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Orav, Endel

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    Physicians and Electronic Health Records: A Statewide Survey
    (American Medical Association (AMA), 2007-03-12) Simon, Steven R.; Kaushal, Rainu; Cleary, Paul; Jenter, Chelsea A.; Volk, Lynn A.; Orav, Endel; Burdick, Elisabeth; Poon, Eric G.; Bates, David
    Background: Electronic health records (EHRs) allow for a variety of functions, ranging from visit documen- tation to laboratory test ordering, but little is known about physicians’ actual use of these functions. Methods: We surveyed a random sample of 1884 phy- sicians in Massachusetts by mail and assessed availabil- ity and use of EHR functions, predictors of use, and the relationships between EHR use and physicians’ percep- tions of medical practice. Results: A total of 1345 physicians responded to the sur- vey (71.4% response rate), and 387 (28.8%) reported that their practice had adopted EHRs. More than 80% of phy- sicians with EHRs reported having the ability to view labo- ratory reports (84.8%) and document visits electroni- cally (84.0%), but considerably fewer reported being able to order laboratory tests electronically (46.8%) or trans- mit prescriptions to a pharmacy electronically (44.7%). Fewer than half of the physicians who had systems with clinical decision support, transmittal of electronic pre- scriptions, and radiology order entry actually used these functions most or all of the time. Compared with phy- sicians who had not adopted EHRs, EHR users reported more positive views of the effects of computers on health care; there were no significant differences in these atti- tudes between high and low users of EHRs. Overall, about 1 in 4 physicians reported dissatisfaction with medical practice; there was no difference in this measure by EHR adoption or use. Conclusions: There is considerable variability in the func- tions available in EHRs and in the extent to which phy- sicians use them. Future work should emphasize fac- tors that affect the use of available functions.
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    Both The 'Private Option And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults
    (Health Affairs (Project Hope), 2016) Sommers, Benjamin; Blendon, Robert; Orav, Endel
    Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the “private option”). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November–December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky’s traditional Medicaid expansion and Arkansas’s private option, which suggests that both approaches improved access among low-income adults.
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    Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance
    (American Medical Association (AMA), 2016) Sommers, Benjamin; Blendon, Robert; Orav, Endel; Epstein, Arnold
    Importance Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the “private option”). In addition, while coverage gains from the ACA’s Medicaid expansion are well documented, impacts on utilization and health are unclear. Objective To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA. Design, Setting, and Participants Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016. Exposures Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas. Main Outcomes and Measures Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health. Results Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (−11.6 percentage points; P < .001), reduced out-of-pocket spending (−29.5%; P = .02), reduced likelihood of emergency department visits (−6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (−7.1 percentage points with “fair/poor quality of care”; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P  < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences. Conclusions and Relevance In the second year of expansion, Kentucky’s Medicaid program and Arkansas’s private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.
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    Three-Year Impacts Of The Affordable Care Act: Improved Medical Care And Health Among Low-Income Adults
    (Health Affairs (Project Hope), 2017) Sommers, Benjamin; Maylone, Bethany; Blendon, Robert; Orav, Endel; Epstein, Arnold
    Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA’s coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in “excellent” self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health.
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    Does the Computerized Display of Charges Affect Inpatient Ancillary Test Utilization?
    (American Medical Association (AMA), 1997-11-24) Bates, David; Kuperman, Gilad J.; Jha, Ashish; Teich, Jonathan; Orav, Endel; Ma'luf, Nell; Onderdonk, Andrew; Pugatch, Robert; Wybenga, Donald; Winkelman, James; Brennan, Troyen; Komaroff, Anthony; Tanasijevic, Milenko
    Background: The computerized display of charges for ancillary tests in outpatients has been found to affect physician-ordering behavior, but this issue has not been studied in inpatients. Objective: To assess whether the computerized display of charges for clinical laboratory or radiological tests affected physician-ordering behavior. Patients and methods: Two prospective controlled trials, randomized by patient, were performed. Each trial included all medical and surgical inpatients at 1 large teaching hospital during 4 and 7 months: 3536 intervention and 3554 control inpatients in the group with clinical laboratory tests, and 8728 intervention and 8653 control inpatients in the group with radiological tests. The intervention consisted of the computerized display of charges for tests at the time of ordering. Main outcome measures: The number of clinical laboratory and radiological tests ordered per admission and the charges for these tests. Results: For the clinical laboratory tests, during a 4-month study period, patients in the intervention group had 4.5% fewer tests ordered, and the total charges for these tests were 4.2% lower, although neither difference was statistically significant. Compared with historical controls from the same 4-month period a year before, the charges for the tests per admission had decreased 13.3%, but the decrease was temporally correlated with a restriction of future ordering of tests, and not with the introduction of the display of charges. For the radiological tests, during a 7-month period, the intervention group had almost identical numbers of tests ordered and charges for these tests. Conclusions: The computerized display of charges had no statistically significant effect on the number of clinical laboratory tests or radiological procedures ordered or performed, although small trends were present for clinical laboratory tests. More intensive interventions may be needed to affect physician test utilization.
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    Impact of an Automated Test Results Management System on Patients' Satisfaction About Test Result Communication
    (American Medical Association (AMA), 2007-11-12) Matheny, Michael; Gandhi, Tejal; Orav, Endel; Ladak-Merchant, Zahra; Bates, David W.; Kuperman, Gilad J.; Poon, Eric G.
    Background: Few reliable and efficient systems sup- port the communication of test results to outpatients, and this may lead to patient dissatisfaction with test result communication. The objective of this study was to assess the impact of physicians’ use of a test results management tool embedded in an electronic health record on patient satisfaction with test result communication. Methods: A prospective, cluster-randomized, con- trolled trial of 570 patient encounters in 26 outpatient primary care practices was performed from December 1, 2002, to April 31, 2005. Physicians in the intervention practices were trained and given access to a physician test results management tool with imbedded patient notification functions to evaluate whether patient satisfaction with communication of test results ordered by the primary care provider was improved. Patient satisfaction surveys were conducted by telephone after the patient underwent the test and were administered before and after the intervention in both arms. Results: The survey response rate after successful patient contact was 74.2% (570/768). After adjusting for patient age, sex, race, socioeconomic status, and insurance type, the intervention significantly increased patient satisfaction with test results communication (odds ratio, 2.35; 95% confidence interval, 1.05-5.25; P=.03). In addition, patients in the postintervention group were more satisfied with information given them for medical treatments and conditions regarding their results (odds ratio, 3.45; 95% confidence interval, 1.30-9.17; P = .02). Conclusion: An automated test results management system can improve patient satisfaction with communication of test results ordered by their primary care provider and can improve patient satisfaction with the communication of information regarding their condition and treatment plans.