A national study of small and midsize physician practices finds that, although a quarter of them use electronic health records for progress notes, much smaller percentages are using those EHRs for the functions that specialty societies have defined as essential components of the patient-centered medical home. These elements include electronic disease registries, electronic prescribing, online messaging with patients, improvement of care processes, and care coordination across healthcare settings.

Overall, the survey of practices ranging from one to 19 doctors shows that, on average, they use only about a fifth of the care processes required for medical homes. This has implications for healthcare reform and for accountable care organizations (ACOs), which will require a level of care coordination far higher than today's norm.

Smaller practices had far fewer of the requisite care processes than large ones did, including IT components such as EHRs, electronic prescribing, registries, electronic data for quality measurement, and clinical decision support tools.

For example, just 17% of one- and two-doctor practices had EHRs, versus 26% for the entire cohort. Similarly, less than 19% of the small practices did e-prescribing, compared to 28% for all of the groups.

The prevalence of registries was also largely a function of size. Overall, 9% of the practices had registries, and just 6% of the very small ones did. In contrast, 34% of practices in the 13 to 19-doctor range used registries to track and reach out to patients who needed preventive or chronic care.

Overall, the majority of physicians communicated online with patients in just under 9% of the practices.

Why are so many practices with EHRs not using key functions that could improve the quality of care? "Both the registries and the email with patients require somewhat more change and energy and effort on the part of practices than simply incorporating progress notes," explained Steven M. Shortell, dean of the School of Public Health and professor of health policy and management, University of California at Berkeley. Smaller practices, he added, have fewer resources than big ones, so they take longer "in ramping up to provide an EHR's full functionality."

Whether or not physicians exchange secure email with their patients, he added, depends partly on whether the patients are online and whether they want to communicate with their doctors that way. "So part of it is the nature of the patient population those practices are dealing with," he said.

As for registries, Shortell pointed out, some practices are building them for patients with diabetes, but they rarely go beyond that. "Many of these are small practices and don't have the time or technical support to develop these kinds of things," he said.

An earlier study of a medical home pilot found that using registries, e-prescribing, and patient portals was more difficult than expected "because the health IT currently marketed to primary care practices resembles a jumble of jigsaw pieces rather than components of an integrated and interoperable system."

Shortell noted that small physician groups need leadership and technical assistance to surmount the obstacles to full EHR implementation. The regional extension centers (RECs) funded by the federal government will probably do more to help these practices than the Meaningful Use incentive program will, he predicted.

However, only 31,000 of the 81,000 physicians who have signed up for the REC program so far are small practices, according to Kaiser Health News.

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