1

Physicians’ Views on Quality of Care:Findings from the Commonwealth Fund

National Survey of Physiciansand Quality of Care

Anne-Marie J. Audet, Michelle M. Doty,Jamil Shamasdin, and Stephen C. Schoenbaum

May 2005

2

Chapter I

Information Technologies:Current Use, Future Plans,

and Perceived Barriers

3

Use of Information Technologiesin Clinical Practice

4

73

37

18 176 7

6

21

9 918 21

314

0

20

40

60

80

100

Electronic

Billing

Access

to Test

Results

Electronic

Medical

Records

Electronic

Ordering

Clinical

Decision

Support

E-mail

with

Doctors

E-mail

with

Patients

Percent indicating “routine” or “occasional” use

Chart I-1. Use of Information Technologies

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

58

27 27 2428

18

Yes, used routinely

Yes, used occasionally

* Electronic ordering of tests, procedures, or drugs.

*

79

5

1413

36

61

23 25

66

35 3746

57

87

0

25

50

75

100

Electronic Access to

Test Results

Electronic Medical

Records

Electronic Ordering

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Chart I-2. Electronic Access to PatientTest Results, Electronic Medical Records,and Electronic Ordering, by Practice Size

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent who currently “routinely/occasionally” use the following

* Electronic ordering of tests, procedures, or drugs.

*

6

61

33

161719 21 21

13

2935

19

40

0

25

50

75

100

Clinical Decision Support E-mail with Doctors E-mail with Patients

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Chart I-3. Use of Clinical Decision Support,E-mail with Doctors, and E-mail with Patients,

by Practice Size

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent who currently “routinely/occasionally” use the following

7

12 10 21

33

3126

0

50

100

Drug Alerts Follow-Up Alerts Reminders

Yes, using a manual system

Yes, using a computerized system

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

38 41

54

8

21

31

1356

10 9

2217

11

2327

0

25

50

75

100

Drug Alerts Follow-Up Alerts Reminders

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Chart I-5. Use of Electronic Drug Alerts,Follow-Up Alerts, and Reminders, by Practice Size

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent who currently use a “computerized system” for the following

9

Future Use of IT

10

614 20 19 17 12 11

15

27

53 53 5857

71

0

20

40

60

80

100

Electronic

Billing

Access

to Test

Results

Electronic

Medical

Records

Electronic

Ordering

Clinical

Decision

Support

E-mail with

Doctors

E-mail with

Patients

Percent expecting use

Chart I-6. Planned Future Use of IT

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

41

Not used, PLAN to use within next year

Not used, NO plan to use within next year

63 62 7569

82

* Electronic ordering of tests, procedures, or drugs.

*

21

11

16 13 10

344344

0

50

100

Drug Alerts Follow-Up Alerts Reminders

Not done, NO plan to in next year

Not done, PLAN to in next year

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart I-7. Planned Future Use ofReminders or Alerts

Percent expecting future use of the following

60 56

44

12

28 22

53 73 37

22

211320

56

0

50

100

Total 1 Physician 2–9

Physicians

10–49

Physicians

50+

Physicians

Not used, NO plan to use within next year

Not used, PLAN to use within next year

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart I-8. Planned Future Use ofElectronic Medical Records, by Practice Size

Percent expecting use

73

8677

65

44

13

Perceived Barriers to IT Adoption

14

56%

39%

37%

26%

21%

16%

28%

40%

44%

46%

38%

49%

47%

15%

14%

16%

15%

35%

29%

36%

44%

Start-up costs

Lack of uniform standards

Lack of time

Maintenance costs

Lack of evidence of effectiveness

Privacy concerns

Lack training/knowledge

Major Barrier Minor Barrier Not a Barrier

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart I-9. Barriers to Adoption

15

1115

30

40

62 59

2417

49

17 19

43

0

25

50

75

100

Start-Up Costs Scientific Evidence Privacy Concerns

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart I-10. Barriers to Adoption ofInformation Technologies, by Practice Size

Percent indicating start-up costs, scientific evidence, or privacy concernsas a “major barrier” to greater use of information technologies

16

Chapter II

Practice-Level and Performance Data: Availability,

Sources,and Willingness to Share

17

Access to Patient Panel Data

18

Chart II-1. Physicians’ Access toPatient Panel Data

51 55

83 84

43

0

50

100

Age Group Diagnosis/

Health Risk

Lab Results Current

Medications

Any Data

Percent indicating “very/somewhat” difficult or cannot generate lists of patients by

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

19

6157 6150

58

0

50

100

Total 1 Physician 2–9

Physicians

10–49

Physicians

50+

Physicians

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart II-2. Physicians’ Access toAny Patient Panel Data, by Practice Size

Percent indicating “very/somewhat” easy to generate lists of patients using any* criteria

* 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.

20

27 27

1212

3946

12 12

46

22 20

45

0

25

50

75

100

Diagnosis/Health Risk Lab Results Current Medications

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Chart II-3. Physicians’ Access toPatient Panel Data, by Practice Size

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent indicating “very/somewhat” easy to generate lists of patients by

21

Chart II-4. Physicians’ Access to Any PatientPanel Data, by Electronic Medical Record Use

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

5762

55

0

50

100

Total EMR Used Routinely/

Occasionally

Do Not Use EMR

Percent indicating “very/somewhat” easy to generate lists of patients using any* criteria

* 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.

22

Access to Quality-of-Careor Performance Data

23

Chart II-5. Physicians’ Access toQuality-of-Care or Performance Data

20 1825

33

0

50

100

Process of Care

Data

Clinical

Outcomes Data

Patient Survey

Data

Any Data

Percent receiving data on the following aspects of patient care

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

24

27

1511

1421 18

2420 23

29

44

27

0

25

50

75

100

Process of Care Clinical Outcomes Data Patient Survey Data

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Chart II-6. Physicians’ Access toQuality-of-Care Data, by Practice Size

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent receiving data on the following aspects of patient care

25

25

13

7

7

4

3

3

1

3No answer

Other

Employer groups

Regulatory agencies

CMS

Professional societies

Accreditation agencies

Internal sources

Health plans

Percent of physicians indicating each as a source of quality of care data

Chart II-7. Physicians’ Sources ofQuality-of-Care Data

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

26

1121

28

611

20

0

50

100

1 Physician 2–9

Physicians

10–49

Physicians

50+

Physicians

EMR Used

Routinely/

Occasionally

Do Not Use

EMR

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart II-8. Physicians’ Ability to GenerateAny Quality-of-Care Data Internally

Percent indicating they receive quality-of-care data from internal sources

27

Ability to Benchmark

28

3%

1%

1%

11%

19%

22%

24%

No comparison with other physicians possible

Some other comparison group

Other hospitals/clinics/health centers

Other physicians nationally

Other physicians in practice/local area

Other physicians in the same health plan

Other physicians in specialty

Percent of physicians able to compare themselves to

Chart II-9. Physicians’ Ability toCompare Performance

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

29

Sharing Performance Information

30

Medical leadership

Physicians’ own patients

General public

Willingness to share data with:*

27%

44%

69%

Chart II-10. Physicians’ Willingnessto Share Quality-of-Care Data

No, Definitely/ Probably Not

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Yes, Definitely/ Probably

71%

55%

29%

Other physicians 26%72%

* 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?”

31

Chapter III

Physicians’ Involvementin Quality Improvement

Activities

32

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent indicating involvement in redesign and collaborative efforts

Chart III-1. Physicians’ Participation in Redesign and Collaborative Activities, by Practice Size

43

20

3339

50

32

47

35

24

34

0

50

100

Redesign Efforts Collaborative Efforts

Total 10–49 Physicians1 Physician 50+ Physicians2–9 Physicians

* Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years.

*

33

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

3036

3231

4234

0

50

100 Total Primary care physician Specialist

Redesign Efforts Collaborative Efforts

* Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years.

*

34

67

23

8 6

0

50

100 No, have not been involved Yes, a LOCAL effort

Yes, a REGIONAL effort Yes, a NATIONAL effort

Chart III-3. Physicians’ Involvement in Collaborative Efforts to Improve Quality of Care

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent indicating involvement in any collaborative efforts in past two years*

* Multiple answers possible.

Involved in at least one effort (32%)

35

817683

6877

0

50

100

Total 1 Physic ian 2-9

Physic ians

10-49

Physic ians

50+

Physic ians

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 effortsis “very/somewhat” effective in improving quality of care

36

Chapter IV

Coordination of Careand Referrals

37

Patient’s medical record, test results, or other relevant clinical information were not available at the time of the scheduled visit

Tests or procedures had to be repeated because findings were unavailable or inadequate for interpretation

Patient’s care was compromised because he/she received conflicting information from different doctors or other health professionals

Patient experienced a problem following discharge from a hospital because physician did not receive needed information from the hospital in a timely manner

Coordination of care problems

72%

34%

28%

26%

Chart IV-1. Coordination of Care ProblemsPhysicians Observe

Percent who observed problem sometimes or

often in past 12 months

Patient had a positive test result that was not followed-up appropriately 15%

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Patient received the wrong drug, wrong dose, or had a preventabledrug-drug interaction

11%

38

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

76

44

333333

7874

64

0

50

100

Clinical InformationNot Available at Visit

Tests Repeated

10–49 Physicians1 Physician 50+ Physicians2–9 Physicians

Chart IV-2. Coordination of Care Problems, by Practice Size

Percent who say “often/sometimes” observed the following

39

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

22

13 14109

171510

0

50

100

Test ResultsNot Followed Up Properly

Wrong Dose/Medication

Chart IV-3. Coordination of Care Problems, by Practice Size

Percent who say “often/sometimes” observed the following

10–49 Physicians1 Physician 50+ Physicians2–9 Physicians

40

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

29 2734

243129

2425

0

50

100

Patient Experienced Coordination Problem Post

Hospital Discharge*

Patient’s Care Compromised Because He/She Received

Conflicting Information

Chart IV-4. Coordination of Care Problems, by Practice Size

Percent who say “often/sometimes” observed the following

10–49 Physicians1 Physician 50+ Physicians2–9 Physicians

* A patient experienced a problem following discharge from a hospital becausehis/her physician did not receive needed information from the hospital in a timely manner.

41

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

32

23

37

28

0

50

100

Tests Repeated

Primary care physician Specialist

Chart IV-5. Coordination of Care Problems, by Physician Type

Percent who say “often/sometimes” observed the following

Patient Experienced Coordination Problem

Post-Hospital Discharge*

* A patient experienced a problem following discharge from a hospital becausehis/her physician did not receive needed information from the hospital in a timely manner.

42

152317

43

54

46

0

50

100

Total Primary Care Physician Specialist

Often

Always

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart IV-6. Ability of Physicians to ProvideSame-Day Appointments, by Physician Type

Percent indicating how often they can provide same-day appointments

64

77

58

43

Chart IV-7. Receipt of TimelyReferral Information

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent who say they receive timely information about the results of a referral

Often54%

Sometimes28%

Rarely6%

Always11%

34%

44

67 66

55 58

7162

0

25

50

75

100

1

Physician

2–9

Physicians

10–49

Physicians

50+

Physicians

Primary

Care

Physician

Specialist

Chart IV-8. Receipt of TimelyReferral Information

Percent who say they “always/often” receive timely informationabout the results of a referral

Practice Size Physician Type

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

45

Chart IV-9. Availability of Quality-of-Care Data When Making Referrals

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent indicating how often they have any data about a physician’squality of care when making referrals

Often14%

Sometimes16%

Rarely32%

Always5%

Never32%

64%

46

2417 15 17 18

11

22

0

25

50

75

100

1 Physician 2–9

Physicians

10–49

Physicians

50+

Physicians

10 Years or

Less

11–15

Years

16+ Years

Years in PracticePractice Size

Chart IV-10. Availability of Quality-of-Care Data When Making Referrals

Percent indicating they “always/often” have data about a physician’squality of care when making a referral

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

47

Physician’s technical qualifications (e.g., training, education, board certification)

Experiences with the physician

Physician’s bedside manner, as reported by patients

25%

64%

25%

Chart IV-11. Relative Importance ofQuality-of-Care Data

Percent indicating following information is MORE

important than quality-of-care data*

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Physician’s reputation among peers 42%

* Indicates physicians who responded that the above information was more important than quality-of-care data.

48

Chapter V

Strategies to Improve Quality of Care

49

21%

23%

25%

35%

41%

52%

Better treatment guidelines for common conditions

Better information on best specialized

physicians/centers

More use of computer technology

Improved teamwork and communication

Better patient access to preventive care

Having more time to spend with patients

Percent of physicians who indicate the followingare “very effective” in improving quality of care

Chart V-1. Physicians’ Opinions on Strategiesto Improve Quality of Care

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

50

The team process makes care more cumbersome

The involvement of multiple team members increasesthe likelihood of medical errors

32%

24%

Chart V-2. Physicians’ Opinion on Team Care

Percent indicatingthey “agree” or

“strongly agree” that*

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

The give and take among team members results inbetter decisions regarding patient care

73%

* Indicates physicians who, based on their experience working in teams,said that they agree or disagree with the above.

51

Chart V-3. Physicians’ Opinion on Team Care,by Practice Size

65

3732

73

3323

80

2819

81

2717

0

50

100

The give and take among team

members results in better

decisions regarding patient

care

The team process makes care

more cumbersome

The involvement of multiple

team members increases the

likelihood of medical errors

1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent who agree/strongly agree

52

4133 32

45

0

25

50

75

100

Primary Care

Physician

Specialist Male Female

GenderPhysician Type

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

53

Chapter VI

Incentives and Disincentives to Providing Quality Care and

Physicians’ Satisfactionwith Current Practice

54

8%

11%

58%

15%

19%

19%

28%

14%

80%

72%

72%

60%

27%

4%

8%

Quality Bonus/Incentive Payments from

Insurance Plans

Patient Surveys/ Experience

Measures of Clinical Care

Board Re-Certification Status

Productivity/ Billing

Major Factor Minor Factor Not a Factor

Chart VI-1. Factors AffectingPhysicians’ Compensation

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Percent indicating the following as factorsin determining compensation or income

72%

39%

27%

27%

19%

55

4641

5258

51

0

50

100

Total 1 Physician 2–9

Physicians

10–49

Physicians

50+

Physicians

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

56

Very satisfied33%

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart VI-3. Physicians’ Satisfaction withCurrent Medical Practice

Somewhat satisfied45%

Somewhat dissatisfied17%

Very dissatisfied5%

57

14

2119

27

21

0

25

50

Total 1 Physician 2–9

Physicians

10–49

Physicians

50+

Physicians

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Chart VI-4. Physicians’ Dissatisfaction withCurrent Practice, by Practice Size

Percent “very or somewhat” dissatisfied with current practice

58

Appendix

Profile ofPhysician Respondents

59

Practice Characteristics Total1

Physician2–9

Physicians10–49

Physicians50+

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

Chart A-1. Characteristics of Small and Large Group Physician Practices

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.