenty-seven percent of physicians in groups of 50 or more find it very or somewhat easy to generate lists of patients by laboratory results or by medications prescribed, compared with 12 percent of solo physicians. (Chart II-3) • Physicians who provide less than 20 hours of direct patient care per week are less likely to easily generate practice data, compared with physicians working 40 hours per week or more (51% vs. 61%). (Table II-3) • Physicians who use EMRs routinely or occasionally are more likely than those who do not to say that data about their practice can easily be generated (62% vs. 55%). (Chart II-4) 11 Access to Performance Data In general, physicians do not routinely use data to assess the quality of their clinical practices. • Thirty-three percent of all physicians say they have access to performance data. (Chart II-5) • Patient surveys represent the most commonly used type of performance data; one- quarter of physicians say they have access to such information. • One of five physicians has access to process-of-care data. • Only 18 percent of all physicians have data on patients’ outcomes. Access to information about quality varies significantly by practice size. • One quarter of physicians in groups of 50 or more (27%) say they receive process- of-care data, compared with 14 percent of solo physicians. A similar pattern exists for clinical outcome data. (Chart II-6) • Forty-four percent of physicians in groups of 50 or more say they receive patient survey data, compared with only 15 percent of solo physicians. For the most part, physicians rely on external sources of performance data. • One-quarter of physicians say their clinical performance data come from health plans. (Chart II-7) • Only 13 percent of survey respondents generate performance data themselves. Physicians who work in large groups, salaried physicians, and physicians who use EMRs are more likely to generate their own performance data. • Twenty-eight percent of physicians in practices of 50 or more generate their own performance data, while only 6 percent of solo physicians do so. (Chart II-8) • Nearly twice the percentage of salaried as non-salaried physicians generate their own data (19% vs. 10%). (Table II-2) • Twenty-one percent of physicians who use EMRs routinely or occasionally generate performance data internally, compared with 11 percent of physicians who do not use EMRs. (Chart II-8) 12 Ability to Benchmark • Physicians reported they are able to use quality-of-care data to compare themselves with physicians in the same specialty (24%) or with physicians in the same health plan (22%). (Chart II-9) • Nineteen percent said they can compare themselves to physicians who practice in their group or within a local community. • About one of 10 physicians can compare quality-of-care data to national benchmarks. Sharing Performance Information For the most part, physicians are unwilling to share data about the care they provide, even if patients are increasingly requesting that information. • One-third (33%) of all physicians said their patients are more likely to ask about quality of care than they were two years ago. Specialists are more likely to be asked than are primary care physicians (36% vs. 26%). (Table II-2) • Nearly three-quarters (71%) of physicians definitely or probably agreed that information about clinical performance should be shared with the medical leadership of their health systems or the facilities at which they have admitting privileges. (Chart II-10) • Slightly more than one-half of physicians (55%) agreed that performance data should be shared with their patients, but only 13 percent were in definite agreement. • Sixty-nine percent of physicians said the general public should probably or definitely not have access to such information. Sharing EMRs with patients Although the Institute of Medicine’s (IOM) Crossing the Quality Chasm report recommends that patients “should have unfettered access to their health record,” 27 most physicians do not agree with giving patients easy access to their medical records. • Less than one-half of physicians (41%) definitely agree that patients should have access to their own medical records. Most physicians are not convinced of the idea, with 45 percent reporting that they probably agree that patients should have access to the records, and an additional 14 percent saying they disagree that patients should have such access. (Table II-1) • A greater percentage of specialists than primary-care physicians definitely agreed that patients should have easy access to their records (43% vs. 35%). (Table II-2) 13 Chart II-1. Physicians’ Access to Patient Panel Data Percent indicating “very/somewhat” difficult or cannot generate lists of patients by 100 83 84 51 55 50 43 0 Age Group Diagnosis/ Lab Results Current Any Data Health Risk Medications Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart II-2. Physicians’ Access to Any Patient Panel Data, by Practice Size Percent indicating “very/somewhat” easy to generate lists of patients using any* criteria 100 58 61 61 57 50 50 0 Total 1 Physician 2–9 10–49 50+ Physicians Physicians Physicians * Indicates “very/somewhat” easy to generate lists of patients using any of the following criteria: age group, diagnosis/health risk, lab results, or current medications. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 14 Chart II-3. Physicians’ Access to Patient Panel Data, by Practice Size Percent indicating “very/somewhat” easy to generate lists of patients by 100 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 75 50 46 46 45 39 27 27 25 22 20 12 12 12 12 0 Diagnosis/Health Risk Lab Results Current Medications Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart II-4. Physicians’ Access to Any Patient Panel Data, by Electronic Medical Record Use Percent indicating “very/somewhat” easy to generate lists of patients using any* criteria 100 62 57 55 50 0 Total EMR Used Routinely/ Do Not Use EMR Occasionally * Indicates “very/somewhat” easy to generate lists of patients using any of the following criteria: age group, diagnosis/health risk, lab results, or current medications. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 15 Chart II-5. Physicians’ Access to Quality-of-Care or Performance Data Percent receiving data on the following aspects of patient care 100 50 33 25 20 18 0 Process of Care Clinical Patient Survey Any Data Data Outcomes Data Data Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart II-6. Physicians’ Access to Quality-of-Care Data, by Practice Size Percent receiving data on the following aspects of patient care 100 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 75 50 44 27 27 29 21 23 24 25 20 18 14 15 11 0 Process of Care Clinical Outcomes Data Patient Survey Data Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 16 Chart II-7. Physicians’ Sources of Quality-of-Care Data Percent of physicians indicating each as a source of quality of care data Health plans 25 Internal sources 13 Accreditation agencies 7 Professional societies 7 CMS 4 Regulatory agencies 3 Employer groups 3 Other 1 No answer 3 Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart II-8. Physicians’ Ability to Generate Any Quality-of-Care Data Internally Percent indicating they receive quality-of-care data from internal sources 100 50 28 20 21 11 11 6 0 1 Physician 2–9 10–49 50+ EMR Used Do Not Use Physicians Physicians Physicians Routinely/ EMR Occasionally Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 17 Chart II-9. Physicians’ Ability to Compare Performance Percent of physicians able to compare themselves to Other physicians in specialty 24% Other physicians in the same health plan 22% Other physicians in practice/local area 19% Other physicians nationally 11% Other hospitals/clinics/health centers 1% Some other comparison group 1% No comparison with other physicians possible 3% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart II-10. Physicians’ Willingness to Share Quality-of-Care Data Yes, No, Definitely/ Definitely/ Willingness to share data with:* Probably Probably Not Medical leadership 71% 27% Physicians’ own patients 55% 44% General public 29% 69% Other physicians 72% 26% * Answers to survey question: “To improve high quality of care in the U.S., which of the following do you think should have access to ‘Quality of Care’ data about individual physicians?” Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 18 III. PHYSICIANS’ INVOLVEMENT IN QUALITY IMPROVEMENT ACTIVITIES Historically, physicians have reacted with skepticism to proposed changes in practice methods.28 For example, when practice guidelines were first introduced, physicians opposed them based on issues like self-efficacy and environmental factors, among others.29 Similarly, physicians cite barriers, including increased costs, poor reimbursement, and insufficient staff support, to adopting quality improvement methods. This survey confirms that the medical profession has not yet fully embraced quality improvement. Only a minority of surveyed physicians have been involved in redesign efforts at their own practice settings or at the hospitals in which they practice. • Only about one-third of physicians (34%) have engaged in a redesign effort to improve system performance. (Chart III-1) Physicians in larger groups, salaried physicians, physicians who work full time, and primary care physicians are more likely to engage in redesign activities. • Nearly twice the percentage of physicians in practices with more than 50 have engaged in redesign, compared with solo physicians (47% vs. 24%). • Salaried physicians (41%) are more likely than non-salaried physicians (30%) to be engaged in redesign. (Table III-2) • Thirty-seven percent of physicians who spend more than 40 hours per week providing direct patient care have engaged in redesign activities, compared with 23 percent of those practicing less than 20 hours per week. (Table III-3) • Forty-two percent of primary care physicians say they are involved in redesign efforts, compared with 31percent of specialists. (Chart III-2) Collaborative efforts are another way to create system-wide quality improvements. A collaborative effort might involve multiple practices, hospitals, health plans, public agencies, or community groups working together to improve outcomes for patients with specific conditions. This type of activity has not been practiced widely among physicians. • Two-thirds of physicians (67%) have not been involved, within the past two years, in collaborative efforts to improve quality of care. (Chart III-3) • Most collaborative efforts are aimed at the local level (23%), versus the regional (8%) or national (6%) level. 19 Physicians in larger practices, salaried physicians, and primary care physicians are more likely than others to be involved in collaborative efforts. Solo practitioners are less likely to be involved and are also less impressed by the effectiveness of collaborative efforts. • More than twice the percentage of physicians in practices of more than 50, compared with physicians in solo practices, have engaged in collaborative efforts (50% vs. 20%). (Chart III-1) • Salaried physicians (39%) are more likely than non-salaried physicians (28%) to be engaged in collaborative efforts. (Table III-2) • Thirty-six percent of primary care physicians said they are involved in collaborative efforts, compared with 30 percent of specialists. (Chart III-2) Most physicians (65%) think collaborative efforts are somewhat effective. Eleven percent think they are very effective. (Table III-1) • Physicians in larger groups are more likely to rate collaboratives more favorably than those in solo practice (83% vs. 68%). (Chart III-4) • Physicians involved in collaborative efforts rate them more favorably: 21 percent consider them very effective, compared with only 5 percent of those who have not been involved. (Data not shown) 20 Chart III-1. Physicians’ Participation in Redesign and Collaborative Activities, by Practice Size Percent indicating involvement in redesign and collaborative efforts Total 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 50 50 43 47 39 34 35 33 32 24 20 0 Redesign Efforts Collaborative Efforts* * Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart III-2. Physicians’ Participation in Redesign and Collaborative Activities, by Physician Type Percent indicating involvement in redesign and collaborative efforts 100 Total Primary care physician Specialist 50 42 34 36 31 32 30 0 Redesign Efforts Collaborative Efforts* * Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 21 Chart III-3. Physicians’ Involvement in Collaborative Efforts to Improve Quality of Care Percent indicating involvement in any collaborative efforts in past two years* 100 No, have not been involved Yes, a LOCAL effort Yes, a REGIONAL effort Yes, a NATIONAL effort 67 50 Involved in at least one effort (32%) 23 8 6 0 * Multiple answers possible. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart III-4. Physicians’ Opinions on Effectiveness of Collaborative Activities, by Practice Size Percent saying that involvement in collaborative efforts is “very/somewhat” effective in improving quality of care 100 83 81 76 77 68 50 0 Total 1 Physician 2-9 10-49 50+ Physicians Physicians Physicians Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 22 IV. COORDINATION OF CARE AND REFERRALS Insufficient communication among providers and poor continuity of care may contribute to poor health care quality.30 Older adults, particularly those with multiple chronic conditions, are particularly vulnerable to such problems.31,32,33 The referral process is the critical link between primary care and subspecialty care for outpatients. Prior studies have demonstrated that inadequate information exchange between primary care providers (PCPs) and specialists negatively affects the quality of referrals.34 In addition to dissatisfaction among providers and patients, this has likely contributed to suboptimal care and increased costs. The survey queried physicians about coordination of care problems and explored their opinions and experience with the referral process. Coordination of Care Issues around coordination of care are the most common quality problems, according to surveyed physicians. Most notably, physicians mention disruptions in the process of transferring information and issues of patients receiving conflicting information. • In the past 12 months, most physicians (72%) often or sometimes observed that patients’ medical records, test results, or other relevant information were not available at the time of a scheduled visit. (Chart IV-1) • One-third of physicians (34%) often or sometimes observed that tests or procedures had to be repeated because findings were unavailable or were inadequate for interpretation. • One of four physicians (26%) often or sometimes observed that patients experienced problems following hospital discharge because their physicians did not receive needed information in a timely manner. • Twenty-eight percent of physicians often or sometimes observed that patients’ care was compromised because they received conflicting information from different health professionals. • Fifteen percent of physicians often or sometimes observed patients did not receive follow-up, despite test results that indicated the need for such treatment. • Eleven percent of physicians often or sometimes observed that patients received wrong drugs, wrong doses, or were subject to preventable drug-drug interactions. 23 The frequency of coordination problems differs by practice size. Physicians in large groups are more likely than physicians in solo practices to report observing coordination problems. • Seventy-six percent of physicians who practice in groups of 50 or more often or sometimes observed that patients’ medical records, test results, or other relevant information were not available at the time of scheduled visits, compared with 64 percent of physicians in solo practices. (Chart IV-2) • Twenty-two percent of physicians who practice in groups of 50 or more often or sometimes observed that test results were not followed up properly, compared with 10 percent of solo practice physicians. (Chart IV-3) • Thirty-four percent of physicians who practice in groups of 50 or more often or sometimes observed that care was compromised because patients received conflicting information, compared with 24 percent of physicians who practice in small groups of 2–9 physicians. (Chart IV-4) Primary care physicians and specialists observed different types and frequency of coordination problems. • Compared with primary care physicians, specialists were more likely to observe tests or procedures that had to be repeated sometimes or often because results were unavailable or inadequate for interpretation (37% of specialists vs. 28% of primary care physicians). (Chart IV-5) • Thirty-two percent of primary care physicians said they sometimes or often observed patients with problems following hospital discharge because physicians did not receive needed information from the hospital in a timely manner, compared with 23 percent of specialists. Same-day appointments Physicians’ ability to provide same-day appointments is often an indicator that they are able to provides access on a broader level, including being able to coordinate the care needs of their patients. • Almost two of three physicians are always (17%) or often (46%) able to provide a same-day appointment. (Chart IV-6) • Three of four primary care physicians (77%) are able to provide a same-day appointment always or often, compared with 58 percent of specialists. 24 Referrals Physicians report coordination problems during the referral process, in terms of the timeliness and efficiency. Timeliness • One in three physicians say they receive timely feedback on the results of a referral sometimes (28%) or rarely (6%). (Chart IV-7) • Sixty-seven percent of physicians in solo practice always or often receive timely referral information, compared with 58 percent of physicians who practice in groups larger than 50. (Chart IV-8) • Seventy-one percent of primary care physicians always or often receive timely referral information, compared with 62 percent of specialists. • Seventy-two percent of physicians who have been in practice more than 16 years always or often receive timely referral information, compared with 60 percent of those in practice 10 years or less. (Table IV-3) Availability of quality-of-care data • Almost two of three physicians (64%) say they rarely or never have information about the performance of physicians to whom they refer patients. (Chart IV-9) • Twenty-four percent of physicians in solo practice say they always or often have data on physicians’ quality of care when making referrals, compared with 17 percent of those in groups larger than 50. (Chart IV-10) • Twenty-two percent of physicians who have been in practice for more than 16 years say they always or often have data on physicians’ quality of care when making referrals, compared with 18 percent of those who have been in practice 10 years or less. Overall, quality-of-care data appear to make little impact on decisions about referrals. Most physicians find other types of information, such as patients’ experiences with specific physicians or professional reputation, to be equally or more important qualifying factors. • Most physicians (64%) believe that their own experience and their patients’ experiences with a physician are more important than quality-of-care data. (Chart IV-11) • Forty-two percent think reputation is more important; 25 percent think bedside manner is more important; and 25 percent think technical qualifications are more important than quality-of-care data when making referrals. 25 Chart IV-1. Coordination of Care Problems Physicians Observe Percent who observed problem sometimes or often Coordination of care problems in past 12 months Patient’s medical record, test results, or other relevant clinical 72% information were not available at the time of the scheduled visit Tests or procedures had to be repeated because findings were 34% unavailable or inadequate for interpretation Patient experienced a problem following discharge from a hospital because 26% physician did not receive needed information from the hospital in a timely manner Patient’s care was compromised because he/she received conflicting 28% information from different doctors or other health professionals Patient had a positive test result that was not followed-up appropriately 15% Patient received the wrong drug, wrong dose, or had a preventable 11% drug-drug interaction Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart IV-2. Coordination of Care Problems, by Practice Size Percent who say “often/sometimes” observed the following 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 78 76 74 64 50 44 33 33 33 0 Clinical Information Tests Repeated Not Available at Visit Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 26 Chart IV-3. Coordination of Care Problems, by Practice Size Percent who say “often/sometimes” observed the following 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 50 22 15 17 13 14 10 9 10 0 Test Results Wrong Dose/Medication Not Followed Up Properly Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart IV-4. Coordination of Care Problems, by Practice Size Percent who say “often/sometimes” observed the following 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 50 34 29 29 31 27 25 24 24 0 Patient Experienced Patient’s Care Compromised Coordination Problem Post Because He/She Received Hospital Discharge* Conflicting Information * A patient experienced a problem following discharge from a hospital because his/her physician did not receive needed information from the hospital in a timely manner. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 27 Chart IV-5. Coordination of Care Problems, by Physician Type Percent who say “often/sometimes” observed the following 100 Primary care physician Specialist 50 37 32 28 23 0 Tests Repeated Patient Experienced Coordination Problem Post-Hospital Discharge* * A patient experienced a problem following discharge from a hospital because his/her physician did not receive needed information from the hospital in a timely manner. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart IV-6. Ability of Physicians to Provide Same-Day Appointments, by Physician Type Percent indicating how often they can provide same-day appointments 100 Often Always 77 64 58 50 54 46 43 17 23 15 0 Total Primary Care Physician Specialist Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 28 Chart IV-7. Receipt of Timely Referral Information Percent who say they receive timely information about the results of a referral Sometimes 28% 34% Often 54% Rarely 6% Always 11% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart IV-8. Receipt of Timely Referral Information Percent who say they “always/often” receive timely information about the results of a referral 100 71 75 67 66 62 55 58 50 25 0 1 2–9 10–49 50+ Primary Specialist Physician Physicians Physicians Physicians Care Physician Practice Size Physician Type Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 29 Chart IV-9. Availability of Quality-of-Care Data When Making Referrals Percent indicating how often they have any data about a physician’s quality of care when making referrals Rarely Sometimes 32% 16% 64% Often 14% Never 32% Always 5% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart IV-10. Availability of Quality-of-Care Data When Making Referrals Percent indicating they “always/often” have data about a physician’s quality of care when making a referral 100 75 50 24 22 25 17 15 17 18 11 0 1 Physician 2–9 10–49 50+ 10 Years or 11–15 16+ Years Physicians Physicians Physicians Less Years Practice Size Years in Practice Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 30 Chart IV-11. Relative Importance of Quality-of-Care Data Percent indicating following information is MORE important than quality-of-care data* Physician’s reputation among peers 42% Physician’s technical qualifications (e.g., training, education, board certification) 25% Experiences with the physician 64% Physician’s bedside manner, as reported by patients 25% * Indicates physicians who responded that the above information was more important than quality-of-care data. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 31 V. STRATEGIES TO IMPROVE QUALITY OF CARE The survey explored physicians’ opinions on the effectiveness of six potential strategies to improve quality of care: appropriate time spent with patients; patients’ access to preventive care and health education; treatment guidelines or protocols; information technologies; information about specialists and specialty centers for referrals; and team work and communication. Overall, physicians said that more time spent with patients, increased access to preventive care and health education, and better teamwork are the most effective ways to improve care. Other approaches such as guidelines, electronic medical records and e-prescribing, and performance data, received only limited support from physicians. • Compared with all other strategies, having more time with patients is seen as very effective in improving quality of care by the greatest number of physicians. One-half of physicians (52%) believe that having more time to spend with patients would be very effective in improving the care they provide. (Chart V-1) • The second strategy most frequently cited—by two in five physicians or 41 percent—is increasing access to preventive care and health education. • One-third of physicians (35%) cited improved teamwork and communication among health care professionals as a very effective strategy in improving quality of care. • One of four (25%) physicians thinks increased use of computer technology for patient medical records and prescribing drugs and medical tests would be very effective. • Almost one of four physicians (23%) thinks having better information about physicians and centers to refer patients for specialized care would be very effective in improving the quality of care they provide. • One of five physicians (21%) thinks that having better treatment guidelines or protocols for common conditions or procedures would be very effective. Team Care Most physicians believe that team care results in better decisions, although some physicians remain skeptical. • Three of four physicians (73%) agreed or strongly agreed that the give and take among team members results in better decisions. (Chart V-2) 32 • One of three (32%) agreed or strongly agreed that the team process makes care more cumbersome. • One of four (24%) agreed or strongly agreed that involving multiple team members increases the likelihood of medical errors. Physicians in solo practice are less supportive of team care than those in larger groups settings. • Sixty-five percent of solo physicians agree or strongly agree that teamwork results in better decisions regarding patient care, compared with 81 percent of physicians in groups larger than 50. (Chart V-3) • Thirty-seven percent of solo physicians say that the team process makes care more cumbersome, compared with 27 percent of physicians in groups larger than 50. • One-third (32%) of solo physicians say that involving multiple team members increases the likelihood of medical errors, compared with 17 percent of those in groups larger than 50. Specialty and gender are also significant factors in a physician’s opinion about team care. • Forty-one percent of primary care physicians say teamwork and communication are effective strategies, compared with 33 percent of specialists. (Chart V-4) • Thirty-two percent of male physicians say teamwork and communication are effective strategies, compared with 45 percent of female physicians. 33 Chart V-1. Physicians’ Opinions on Strategies to Improve Quality of Care Percent of physicians who indicate the following are “very effective” in improving quality of care Having more time to spend with patients 52% Better patient access to preventive care 41% Improved teamwork and communication 35% More use of computer technology 25% Better information on best specialized physicians/centers 23% Better treatment guidelines for common conditions 21% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart V-2. Physicians’ Opinion on Team Care Percent indicating they “agree” or “strongly agree” that* The give and take among team members results in 73% better decisions regarding patient care The team process makes care more cumbersome 32% The involvement of multiple team members increases 24% the likelihood of medical errors * Indicates physicians who, based on their experience working in teams, said that they agree or disagree with the above. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 34 Chart V-3. Physicians’ Opinion on Team Care, by Practice Size Percent who agree/strongly agree 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians 100 80 81 73 65 50 37 33 32 28 27 23 19 17 0 The give and take among team The team process makes care The involvement of multiple members results in better more cumbersome team members increases the decisions regarding patient likelihood of medical errors care Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart V-4. Physicians’ Opinions on Team Care, by Physician Type Percent who say improved teamwork would be “very effective” in improving quality of care 100 75 45 50 41 33 32 25 0 Primary Care Specialist Male Female Physician Physician Type Gender Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 35 VI. INCENTIVES AND DISINCENTIVES TO PROVIDING QUALITY CARE AND PHYSICIANS’ SATISFACTION WITH CURRENT PRACTICE To foster quality in a complex health care system, it is crucial to design incentives that allow the major stakeholders to align their policies and actions toward a goal of improvement. It is also important to remove the disincentives that are barriers to quality. In 2001, the IOM report, Crossing the Quality Chasm, recognized that aligning payment policies with quality improvement is an important step in changing the environment of the health care delivery system. The committee called for public and private purchasers to reexamine their payment policies to remove barriers that impede quality improvement and build stronger incentives for quality enhancement. The survey asked physicians about their experiences with financial incentives or disincentives to providing high-quality care. Reimbursement for Appropriate Care Services Overall, surveyed physicians indicated there are few incentives that foster quality of care. • None of the surveyed physicians were reimbursed for e-mail consultations and very few received reimbursements for phone consultations (4%) or group patient visits (5%). (Table VI-1) Factors Affecting Compensation Aligning payment policies with performance is an important step in fostering quality and quality improvement. However, for most physicians, quality-of-care measures or evidence of involvement in quality improvement activities (e.g., board recertification) are rarely important factors in determining compensation. Instead, billing and productivity are the primary determinants of compensation. • Almost three-quarters of physicians (72%) said productivity or billing is a determinant of compensation. (Chart VI-1) • One of five (19%) physicians said that quality bonuses or incentive programs from insurance plans play a role. • Close to three-quarters of physicians (72%) said that measures of clinical care or patient surveys play no role at all in compensation. • Thirty-nine percent of physicians reported that board recertification status is a factor in compensation. 36 Disincentives to Quality Care • Altogether, one-half of physicians (51%) said that providing the best quality of care often (23%) or sometimes (28%) translates into lower revenues (Chart VI-2) • Physicians in solo practice are more likely than physicians in larger group practices to say that providing the best quality of care often translates into lower revenues (58% vs. 46% respectively. Satisfaction with Current Practice Most surveyed physicians (78%) are at least somewhat satisfied with their current practices and one-third (33%) are very satisfied. (Chart VI-3) Still, one of five surveyed physicians is either somewhat or very dissatisfied. Physicians in solo practices who have been practicing longer are somewhat more dissatisfied than those who have been practicing for less time and those in larger practices. • Twenty-seven percent of physicians in solo practices are very or somewhat dissatisfied (Chart VI-4), compared with 14 percent of physicians in practices with 50 or more physicians. • Twenty-six percent of physicians who have been practicing 21 or more years are dissatisfied, compared with 17 percent who have been practicing 10 years or less. (Data not shown) 37 Chart VI-1. Factors Affecting Physicians’ Compensation Percent indicating the following as factors in determining compensation or income Major Factor Minor Factor Not a Factor Productivity/ Billing 58% 14% 27% 72% Board Re-Certification Status 11% 28% 60% 39% Measures of Clinical Care 8% 19% 72% 27% Patient Surveys/ Experience 8% 19% 72% 27% Quality Bonus/Incentive Payments from 4% 15% 80% Insurance Plans 19% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart VI-2. Financial Consequences of Providing High Quality of Care, by Practice Size Percent indicating that providing high quality of care “often/sometimes” means less income 100 58 51 52 46 50 41 0 Total 1 Physician 2–9 10–49 50+ Physicians Physicians Physicians Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 38 Chart VI-3. Physicians’ Satisfaction with Current Medical Practice Somewhat dissatisfied 17% Somewhat satisfied Very dissatisfied 45% 5% Very satisfied 33% Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Chart VI-4. Physicians’ Dissatisfaction with Current Practice, by Practice Size Percent “very or somewhat” dissatisfied with current practice 50 27 25 21 19 21 14 0 Total 1 Physician 2–9 10–49 50+ Physicians Physicians Physicians Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 39 APPENDIX A. PHYSICIAN AND PRACTICE CHARACTERISTICS The Commonwealth Fund National Survey of Physicians and Quality of Care surveyed a national, representative cross-section of primary care and specialist physicians involved in direct care of adults. The sample of physicians who responded includes mainly specialists (71%), and a much smaller percentage of primary care providers (29%). Most of the respondents are male (77%) and under 54 years of age (67%). More than one-half of respondents (55%) have been in practice for more than 16 years, and 62 percent perform more than 40 hours of direct patient care per week. More than one-third of physicians (36%) are full owners of their practices. One of five (21%) surveyed physicians is planning to retire or discontinue direct patient care within the next five years. (Data not shown) Most physicians surveyed (68%) are in small practices of less than 10 physicians; 27 percent are in solo practices and 41 percent are in small groups of two to nine physicians. Only 12 percent of surveyed physicians are in large practices of 50 or more physicians. (Chart A-1) Physicians in solo practices tend to own their practices and are less likely to be salaried than physicians in larger practice settings. • Ninety percent of solo practitioners are full owners of their practices, compared with just 13 percent and 7 percent of physicians in mid- and large-size practices, respectively. • Only 16 percent of physicians in solo practice are salaried, compared with 53 percent of physicians in mid-size practices and 72 percent of those in large practices. Solo practice physicians are older than physicians practicing in groups and have been practicing for longer periods of time. • Fifty percent of solo practice physicians are 55 years or older, compared with just one-quarter (26%) of physicians in mid-size and large practices. (Data not shown) • Seventy percent of solo physicians have been practicing for 16 or more years, compared with just one-half of physicians in smaller and mid-size practices. (Data not shown) Most physicians (52%) practice in a single specialty or multi-specialty group setting. One- quarter practice in solo settings. Fourteen percent of surveyed physicians practice in hospital or clinic settings. Of these, 20 percent are in solo or small groups of two to nine 40 physicians, 20 percent are in mid-size groups of 10 to 49 physicians, and 23 percent are in large groups of 50 or more. (Chart A-1) Physicians practicing in hospital or clinic settings (89%) are more likely to be salaried than those in solo (12%) or single or multi-specialty group (37%) settings. Physicians in single or multi-specialty group settings provide more hours in direct patient care than do physicians in all other settings. • Seventy percent of physicians in single or multi-specialty group settings provide 41 or more hours per week in direct patient care. In contrast, 50 percent of physicians in hospital or clinic settings provide as many hours of care. (Data not shown) • Hospital or clinic settings tend to have more primary care providers and women than other practice settings. (Data not shown) Primary care physicians are younger and have fewer years in practice than specialists. • Forty percent of primary care physicians and 29 percent of specialists are under age 45. (Data not shown) • Less than one-half (47%) of primary care physicians have been practicing for 16 or more years, compared with 59 percent of specialists. (Data not shown) Chart A-1. Characteristics of Small and Large Group Physician Practices 1 2–9 10–49 50+ Practice Characteristics Total Physician Physicians Physicians Physicians Percent Distribution 27% 41% 17% 12% 100% 100% 100% 100% Practice Setting Hospital or public clinic 14 5 15 20 23 Single or multi-specialty group 52 — 78 69 55 Solo 25 93 — — — Other 9 2 6 11 22 Salary Status Salaried (yes) 41 16 43 53 72 Ownership of Practice Full owner 36 90 20 13 7 Part owner 28 2 45 35 24 Not an owner 35 8 34 52 68 Physician Type Primary care 29 26 29 37 28 Specialist 71 74 71 63 72 Hours in Direct Care 20 hours or fewer 8 10 6 7 8 21–40 hours 30 32 16 35 34 More than 40 hours 62 58 68 58 57 Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 41 APPENDIX B. SURVEY METHODOLOGY The Commonwealth Fund National Survey of Physicians and Quality of Care was conducted by Harris Interactive on behalf of The Commonwealth Fund, between March 17 and May 30, 2003. A self-administered questionnaire was mailed to 3,598 U.S. physicians, randomly selected from an American Medical Association (AMA) list, including AMA members and nonmembers. All physicians in the sample were involved in direct care of adults and had been in practice at least three years post-residency. Specialists unlikely to be involved in patient care long term (e.g., radiologists, anesthesiologists, pathologists, dermatologists) were excluded. Identification of primary versus specialty care physicians was done using the AMA master file. In the final analyses, data were weighted by gender, age, and practice setting to reflect the national distribution of physicians in the AMA master file. Study Variables A total of 1,837 surveys were returned, a response rate of 52.8% (calculated using Response Rate #1 as defined by the American Association for Public Opinion Research). The majority of physicians completed the survey by mail (91%), while a much smaller portion (9%) completed it online. There were no statistically significant differences between respondents and non-respondents according to gender, age, practice size, specialty, or years in practice. All analyses were conducted using STATA version 7.0 (Stata Corp, College Station, Texas), and use the weighted survey estimator to adjust standard errors for clustering and stratification involved in the survey design. 42 APPENDIX C. TABLES General Notes: On all tables, numbers may not add up to 100 percent. Two factors account for this—unknown responses are not shown, and the rounding of results. * = Response rate of less than 1 percent. — = No response to question category. 43 Table I-1. Information Technologies: Current Use, Future Plans, and Perceived Barriers Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Percent Distribution (Weighted) 100% 25% 52% 14% 9% 27% 41% 17% 12% Do you currently use any of the following? Electronic billing Yes, used routinely 73 63 85 62 54 63 81 76 71 Yes, used occasionally 6 5 4 11 7 5 4 8 6 Not used, PLAN to use within the next year 6 8 4 9 8 8 5 4 7 Not used, NO plan to use within the next year 15 23 7 17 29 23 9 12 15 Electronic ordering Yes, used routinely 17 6 18 23 39 6 16 26 35 Yes, used occasionally 9 7 10 13 6 6 9 11 11 Not used, PLAN to use within the next year 19 14 21 21 21 14 19 23 25 Not used, NO plan to use within the next year 53 72 51 43 32 71 56 39 28 Electronic medical records Yes, used routinely 18 8 18 23 36 8 14 26 39 Yes, used occasionally 9 4 9 13 15 5 9 9 18 Not used, PLAN to use within the next year 20 13 23 22 17 13 21 28 22 Not used, NO plan to use within the next year 53 74 49 42 31 73 56 37 22 Electronic access to patient test results Yes, used routinely 37 15 40 52 62 16 37 46 73 Yes, used occasionally 21 20 23 20 15 20 24 20 14 Not used, PLAN to use within the next year 14 17 14 14 4 17 15 13 7 Not used, NO plan to use within the next year 27 47 22 13 17 46 24 20 6 44 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians E-mail with patients Yes, used routinely 3 3 3 2 7 3 3 2 6 Yes, used occasionally 14 13 13 13 26 13 11 17 27 Not used, PLAN to use within the next year 11 10 10 14 8 11 10 13 10 Not used, NO plan to use within the next year 71 72 73 70 56 72 75 67 58 E-mail with doctors Yes, used routinely 7 2 7 8 16 2 5 8 22 Yes, used occasionally 21 15 19 30 34 15 16 28 38 Not used, PLAN to use within the next year 12 14 12 13 8 14 12 13 10 Not used, NO plan to use within the next year 57 66 60 46 39 66 65 49 28 Clinical decision support Yes, used routinely 6 4 6 8 9 5 4 8 13 Yes, used occasionally 18 14 17 26 24 15 17 21 27 Not used, PLAN to use within the next year 17 17 17 17 16 16 16 19 17 Not used, NO plan to use within the next year 58 64 59 49 48 63 62 51 42 Are the following tasks currently performed in your office? Patient reminders Yes, using a computerized system 21 14 27 11 24 13 22 23 31 Yes, using a manual system 33 38 33 34 19 38 35 29 25 No, not done, PLAN to in next year 10 10 8 15 13 10 10 12 6 No, not done, NO plan to in next year 34 37 31 37 40 37 31 33 37 45 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Follow-up alert Yes, using a computerized system 10 5 11 11 21 5 9 11 21 Yes, using a manual system 31 39 29 32 17 39 30 27 25 No, not done, PLAN to in next year 13 12 14 14 12 12 14 17 9 No, not done, NO plan to in next year 43 41 45 41 48 41 46 40 44 Drug alert Yes, using a computerized system 12 6 11 18 29 6 10 17 27 Yes, using a manual system 26 36 20 28 26 36 22 21 22 No, not done, PLAN to in next year 16 16 17 15 14 16 14 22 14 No, not done, NO plan to in next year 44 41 51 37 29 40 53 37 37 How much are the following a barrier to implementing information technology? Start-up costs too high Not a barrier 15 10 15 17 26 10 13 20 27 Minor barrier 28 28 28 27 31 28 28 29 30 Major barrier 56 61 55 55 43 62 59 49 43 Lack of uniform standards within the industry Not a barrier 14 11 13 17 22 10 14 16 18 Minor barrier 40 35 42 45 40 34 41 40 48 Major barrier 44 52 44 37 36 53 45 42 33 Lack of time to acquire, implement, use such a system Not a barrier 16 12 15 21 23 12 14 21 23 Minor barrier 44 38 36 42 49 38 44 47 51 Major barrier 39 49 37 36 27 49 41 30 26 46 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Maintenance costs too high Not a barrier 15 11 14 19 24 12 13 21 23 Minor barrier 46 38 49 49 51 39 48 50 50 Major barrier 37 50 35 31 22 48 38 27 25 Lack of evidence of effectiveness of such technologies Not a barrier 35 23 36 45 47 25 34 42 48 Minor barrier 38 35 39 42 36 35 41 39 40 Major barrier 26 41 24 12 15 40 24 17 11 Privacy concerns Not a barrier 29 24 32 28 30 23 30 33 33 Minor barrier 49 44 49 52 50 45 52 45 51 Major barrier 21 30 17 19 18 30 17 19 15 Lack training/knowledge on how to use computer technology Not a barrier 36 36 38 33 37 34 37 38 38 Minor barrier 47 41 47 51 49 42 45 48 56 Major barrier 16 21 14 15 13 22 17 12 6 47 Table I-2. Information Technologies: Current Use, Future Plans, and Perceived Barriers Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Percent Distribution (Weighted) 100% 41% 56% 29% 71% Do you currently use any of the following? Electronic billing Yes, used routinely 73 69 77 73 73 Yes, used occasionally 6 8 4 6 6 Not used, PLAN to use within the next year 6 7 5 8 5 Not used, NO plan to use within the next year 15 15 14 13 15 Electronic ordering Yes, used routinely 17 24 13 18 17 Yes, used occasionally 9 12 8 8 10 Not used, PLAN to use within the next year 19 21 17 20 19 Not used, NO plan to use within the next year 53 43 62 52 54 Electronic medical records Yes, used routinely 18 24 14 16 19 Yes, used occasionally 9 12 7 7 10 Not used, PLAN to use within the next year 20 21 19 23 19 Not used, NO plan to use within the next year 53 43 60 53 53 Electronic access to patient test results Yes, used routinely 37 50 28 36 38 Yes, used occasionally 21 19 23 20 22 Not used, PLAN to use within the next year 14 11 16 17 13 Not used, NO plan to use within the next year 27 19 32 25 27 48 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist E-mail with patients Yes, used routinely 3 4 2 1 4 Yes, used occasionally 14 17 12 14 14 Not used, PLAN to use within the next year 11 11 11 12 10 Not used, NO plan to use within the next year 71 67 73 71 70 E-mail with doctors Yes, used routinely 7 12 3 5 7 Yes, used occasionally 21 27 17 17 23 Not used, PLAN to use within the next year 12 11 13 13 12 Not used, NO plan to use within the next year 57 48 65 62 55 Clinical decision support Yes, used routinely 6 8 5 8 5 Yes, used occasionally 18 23 15 19 18 Not used, PLAN to use within the next year 17 17 16 21 15 Not used, NO plan to use within the next year 58 50 63 50 61 Are the following tasks currently performed in your office? Patient reminders Yes, using a computerized system 21 20 22 14 24 Yes, using a manual system 33 33 34 33 33 No, not done, PLAN to in next year 10 12 8 19 6 No, not done, NO plan to in next year 34 33 34 32 35 49 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Follow-up alert Yes, using a computerized system 10 14 8 8 11 Yes, using a manual system 31 29 32 35 29 No, not done, PLAN to in next year 13 15 12 16 12 No, not done, NO plan to in next year 43 41 46 39 45 Drug alert Yes, using a computerized system 12 19 8 16 11 Yes, using a manual system 26 25 26 25 26 No, not done, PLAN to in next year 16 17 15 21 14 No, not done, NO plan to in next year 44 39 49 36 48 How much of a barrier to information technology? Start-up costs too high Not a barrier 15 21 11 12 17 Minor barrier 28 27 29 26 29 Major barrier 56 51 59 61 53 Lack of uniform standards within the industry Not a barrier 14 18 11 15 13 Minor barrier 40 43 38 40 40 Major barrier 44 38 49 43 45 Lack of time to acquire, implement, use such a system Not a barrier 16 19 13 16 16 Minor barrier 44 46 43 40 45 Major barrier 39 34 43 42 38 Maintenance costs too high Not a barrier 15 20 12 12 16 Minor barrier 46 49 43 47 46 Major barrier 37 30 43 39 36 50 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Lack of evidence of effectiveness of such technologies Not a barrier 35 43 30 37 35 Minor barrier 38 41 37 40 37 Major barrier 26 16 32 22 27 Privacy concerns Not a barrier 29 31 28 28 30 Minor barrier 49 49 48 51 48 Major barrier 21 19 22 19 22 Lack training/knowledge on how to use computer technology Not a barrier 36 38 36 34 37 Minor barrier 47 48 46 48 46 Major barrier 16 14 17 17 16 51 Table I-3. Information Technologies: Current Use, Future Plans, and Perceived Barriers Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Percent Distribution (Weighted) 100% 23 22 55 8% 30% 62% Do you currently use any of the following? Electronic billing Yes, used routinely 73 75 76 72 56 66 79 Yes, used occasionally 6 8 5 5 6 8 5 Not used, PLAN to use within the next year 6 7 5 6 9 6 6 Not used, NO plan to use within the next year 15 10 14 17 29 19 10 Electronic ordering Yes, used routinely 17 16 19 17 16 19 17 Yes, used occasionally 9 9 13 8 5 8 11 Not used, PLAN to use within the next year 19 21 17 19 24 15 21 Not used, NO plan to use within the next year 53 53 51 54 53 58 51 Electronic medical records Yes, used routinely 18 14 24 17 25 19 16 Yes, used occasionally 9 12 6 9 11 7 9 Not used, PLAN to use within the next year 20 26 18 18 12 17 22 Not used, NO plan to use within the next year 53 47 51 56 50 56 52 Electronic access to patient test results Yes, used routinely 37 38 40 36 38 35 38 Yes, used occasionally 21 22 20 21 18 20 22 Not used, PLAN to use within the next year 14 14 13 14 9 13 15 Not used, NO plan to use within the next year 27 25 26 28 35 30 24 52 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours E-mail with patients Yes, used routinely 3 3 3 4 5 3 3 Yes, used occasionally 14 12 19 13 19 15 13 Not used, PLAN to use within the next year 11 10 8 12 12 11 10 Not used, NO plan to use within the next year 71 74 69 70 63 70 72 E-mail with doctors Yes, used routinely 7 6 10 6 13 6 6 Yes, used occasionally 21 20 22 21 25 23 19 Not used, PLAN to use within the next year 12 11 9 14 10 12 13 Not used, NO plan to use within the next year 57 61 58 56 50 55 60 Clinical decision support Yes, used routinely 6 6 5 7 8 6 6 Yes, used occasionally 18 20 18 17 20 19 17 Not used, PLAN to use within the next year 17 18 14 18 17 15 18 Not used, NO plan to use within the next year 58 55 61 57 52 58 58 Are the following tasks currently performed in your office? Patient reminders Yes, using a computerized system 21 18 23 21 12 20 23 Yes, using a manual system 33 35 30 34 28 33 34 No, not done, PLAN to in next year 10 12 11 9 10 11 10 No, not done, NO plan to in next year 34 34 33 35 47 34 32 53 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Follow-up alert Yes, using a computerized system 10 11 11 10 10 12 10 Yes, using a manual system 31 27 30 33 35 27 33 No, not done, PLAN to in next year 13 12 12 14 10 13 14 No, not done, NO plan to in next year 43 48 45 41 42 45 43 Drug alert Yes, using a computerized system 12 13 13 12 14 13 12 Yes, using a manual system 26 21 24 29 33 23 26 No, not done, PLAN to in next year 16 17 16 15 10 18 16 No, not done, NO plan to in next year 44 48 46 43 40 44 45 How much of a barrier to information technology? Start-up costs too high Not a barrier 15 14 12 17 18 16 15 Minor barrier 28 30 29 27 28 28 29 Major barrier 56 56 58 54 54 56 55 Lack of uniform standards within the industry Not a barrier 14 13 14 14 20 18 11 Minor barrier 40 43 46 40 40 40 40 Major barrier 44 44 37 47 39 40 47 Lack of time to acquire, implement, use such a system Not a barrier 16 13 16 17 19 17 15 Minor barrier 44 46 44 43 44 44 44 Major barrier 39 41 39 39 37 38 40 54 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Maintenance costs too high Not a barrier 15 14 15 16 20 16 14 Minor barrier 46 52 45 44 41 47 46 Major barrier 37 33 38 39 39 36 38 Lack of evidence of effectiveness of such technologies Not a barrier 35 38 36 33 42 40 32 Minor barrier 38 41 38 37 30 35 41 Major barrier 26 20 24 28 28 24 26 Privacy concerns Not a barrier 29 28 31 29 30 32 28 Minor barrier 49 50 52 47 42 47 50 Major barrier 21 21 17 23 28 20 20 Lack training/knowledge on how to use computer technology Not a barrier 36 36 37 36 30 34 39 Minor barrier 47 49 50 44 47 50 45 Major barrier 16 14 12 19 23 15 16 55 Table II-1. Practice-Level and Performance Data: Availability, Sources, and Willingness to Share Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Percent Distribution (Weighted) 100% 25% 52% 14% 9% 27% 41% 17% 12% With current patient records, how easy is it to generate the following? Very/somewhat easy to generate list of patients by 57 47 39 52 43 50 58 61 61 ANY criteria List of patients by age group Very easy 21 19 23 16 24 18 23 23 21 Somewhat easy 28 27 29 23 26 26 27 31 29 Somewhat difficult 21 18 21 26 20 20 21 20 25 Very difficult 15 16 14 17 17 16 16 13 15 Cannot generate 14 19 11 17 12 20 11 11 10 List of patients by diagnosis/health risk Very easy 18 17 20 13 20 16 20 20 15 Somewhat easy 26 24 27 24 25 23 26 26 30 Somewhat difficult 21 20 21 24 23 21 20 22 26 Very difficult 16 17 16 19 17 18 17 15 15 Cannot generate 17 20 15 20 14 21 17 15 13 List of patients by lab results Very easy 6 3 6 6 14 3 6 9 8 Somewhat easy 10 9 8 12 19 9 7 13 19 Somewhat difficult 20 17 20 21 25 17 18 22 28 Very difficult 24 25 24 29 18 25 25 23 22 Cannot generate 39 45 41 31 23 45 43 31 22 List of patients by current medications taken Very easy 5 3 4 7 16 3 5 9 8 Somewhat easy 10 8 8 13 20 8 7 12 19 Somewhat difficult 16 15 15 17 19 15 13 15 25 Very difficult 24 24 25 27 17 24 25 26 20 Cannot generate 44 48 48 35 26 48 50 38 28 56 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Receives quality-of-care data about the following: Proportion of patients who receive 20 14 21 20 24 14 21 20 27 recommended care Patients’ clinical outcomes 18 11 21 18 23 11 18 23 27 Patient surveys or experiences with care 25 14 26 31 37 15 24 29 44 Receives any of above quality care data 33 21 36 34 42 21 34 36 47 Does the quality-of-care data allow you to compare yourself to…? Other physicians in your specialty 24 17 28 22 26 17 26 25 35 Other physicians in the same health plans 22 18 24 19 24 18 23 19 28 Other physicians in your practice or local area 19 13 22 17 20 14 18 26 26 Other physicians nationally 11 8 13 10 9 9 10 15 16 Other hospital/clinics/ health centers 1 0 1 3 1 1 1 2 2 How useful are the following data? Proportion of patients who receive recommended care Not useful 3 2 4 1 3 2 4 2 2 Somewhat useful 9 6 10 8 15 6 10 10 14 Useful 7 5 6 11 6 5 6 8 11 Patients’ clinical outcomes Not useful 2 1 3 1 3 1 3 3 1 Somewhat useful 7 5 8 4 9 5 6 10 11 Useful 8 4 8 13 10 4 8 11 15 57 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Patient surveys or experiences with care Not useful 3 2 4 4 3 2 4 5 3 Somewhat useful 12 6 12 16 19 7 13 11 19 Useful 9 5 9 11 14 5 7 12 20 From which of the following sources do you receive quality-of-care data? Commercial insurance companies or health plans 25 22 29 18 15 21 28 24 22 Internal sources 13 5 14 19 27 6 11 20 28 Accreditation agencies 7 4 6 11 14 4 7 8 11 Medical, professional, or specialty societies 7 6 8 4 7 6 7 6 9 CMS 4 3 4 6 4 4 5 3 6 Regulatory agencies 3 3 3 5 2 3 3 3 4 Employer groups 3 1 3 2 5 1 3 3 5 To improve quality of care, who should have access to data about physicians? Individual physician himself Yes, definitely 77 74 78 81 78 74 78 77 83 Yes, probably 19 20 18 16 20 20 19 18 14 No, probably not 2 3 2 — — 3 1 2 * No, definitely not 1 2 1 2 1 2 1 1 2 Other physicians Yes, definitely 24 24 25 25 18 25 22 25 26 Yes, probably 48 42 48 49 65 42 51 45 56 No, probably not 18 21 19 16 9 20 18 20 13 No, definitely not 8 11 6 8 7 11 7 6 4 58 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Medical leadership in physicians’ own organization Yes, definitely 25 22 24 30 28 22 26 21 40 Yes, probably 47 42 48 49 51 43 51 46 45 No, probably not 19 23 19 15 11 22 19 19 10 No, definitely not 8 11 7 5 8 11 8 6 4 Medical leadership in health plans(s) Yes, definitely 17 18 14 19 23 18 13 17 25 Yes, probably 46 43 45 51 53 43 46 47 51 No, probably not 23 24 26 17 16 23 26 21 17 No, definitely not 12 13 12 11 6 13 13 12 7 Hospitals where physicians admit Yes, definitely 28 28 25 37 34 30 26 26 35 Yes, probably 52 48 53 52 51 48 54 53 54 No, probably not 12 14 14 7 9 13 13 12 8 No, definitely not 6 8 7 4 5 8 6 6 3 Accrediting or licensing agencies Yes, definitely 24 25 22 28 30 25 22 22 30 Yes, probably 47 44 48 46 47 45 48 48 44 No, probably not 17 17 19 15 13 16 18 16 19 No, definitely not 10 12 10 9 8 11 10 11 6 A physician’s own patients Yes, definitely 13 16 10 19 14 16 11 12 12 Yes, probably 41 38 42 40 49 39 42 41 45 No, probably not 29 28 31 26 26 28 30 31 31 No, definitely not 15 15 15 15 9 15 15 14 11 The general public Yes, definitely 7 9 6 8 8 10 6 6 7 Yes, probably 22 20 22 25 25 21 23 23 24 No, probably not 34 32 34 36 33 31 35 36 34 No, definitely not 35 36 36 31 32 35 35 33 34 59 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Do you think patients should have easy access to their own medical records? Yes, definitely 41 39 41 42 45 39 41 43 41 Yes, probably 45 43 45 44 48 43 46 42 50 No 14 18 13 14 7 18 13 14 9 Compared to two years ago, likelihood patients ask about your clinical experience with the management of certain conditions or procedures? More likely 33 33 35 28 31 33 32 34 36 Equally likely 61 59 60 62 65 59 62 61 59 Less likely 6 7 5 9 4 8 6 5 5 60 Table II-2. Practice-Level and Performance Data: Availability, Sources, and Willingness to Share Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Percent Distribution (Weighted) 100% 41% 56% 29% 71% With current patient records, how easy is it to generate the following? Very/somewhat easy to generate list of patients by 57 55 58 54 58 ANY criteria Patients by age group Very easy 21 19 23 22 21 Somewhat easy 28 28 28 26 28 Somewhat difficult 21 21 20 20 22 Very difficult 15 17 15 17 15 Cannot generate 14 14 13 13 14 Patients by diagnosis or health risk Very easy 18 17 19 16 19 Somewhat easy 26 25 26 25 26 Somewhat difficult 21 22 21 22 21 Very difficult 16 18 15 17 16 Cannot generate 17 17 17 18 17 Patients by lab results Very easy 6 8 4 7 5 Somewhat easy 10 12 8 10 10 Somewhat difficult 20 22 19 23 19 Very difficult 24 24 24 25 24 Cannot generate 39 33 43 33 41 Patients by current medications taken Very easy 5 8 4 6 5 Somewhat easy 10 12 8 12 9 Somewhat difficult 16 16 15 17 15 Very difficult 24 25 24 25 23 Cannot generate 44 38 49 39 46 61 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Receives quality of care data about the following: Proportion of patients who receive recommended care 20 22 18 37 12 Patients’ clinical outcomes 18 21 16 34 11 Patient surveys or experiences with care 25 32 20 36 20 Receives any of above 33 38 29 49 26 quality care data Quality-of-care data allows you to compare yourself to: Other physicians in your specialty 24 25 23 34 20 Other physicians in the same health plans 22 23 21 39 15 Other physicians in your practice or local area 19 22 17 29 15 Other physicians nationally 11 12 11 14 10 Other hospital/clinics/ health centers 1 2 1 1 1 How useful are the following data? Proportion of patients who receive recommended care Not useful 3 3 3 5 2 Somewhat useful 9 11 9 17 6 Useful 7 8 6 15 3 Patients’ clinical outcomes Not useful 2 2 2 5 1 Somewhat useful 7 8 6 13 5 Useful 8 11 6 15 5 62 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Patient surveys or experiences with care Not useful 3 4 3 6 2 Somewhat useful 12 15 10 16 10 Useful 9 12 7 13 7 From which of the following sources do you receive quality-of-care data? Commercial insurance companies or health plans 25 24 26 43 17 Internal sources 13 19 10 15 13 Accreditation agencies 7 10 4 7 7 Medical, professional, or specialty societies 7 6 7 6 7 CMS 4 6 3 5 4 Regulatory agencies 3 4 2 3 3 Employer groups 3 3 2 3 2 To improve quality of care, who should have access to data about physicians? Individual physician himself Yes, definitely 77 80 76 81 76 Yes, probably 19 17 20 16 20 No, probably not 2 1 2 1 2 No, definitely not 1 1 2 1 2 Other physicians Yes, definitely 24 25 23 23 24 Yes, probably 48 49 47 50 47 No, probably not 18 17 19 17 18 No, definitely not 8 7 9 8 8 63 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Medical leadership in physicians’ own organization Yes, definitely 25 28 22 22 26 Yes, probably 47 47 47 51 45 No, probably not 19 17 20 17 20 No, definitely not 8 5 9 8 8 Medical leadership in health plans(s) Yes, definitely 17 20 14 17 17 Yes, probably 46 47 46 51 44 No, probably not 23 21 24 19 25 No, definitely not 12 10 12 11 12 Hospitals where physicians admit Yes, definitely 28 32 26 26 29 Yes, probably 52 51 52 54 51 No, probably not 12 11 13 12 12 No, definitely not 6 4 7 7 6 Accrediting or licensing agencies Yes, definitely 24 27 22 21 26 Yes, probably 47 47 47 48 46 No, probably not 17 17 18 18 17 No, definitely not 10 8 12 11 10 A physician’s own patients Yes, definitely 13 15 12 13 13 Yes, probably 41 42 41 42 41 No, probably not 29 29 30 28 30 No, definitely not 15 13 15 15 14 The general public Yes, definitely 7 8 7 7 7 Yes, probably 22 23 22 21 23 No, probably not 34 36 32 34 34 No, definitely not 35 32 37 36 34 64 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Do you think patients should have easy access to their own medical records? Yes, definitely 41 42 40 35 43 Yes, probably 45 46 43 47 43 No 14 12 16 17 13 Compared to two years ago, likelihood patients ask about your clinical experience with the management of certain conditions or procedures? More likely 33 32 34 26 36 Equally likely 61 61 60 65 59 Less likely 6 6 6 9 5 65 Table II-3. Practice-Level and Performance Data: Availability, Sources, and Willingness to Share Years in Practice Hours in Direct Patient Care 10 Years 11–15 16 or More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Percent Distribution (Weighted) 100% 23 22 55 8% 30% 62% With current patient records, how easy is it to generate the following? Very/somewhat easy to generate lists of patients by 57 56 61 56 51 50 61 ANY criteria Patients by age group Very easy 21 20 29 19 14 18 23 Somewhat easy 28 24 27 30 25 25 29 Somewhat difficult 21 24 20 20 19 22 21 Very difficult 15 20 12 15 23 16 14 Cannot generate 14 10 12 16 16 17 12 Patients by diagnosis/ health risk Very easy 18 18 22 17 14 16 20 Somewhat easy 26 25 27 26 22 24 27 Somewhat difficult 21 21 21 21 21 19 23 Very difficult 16 18 13 17 22 19 15 Cannot generate 17 16 16 18 18 21 15 Patients by lab results Very easy 6 5 8 5 6 6 6 Somewhat easy 10 8 11 10 12 10 10 Somewhat difficult 20 22 18 20 21 19 20 Very difficult 24 28 23 23 24 24 24 Cannot generate 39 36 10 40 34 39 39 Patients by current medications taken Very easy 5 4 8 5 7 5 5 Somewhat easy 10 10 12 9 10 10 10 Somewhat difficult 16 15 14 16 20 14 16 Very difficult 24 28 20 24 25 25 23 Cannot generate 44 42 45 45 36 44 45 66 Years in Practice Hours in Direct Patient Care 10 Years 11–15 16 or More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Receives quality of care data about the following: Proportion of patients who receive recommended care 20 21 18 20 12 19 21 Patients’ clinical outcomes 18 21 18 17 11 15 20 Patient surveys or experiences with care 25 25 28 24 27 22 26 Receives any of above quality care data 33 35 36 31 28 29 35 Quality-of-care data allows you to compare yourself to: Other physicians in your specialty 24 25 23 24 18 20 27 Other physicians in the same health plans 22 21 20 23 17 17 25 Other physicians in your practice or local area 19 16 19 20 14 17 21 Other physicians nationally 11 12 12 10 6 6 14 Other hospital/clinics/ health centers 1 * * 1 2 1 1 How useful are the following data? Proportion of patients who receive recommended care Not useful 3 4 3 2 1 2 4 Somewhat useful 9 10 9 10 9 8 10 Useful 7 6 6 7 1 8 7 Patients’ clinical outcomes Not useful 2 3 4 2 0 1 3 Somewhat useful 7 9 6 7 6 6 8 Useful 8 9 8 8 5 8 9 67 Years in Practice Hours in Direct Patient Care 10 Years 11–15 16 or More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Patient surveys or experiences with care Not useful 3 4 4 3 4 4 3 Somewhat useful 12 11 14 12 17 11 12 Useful 9 10 9 9 5 6 11 From which of the following sources do you receive quality-of-care data? Commercial insurance companies or health plans 25 26 21 25 15 20 28 Internal sources 13 15 15 13 19 10 14 Accreditation agencies 7 7 6 7 5 7 7 Medical, professional, or specialty societies 7 6 7 7 6 5 8 CMS 4 2 5 5 4 3 5 Regulatory agencies 3 3 2 4 3 2 4 Employer groups 3 2 2 3 2 2 3 To improve quality of care, who should have access to data about physicians? Individual physician himself Yes, definitely 77 76 79 77 74 77 78 Yes, probably 19 18 18 19 22 19 18 No, probably not 2 3 1 1 2 1 2 No, definitely not 1 1 2 1 1 1 2 Other physicians Yes, definitely 24 26 22 24 20 23 24 Yes, probably 48 49 46 49 51 50 47 No, probably not 18 18 23 16 20 18 18 No, definitely not 8 6 8 9 8 6 9 68 Years in Practice Hours in Direct Patient Care 10 Years 11–15 16 or More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Medical leadership in physicians’ own organization Yes, definitely 25 20 24 27 26 24 25 Yes, probably 47 51 46 46 41 51 46 No, probably not 19 20 23 17 23 18 18 No, definitely not 8 8 7 8 9 4 9 Medical leadership in health plans(s) Yes, definitely 17 13 14 19 14 16 17 Yes, probably 46 17 42 48 47 50 44 No, probably not 23 25 29 20 26 22 24 No, definitely not 12 13 13 10 11 8 13 Hospitals where physicians admit Yes, definitely 28 23 26 31 33 28 28 Yes, probably 52 55 55 49 49 54 51 No, probably not 12 15 13 11 14 12 12 No, definitely not 6 6 5 7 4 4 8 Accrediting or licensing agencies Yes, definitely 24 21 22 26 33 22 24 Yes, probably 47 50 46 45 40 51 46 No, probably not 17 18 20 16 20 16 18 No, definitely not 10 10 10 10 6 9 11 A physician’s own patients Yes, definitely 13 11 12 14 14 14 13 Yes, probably 41 45 40 41 40 41 42 No, probably not 29 29 31 29 33 32 28 No, definitely not 15 14 16 14 12 12 16 The general public Yes, definitely 7 7 6 8 6 6 8 Yes, probably 22 22 23 22 22 23 22 No, probably not 34 26 32 34 40 36 32 No, definitely not 35 34 38 34 31 32 36 69 Years in Practice Hours in Direct Patient Care 10 Years 11–15 16 or More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Do you think patients should have easy access to their own medical records? Yes, definitely 41 41 45 39 37 42 40 Yes, probably 45 42 46 45 51 45 44 No 14 16 9 15 12 13 15 Compared to two years ago, likelihood patients ask about your clinical experience with the management of certain conditions or procedures? More likely 33 33 35 32 29 30 35 Equally likely 61 60 61 61 65 65 58 Less likely 6 7 4 6 5 5 7 70 Table III-1. Physicians’ Involvement in Quality Improvement Activities Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Percent Distribution (Weighted) 100% 25% 52% 14% 9% 27% 41% 17% 12% In past two years, have you been involved in redesign efforts? Yes 34 22 37 42 40 24 35 43 47 No 65 77 62 58 58 75 65 57 53 In past two years, have you been involved in collaboratives? Yes to Any 32 19 34 45 37 20 33 38 50 Yes, a LOCAL 23 15 25 30 27 15 23 29 34 Yes, a REGIONAL 8 4 9 13 7 4 8 9 16 Yes, a NATIONAL 6 3 5 7 10 3 5 7 11 No, have not been involved 67 80 65 55 61 80 67 61 49 How effective do you think these collaboratives are in improving quality? Very effective 11 8 9 14 20 8 10 12 16 Somewhat effective 65 59 68 68 61 59 68 69 67 Not very effective 16 20 15 12 10 19 15 13 13 Not at all effective 2 4 2 1 2 4 2 1 1 71 Table III-2. Physicians’ Involvement in Quality Improvement Activities Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Percent Distribution (Weighted) 100% 41% 56% 29% 71% In past two years, have you been involved in redesign efforts? Yes 34 41 30 42 31 No 65 59 69 57 68 In past two years, have you been involved in collaboratives? Yes to Any 32 39 28 36 30 Yes, a LOCAL 23 28 20 25 23 Yes, a REGIONAL 8 10 7 11 7 Yes, a NATIONAL 6 7 5 6 5 No, have not been involved 67 61 72 63 69 How effective do you think these collaboratives are in improving quality? Very effective 11 14 8 11 10 Somewhat effective 65 67 64 64 66 Not very effective 16 11 19 18 15 Not at all effective 2 1 3 2 2 72 Table III-3. Physicians’ Involvement in Quality Improvement Activities Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Percent Distribution (Weighted) 100% 23 22 55 8% 30% 62% In past two years, have you been involved in redesign efforts? Yes 34 34 44 31 23 31 37 No 65 66 56 68 77 68 62 In past two years, have you been involved in collaboratives? Yes to Any 32 35 31 31 27 29 35 Yes, a LOCAL 23 26 24 22 18 19 26 Yes, a REGIONAL 8 8 6 9 6 8 8 Yes, a NATIONAL 6 7 5 5 9 5 5 No, have not been involved 67 64 67 68 71 71 64 How effective do you think these collaboratives are in improving quality? Very effective 11 12 11 10 13 9 11 Somewhat effective 65 72 66 62 52 67 66 Not very effective 16 11 18 17 26 13 15 Not at all effective 2 * 2 3 2 2 3 73 Table IV-1. Coordination of Care and Referrals Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Percent Distribution (Weighted) 100% 25% 52% 14% 9% 27% 41% 17% 12% In the past 12 months, observed the following: Tests had to be repeated because finding unavailable/inadequate Often 6 4 6 8 9 4 6 9 8 Sometimes 28 28 28 33 27 29 27 35 24 Rarely 53 52 54 48 53 52 56 45 54 Never 12 16 12 10 9 15 11 10 12 Patient’s medical records not available at time of visit Often 25 18 27 30 31 19 28 30 25 Sometimes 47 45 48 49 46 45 47 48 51 Rarely 23 30 21 16 20 29 22 17 22 Never 4 7 2 3 1 6 3 3 1 Patient had positive test result not followed-up properly Often 1 1 — 1 1 1 1 — — Sometimes 14 8 12 25 26 9 14 17 22 Rarely 53 57 67 59 63 59 66 65 61 Never 22 32 20 15 8 31 19 18 16 Patient experienced post-discharge problems because physician did not receive information in a timely manner Often 2 2 2 6 2 3 3 2 2 Sometimes 23 22 21 28 32 22 21 26 27 Rarely 46 41 50 45 43 42 49 47 49 Never 27 34 27 22 30 32 27 24 21 74 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Patient had difficulty affording out-of-pocket costs Often 52 51 50 61 47 52 51 55 48 Sometimes 40 41 42 32 35 39 41 39 39 Rarely 7 7 7 6 10 7 7 6 11 Never 1 1 — 1 7 1 1 1 2 Patient received wrong drug/dose or experienced drug-drug interaction Often 1 1 — 1 1 1 — 1 — Sometimes 10 8 9 16 13 8 10 12 13 Rarely 66 56 70 69 69 58 71 67 71 Never 23 35 20 15 15 33 19 19 14 Patient care was compromised because of conflicting information Often 2 4 2 2 3 4 2 1 1 Sometimes 26 27 23 27 33 27 23 26 33 Rarely 55 49 60 56 46 49 61 54 54 Never 16 19 15 15 17 18 14 18 12 Physicians’ ability to provide same-day appointments Always 17 16 17 15 25 17 18 17 18 Often 46 46 51 40 36 45 47 50 41 Sometimes 25 27 23 28 22 26 24 22 27 Rarely 9 10 8 13 12 11 9 7 13 Never 1 1 1 2 — 1 1 1 1 After a referral, how often do you receive timely information back about results? Always 11 14 10 10 7 13 8 9 13 Often 54 53 59 45 45 53 58 55 45 Sometimes 28 26 25 35 35 25 28 24 36 Rarely 6 6 5 8 12 6 5 10 5 Never 8 2 3 3 — 4 3 — 1 75 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians When making referrals, how often do you have quality-of-care data? Always 5 9 4 3 3 8 3 4 3 Often 14 16 13 14 13 16 14 12 13 Sometimes 16 18 14 14 20 18 13 15 19 Rarely 32 29 34 32 28 29 34 34 33 Never 32 27 34 36 33 27 35 35 30 For referrals, are the following less, equally or more important as physicians’ quality-of-care data? Physicians’ reputation Less important 8 9 7 11 10 10 7 8 7 Equally as important 49 51 48 51 49 50 50 43 54 More important 42 39 44 38 42 39 43 47 39 Physicians’ technical qualifications Less important 13 12 13 13 14 12 13 13 14 Equally as important 61 60 61 64 64 60 61 61 63 More important 25 27 26 23 22 26 26 25 23 You and your patients’ experience with physicians Less important 2 2 2 5 1 2 2 3 3 Equally as important 34 34 33 34 38 34 33 32 33 More important 64 64 65 61 61 64 64 64 64 What patients have said about physicians’ bedside manner Less important 25 27 25 27 24 27 24 25 29 Equally as important 48 46 48 51 53 46 48 50 51 More important 25 27 27 22 22 26 27 25 20 76 Table IV-2. Coordination of Care and Referrals Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Percent Distribution (Weighted) 100% 41% 56% 29% 71% In the past 12 months, observed the following: Tests had to be repeated because finding unavailable/ inadequate Often 6 7 6 6 6 Sometimes 28 31 27 23 31 Rarely 53 50 54 60 49 Never 12 11 13 11 13 Patient’s medical records not available at time of visit Often 25 28 24 22 26 Sometimes 47 47 47 50 46 Rarely 23 21 24 23 23 Never 4 3 4 3 4 Patient had positive test result not followed-up properly Often 1 1 1 1 1 Sometimes 14 19 11 14 14 Rarely 63 62 64 66 62 Never 22 18 24 19 23 Patient experienced post- discharge problems because physician did not receive information in a timely manner Often 2 3 2 3 2 Sometimes 23 26 21 29 21 Rarely 46 46 47 46 46 Never 27 24 29 22 30 77 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Patient had difficulty affording out-of-pocket costs Often 52 52 51 62 47 Sometimes 40 38 41 32 43 Rarely 7 8 7 5 8 Never 1 2 * 1 1 Patient received wrong drug/dose or experienced a drug-drug interaction Often 1 * 1 * 1 Sometimes 10 12 9 12 10 Rarely 66 69 65 70 65 Never 23 19 25 17 25 Patient care was compromised because of conflicting information Often 2 2 3 2 3 Sometimes 26 25 26 23 27 Rarely 55 57 55 58 54 Never 16 15 16 16 16 Physicians’ ability to provide same-day appointments Always 17 18 17 23 15 Often 46 43 49 54 43 Sometimes 25 26 24 18 28 Rarely 9 11 8 3 12 Never 1 1 1 1 1 After a referral, how often do you receive timely information back about results? Always 11 12 10 12 10 Often 54 52 56 59 52 Sometimes 28 29 26 23 30 Rarely 6 6 6 5 7 Never 1 1 0 0 0 78 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist When making referrals, how often do you have quality- of-care data? Always 5 4 5 6 4 Often 14 14 14 16 14 Sometimes 16 17 14 16 15 Rarely 32 31 33 30 33 Never 32 32 33 30 33 For referrals, are the following less, equally or more important as physicians’ quality-of-care data? Physicians’ reputation Less important 8 9 8 9 8 Equally as important 49 50 48 52 48 More important 42 40 43 38 43 Physicians’ technical qualifications Less important 13 14 12 13 13 Equally as important 61 61 61 63 60 More important 25 24 26 23 26 You and your patients’ experience with physicians Less important 2 3 2 2 2 Equally as important 34 35 32 33 34 More important 64 61 66 64 63 What patients have said about physicians’ bedside manner Less important 25 27 25 21 27 Equally as important 48 49 48 49 48 More important 25 24 27 29 24 79 Table IV-3. Coordination of Care and Referrals Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Percent Distribution (Weighted) 100% 23 22 55 8% 30% 62% In the past 12 months, observed the following: Tests had to be repeated because finding unavailable/ inadequate Often 6 8 6 6 7 5 7 Sometimes 28 32 26 28 31 25 30 Rarely 53 50 52 54 50 55 52 Never 12 10 14 12 13 14 11 Patient’s medical records not available at time of visit Often 25 31 27 22 17 22 28 Sometimes 47 48 46 47 53 48 46 Rarely 23 16 22 26 26 25 21 Never 4 2 3 4 4 4 3 Patient had positive test result not followed-up properly Often 1 * 1 1 1 1 1 Sometimes 14 18 13 13 19 14 14 Rarely 63 63 65 62 61 62 64 Never 22 19 21 23 18 23 21 Patient experienced post- discharge problems because physician did not receive information in a timely manner Often 2 2 3 3 3 3 2 Sometimes 23 24 22 23 30 23 22 Rarely 46 44 43 48 41 44 48 Never 27 29 31 25 25 29 27 80 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Patient had difficulty affording out-of-pocket costs Often 52 53 54 50 43 51 53 Sometimes 40 38 38 40 42 40 39 Rarely 7 8 7 7 12 8 7 Never 1 1 * 2 3 1 1 Patient received wrong drug/dose or experienced a drug-drug interaction Often 1 — * 1 — 1 1 Sometimes 10 10 10 11 12 10 10 Rarely 66 69 68 65 65 63 68 Never 23 21 22 23 22 26 21 Patient care was compromised because of conflicting information Often 2 1 2 3 4 2 2 Sometimes 26 23 25 27 30 28 24 Rarely 55 61 51 55 54 51 58 Never 16 14 21 15 12 18 15 Physicians’ ability to provide same-day appointments Always 17 14 18 18 14 20 16 Often 46 51 43 46 48 42 49 Sometimes 25 24 26 25 25 24 25 Rarely 9 8 11 9 12 11 8 Never 1 1 1 1 * 1 1 After a referral, how often do you receive timely information back about results? Always 11 7 6 14 15 11 10 Often 54 53 48 58 43 48 59 Sometimes 28 31 36 23 33 30 26 Rarely 6 8 9 5 8 9 4 Never * * 1 * — * 1 81 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours When making referrals, how often do you have quality-of- care data? Always 5 4 2 6 7 5 5 Often 14 14 9 16 18 14 14 Sometimes 16 14 14 17 18 15 15 Rarely 32 33 35 30 25 30 34 Never 32 34 38 30 29 35 31 For referrals, are the following less, equally or more important as physicians’ quality-of-care data? Physicians’ reputation Less important 8 9 9 8 9 11 7 Equally as important 49 54 45 49 48 50 49 More important 42 36 46 42 43 37 44 Physicians’ technical qualifications Less important 13 12 14 13 13 14 12 Equally as important 61 61 60 61 62 64 59 More important 25 25 26 26 25 21 28 You and your patients’ experience with physicians Less important 2 2 3 2 2 4 1 Equally as important 34 32 33 34 28 32 35 More important 64 65 64 63 69 63 64 What patients have said about physicians’ bedside manner Less important 25 18 25 29 30 29 23 Equally as important 48 51 48 47 50 45 50 More important 25 29 27 23 20 25 26 82 Table V-1. Strategies to Improve Quality of Care Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Percent Distribution (Weighted) 100% 25% 52% 14% 9% 27% 41% 17% 12% Effectiveness of the following in improving quality of care More time to spend with patients Very effective 52 50 50 64 55 51 51 55 57 Somewhat effective 36 36 38 26 39 34 38 33 34 Not very effective 9 10 9 9 4 10 9 9 7 Not at all effective 2 3 2 1 1 3 2 1 1 Better patient access to preventive care and health education Very effective 41 41 38 49 46 42 38 49 37 Somewhat effective 46 43 49 42 46 43 50 40 50 Not very effective 10 12 10 8 6 12 9 8 11 Not at all effective 2 3 2 1 1 3 2 2 * Improved teamwork/ communication among MDs Very effective 35 32 32 50 42 34 32 40 40 Somewhat effective 51 48 54 44 52 47 55 48 52 Not very effective 11 15 12 5 4 15 11 9 7 Not at all effective 2 3 2 1 1 3 2 2 — More use of computer technology for EMR Very effective 25 15 27 35 25 17 25 31 35 Somewhat effective 50 41 52 51 58 42 53 53 54 Not very effective 17 27 14 10 12 25 17 9 9 Not at all effective 8 17 6 4 2 16 6 6 2 Better information on specialists to refer to Very effective 23 25 20 32 19 26 21 23 19 Somewhat effective 48 48 48 46 52 47 50 45 52 Not very effective 23 19 26 19 24 19 24 26 23 Not at all effective 5 7 5 2 3 7 4 4 6 83 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Better treatment guidelines Very effective 21 14 21 31 25 16 21 25 22 Somewhat effective 50 47 51 50 53 46 51 51 57 Not very effective 21 25 22 13 18 25 22 17 17 Not at all effective 7 12 6 5 3 12 6 6 4 Based on your experience working in teams, do you agree or disagree with the following? Give-and-take among team members results in better decisions re: patient care Strongly agree 14 12 12 25 16 13 13 15 16 Agree 59 52 63 55 58 52 59 65 65 Neither agree nor disagree 20 26 19 15 18 26 21 15 16 Disagree 5 7 4 5 5 7 4 4 2 Strongly disagree 1 1 1 * 1 1 1 1 — Team process makes care more cumbersome Strongly agree 4 5 4 5 4 6 4 3 6 Agree 28 33 27 23 23 31 29 24 21 Neither agree nor disagree 27 29 28 25 22 28 26 31 27 Disagree 33 27 34 37 41 27 34 34 38 Strongly disagree 6 5 5 10 7 6 6 7 7 Involvement of multiple team members increases likelihood of medical errors Strongly agree 3 5 2 3 2 5 2 3 2 Agree 21 28 19 19 17 28 21 16 15 Neither agree nor disagree 25 26 26 16 26 25 25 25 23 Disagree 41 31 43 48 41 32 41 46 49 Strongly disagree 10 8 9 13 13 9 11 10 10 84 Table V-2. Strategies to Improve Quality of Care Salary Status Physician Type Gender Primary Not Care Questions Total Salaried Salaried Physician Specialist Male Female Percent Distribution (Weighted) 100% 41% 56% 29% 71% 77% 23% Effectiveness of the following in improving quality of care More time to spend with patients Very effective 52 58 48 59 50 51 59 Somewhat effective 36 32 39 31 38 37 33 Not very effective 9 8 10 7 10 10 7 Not at all effective 2 1 2 1 2 2 1 Better patient access to preventive care and health education Very effective 41 46 37 49 38 37 53 Somewhat effective 46 42 49 43 48 49 38 Not very effective 10 10 10 6 11 11 7 Not at all effective 2 2 3 2 2 2 2 Improved teamwork/ communication among MDs Very effective 35 41 31 41 33 32 45 Somewhat effective 51 48 54 46 53 53 46 Not very effective 11 8 13 9 12 12 7 Not at all effective 2 2 2 2 2 2 1 More use of computer technology for EMR Very effective 25 32 20 29 23 25 25 Somewhat effective 50 49 50 50 50 51 48 Not very effective 17 14 19 14 18 16 17 Not at all effective 8 5 10 6 9 8 9 Better information on specialists to refer to Very effective 23 26 21 25 22 20 34 Somewhat effective 48 48 49 50 48 49 46 Not very effective 23 22 23 21 24 25 17 Not at all effective 5 4 6 3 6 6 2 85 Salary Status Physician Type Gender Primary Not Care Questions Total Salaried Salaried Physician Specialist Male Female Better treatment guidelines Very effective 21 27 17 23 20 20 24 Somewhat effective 50 51 49 53 49 51 46 Not very effective 21 17 24 18 23 21 22 Not at all effective 7 5 9 5 8 7 7 Based on your experience working in teams, do you agree or disagree with the following? Give-and-take among team members results in better decisions re: patient care Strongly agree 14 19 11 12 15 13 16 Agree 59 60 58 61 58 58 61 Neither agree nor disagree 20 16 23 19 21 21 18 Disagree 5 5 5 6 4 6 2 Strongly disagree 1 * 2 1 1 1 * Team process makes care more cumbersome Strongly agree 4 4 5 6 4 5 3 Agree 28 24 30 27 28 29 24 Neither agree nor disagree 27 26 29 29 27 28 25 Disagree 33 37 31 32 33 32 37 Strongly disagree 6 9 4 6 6 6 8 Involvement of multiple team members increases likelihood of medical errors Strongly agree 3 3 3 2 3 3 1 Agree 21 18 23 19 22 22 18 Neither agree nor disagree 25 21 27 26 24 25 22 Disagree 41 45 37 43 39 39 44 Strongly disagree 10 12 8 9 11 9 12 86 Table V-3. Strategies to Improve Quality of Care Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Percent Distribution (Weighted) 100% 23 22 55 8% 30% 62% Effectiveness of the following in improving quality of care More time to spend with patients Very effective 52 54 55 51 55 51 53 Somewhat effective 36 36 35 36 32 36 36 Not very effective 9 8 8 10 8 9 9 Not at all effective 2 1 2 3 4 3 2 Better patient access to preventive care and health education Very effective 41 48 39 39 45 43 40 Somewhat effective 46 43 49 47 42 44 48 Not very effective 10 8 10 11 11 11 9 Not at all effective 2 1 2 3 1 2 2 Improved teamwork/ communication among MDs Very effective 35 38 36 34 41 36 34 Somewhat effective 51 51 51 51 47 51 52 Not very effective 11 9 11 12 10 10 12 Not at all effective 2 1 1 3 1 1 2 More use of computer technology for EMR Very effective 25 29 26 23 22 22 27 Somewhat effective 50 53 50 48 46 50 50 Not very effective 17 13 18 18 21 18 15 Not at all effective 8 5 6 10 11 10 7 Better information on specialists to refer to Very effective 23 24 19 24 30 24 22 Somewhat effective 48 50 55 45 42 50 48 Not very effective 23 22 23 23 22 20 24 Not at all effective 5 4 3 6 6 5 5 87 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Better treatment guidelines Very effective 21 24 21 20 26 21 21 Somewhat effective 50 49 47 52 46 49 51 Not very effective 21 20 27 19 18 21 21 Not at all effective 7 7 5 8 9 8 7 Based on your experience working in teams, do you agree or disagree with the following? Give-and-take among team members results in better decisions re: patient care Strongly agree 14 12 15 15 21 14 14 Agree 59 60 59 58 59 59 59 Neither agree nor disagree 20 22 19 20 13 21 21 Disagree 5 4 4 5 3 5 5 Strongly disagree 1 1 1 1 1 * 1 Team process makes care more cumbersome Strongly agree 4 2 3 6 5 5 4 Agree 28 26 25 29 28 26 28 Neither agree nor disagree 27 28 29 26 26 27 28 Disagree 33 36 33 32 33 35 32 Strongly disagree 6 7 8 5 5 6 6 Involvement of multiple team members increases likelihood of medical errors Strongly agree 3 2 2 4 5 2 3 Agree 21 18 19 23 25 22 20 Neither agree nor disagree 25 24 23 25 20 25 25 Disagree 41 43 42 39 37 40 41 Strongly disagree 10 12 12 8 11 10 10 88 Table VI-1. Incentives and Disincentives to Providing Quality Care Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Percent Distribution (Weighted) 100% 25% 52% 14% 9% 27% 41% 17% 12% Which of the following are factors in determining your compensation? Productivity or billing Not a factor 27 29 20 36 47 29 25 24 26 Minor factor 14 13 12 21 21 14 12 18 17 Major factor 58 56 68 42 30 55 63 57 57 Board re-certification status Not a factor 60 68 62 48 44 66 63 50 51 Minor factor 28 22 27 35 37 23 27 33 32 Major factor 11 8 10 17 17 9 9 16 16 Measures of clinical care Not a factor 72 69 75 70 59 69 77 73 60 Minor factor 19 17 17 20 32 17 15 20 32 Major factor 8 12 7 9 7 12 7 6 8 Patient surveys and experience Not a factor 72 68 77 70 57 69 77 74 61 Minor factor 19 17 17 23 31 17 16 21 32 Major factor 8 12 5 6 11 12 6 5 8 Quality bonus or incentive payments from insurance Not a factor 80 80 81 80 71 79 83 76 76 Minor factor 15 13 14 15 23 13 14 18 18 Major factor 4 5 4 5 4 5 3 5 6 89 Practice Setting Practice Size Hospital/ 1 2–9 10–49 50+ Questions Total Solo Group Clinic Other Physician Physicians Physicians Physicians Receives reimbursements for the following: E-mail with patients Yes, from health plans or HMOs — 1 — — — 1 — — — Yes, from other sources — 1 — — 1 1 — — — No 99 98 99 100 99 98 99 98 100 Phone consultation with patients Yes, from health plans or HMOs 1 2 — 1 2 2 — 1 1 Yes, from other sources 3 6 2 1 1 5 2 1 1 No 96 92 97 98 96 92 97 97 98 Group patient visits Yes, from health plans or HMOs 3 3 2 3 4 3 2 2 1 Yes, from other sources 2 4 1 4 2 3 2 2 1 No 94 92 95 93 92 93 95 94 94 With current financial incentive in your practice, how often does providing best quality of care mean less income for you? Often 23 30 23 16 15 29 22 17 20 Sometimes 28 29 29 27 21 30 30 24 25 Rarely 17 16 17 19 12 16 16 19 17 Never 31 23 30 37 51 24 31 38 37 90 Table VI-2. Incentives and Disincentives to Providing Quality Care Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Percent Distribution (Weighted) 100% 41% 56% 29% 71% Which of the following are factors in determining your compensation? Productivity or billing Not a factor 27 31 23 28 26 Minor factor 14 20 10 14 14 Major factor 58 48 66 57 59 Board re-certification status Not a factor 60 53 65 53 62 Minor factor 28 32 25 34 25 Major factor 11 14 9 12 11 Measures of clinical care Not a factor 72 66 76 66 74 Minor factor 19 24 15 24 17 Major factor 8 9 8 9 8 Patient surveys and experience Not a factor 72 70 74 69 73 Minor factor 19 22 17 23 18 Major factor 8 7 8 8 8 Quality bonus or incentive payments from insurance Not a factor 80 78 81 71 83 Minor factor 15 17 13 23 11 Major factor 4 4 4 5 4 91 Salary Status Physician Type Primary Not Care Questions Total Salaried Salaried Physician Specialist Receives reimbursements for the following? E-mail with patients Yes, from health plans or HMOs * — 1 1 * Yes, from other sources * — 1 1 * No 99 99 98 98 99 Phone consultation with patients Yes, from health plans or HMOs 1 1 1 2 1 Yes, from other sources 3 1 4 2 3 No 96 97 95 95 96 Group patient visits Yes, from health plans or HMOs 3 3 2 3 3 Yes, from other sources 2 2 2 1 3 No 94 93 95 95 93 With current financial incentive in your practice, how often does providing best quality of care mean less income for you? Often 23 19 25 23 23 Sometimes 28 25 30 28 28 Rarely 17 17 16 16 17 Never 31 38 26 31 31 92 Table VI-3. Incentives and Disincentives to Providing Quality Care Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Percent Distribution (Weighted) 100% 23 22 55 8% 30% 62% Which of the following are factors in determining your compensation? Productivity or billing Not a factor 27 22 25 29 31 31 24 Minor factor 14 14 13 15 21 15 13 Major factor 58 64 61 54 48 53 62 Board re-certification status Not a factor 60 50 58 64 62 56 61 Minor factor 28 69 29 23 28 31 26 Major factor 11 11 11 11 9 12 12 Measures of clinical care Not a factor 72 71 74 70 70 73 71 Minor factor 19 22 17 18 19 18 19 Major factor 8 7 8 9 10 8 8 Patient surveys and experience Not a factor 72 73 75 70 73 71 72 Minor factor 19 20 16 20 17 20 19 Major factor 8 6 8 8 9 7 8 Quality bonus or incentive payments from insurance Not a factor 80 79 84 79 82 80 79 Minor factor 15 17 11 15 14 13 16 Major factor 4 4 4 4 4 4 4 93 Years in Practice Hours in Direct Patient Care 16 or 10 Years 11–15 More 20 Hours 21–40 More than Questions Total or Less Years Years or Fewer Hours 40 Hours Receives reimbursements for the following? E-mail with patients Yes, from health plans or HMOs * 1 — * * * * Yes, from other sources * * * * — * 1 No 99 99 99 98 99 99 98 Phone consultation with patients Yes, from health plans or HMOs 1 1 1 1 2 1 1 Yes, from other sources 3 2 3 3 6 3 2 No 96 97 96 95 91 96 96 Group patient visits Yes, from health plans or HMOs 3 3 2 3 3 3 3 Yes, from other sources 2 2 4 2 5 3 2 No 94 95 94 93 90 93 94 With current financial incentive in your practice, how often does providing best quality of care mean less income for you? Often 23 23 23 23 22 20 24 Sometimes 28 26 30 28 26 29 28 Rarely 17 17 16 17 20 19 15 Never 31 32 31 31 33 32 31 94 NOTES 1 Berwick DM, Godfrey AB, Roessner J. Curing Health Care: New Strategies for Quality Improvement. San Francisco, CA: Jossey-Bass Inc., 1990. 2 Leatherman S, Berwick D, Iles D, Lewin LS, Davidoff F, Nolan T, Bisognano M. The business case for quality: case studies and an analysis. Health Aff. 2003;22:17-30. 3 Miller RH, Sim I. Physicians’ use of electronic medical records: barriers and solutions. Health Aff. 2004;23:116-126. 4 Miller RH, Sim I, Newman J. Electronic Medical Records: Lessons from Small Physician Practices. California HealthCare Foundation iHealth Report. 2003. Available at: http://www.chcf.org/ documents/ihealth/EMRLessonsSmallPhyscianPractices.pdf. Accessed October 20, 2004. 5 Miller, Physicians’ use, 2004. 6 Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in US primary care. J Am Med Inform Assoc. 2003;10:1-10. 7 Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and outcomes. JAMA. 1998;280:1339-1346. 8 Kane CK. Physician Marketplace Report. Center for Health Policy Research, American Medical Association, 2001. 9 Miller, Physicians’ use, 2004. 10 Mitchell E, Sullivan F. A descriptive feast but an evaluative famine. BMJ. 2001;322:279-282. 11 Fidler H, Lockyer JM, Toews J et al. Changing physicians’ practices: the effect of individual feedback. Acad Med. 1999;74:702-714. 12 Kane, Physician Marketplace Report, 2001. 13 Schoenbaum SC, Audet A-MJ, Davis K. Obtaining greater value from health care: the roles of the U.S. Government. Health Aff. 2003;22:183-190. 14 US Department of Health and Human Services. The Budget for Fiscal Year 2005. Available at: http://a255.g.akamaitech.net/7/255/2422/02feb20041242/www.gpoaccess.gov/usbudget/fy05/ pdf/budget/hhs.pdf. Accessed May 6, 2005. 15 Ibid. 16 Goldsmith J, Blumenthal D, Rishel W. Federal health information policy: a case of arrested development. Health Aff. 2003;22:44-55. 17 Coye MJ, Bernstein WS. Improving America’s health care system by investing in information technology. Health Aff. 2003;22:56-58. 18 Taylor H, Leitman R, eds. European physicians especially in Sweden, Netherlands and Denmark, lead US in use of electronic medical records. Health Care News (Harris Interactive). 2002;2. Available at: http://www.harrisinteractive.com/news/newsletters/healthnews/ HI_HealthCareNews2002Vol2_Iss16.pdf. Accessed October 20, 2004. 19 US Department of Health and Human Services. HHS Health Informatics Initiative: Improving Information for Decision-Making. Available at: http://aspe.hhs.gov/datacncl/informatics.htm. Accessed October 20, 2004. 20 California HealthCare Foundation. Santa Barbara County Care Data Exchange. Available at: http://www.chcf.org/documents/ihealth/SantaBarbaraFSWeb.pdf. Accessed October 20, 2004. 95 21 Accreditation Council for Graduate Medical Education. Common Program Requirements. 2004. Available at: http://www.acgme.org/DutyHours/dutyHoursCommonPR.pdf. Accessed December 12, 2004. 22 Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001. 23 For more information, see the Leapfrog Group compendium, available at http://www.leapfroggroup.org/leapfrog_compendium. 24 Hunt, Effects of computer-based, 1998; See also: Bates DW, Leape LL, Cullen DJ et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316; Miller, Electronic Medical Records, 2003. Available at: http://www.chcf.org/documents/ihealth/EMRLessonsSmallPhyscianPractices.pdf. Accessed October 20, 2004; Bates, Proposal for electronic, 2003; Mitchell, A descriptive feast, 2001. 25 McDonald CJ, Overhage JM, Tierney WM et al. The Regenstrief Medical Record System: a quarter century experience. International Journal of Medical Informatics. 1999;54:225-253. See also: Schoenbaum SC, Barnett GO. Automated ambulatory medical records systems. International Journal of Technology Assessment in Health Care. 1992;8:598-609; Reichert JC, Glasgow M, Narus SP, Clayton PD. Using LOINC to link an EMR to the pertinent paragraph in a structured reference knowledge base. Proceedings/AMIA Annual Symposium. 2002:652-6; Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593-600. 26 Audet A-MJ, Doty MM, Peugh J, Shamasdin J, Zapert K, Schoenbaum SC. Information technologies: when will they make it into physicians’ black bags? Medscape General Medicine. Dec. 6, 2004. 27 IOM Committee on Quality, Crossing the Quality Chasm, 2001. 28 Blumenthal D, Epstein AM. The role of physicians in the future of quality management— part six of six. N Engl J Med. 1996;335:1328-1332. 29 Cabana MD, Rand CS, Powe NR et al. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282:1458-1465. 30 Gandhi T, Sittig DF, Franklin M, Sussman AJ, Fairchild DG. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15:626-631. 31 IOM Committee on Quality, Crossing the Quality Chasm, 2001. 32 Adams K, Corrigan J, eds. and Committee on Identifying Priority Areas for Quality Improvement. Priorities for National Action: Transforming Health Care Quality. Institute of Medicine, National Academy of Sciences. Washington DC: National Academy Press, 2003. 33 Naylor MD, Brooten D, Campbell R, Jacobsen B, Mezey M, Pauly M, Schwartz J. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized controlled trial. JAMA. 1999;281:613-620. 34 Gandhi, Communication breakdown, 2000. 96