Longitudinal Analysis of the Impact of Electronic Health Record and Patient Centered Medical Home Adoption on Staffing Mix in Community Health Centers

Community health centers (CHCs) have been a leader in the adoption of electronic health record (EHR) systems. In CHCs, EHR adoption preceded adoption of the Patient Centered Medical Home (PCMH) model. Both initiatives may have particular impact on lower skilled staff. Research suggests that EHRs require more support staff to facilitate adoption while negatively impacting clinical productivity. PCMH may lead to staffing reconfigurations including the addition of lower skilled staff to help coordinate care and follow up. With ongoing concerns about staffing shortages and challenges in retention in primary care settings, further investigation is needed to understand how these initiatives interact and ultimately impact staff configurations. This study addresses two questions: 1) How does the staffing mix differ before and after the adoption of EHRs in CHCs? 2) Does PCMH status have any incremental impact on staffing mix in a CHC?

The authors primarily use the 2007 to 2013 Uniform Data System (UDS), which is an annual administrative reporting system for all CHCs, to obtain occupation specific full-time equivalent (FTE) data, and facility and patient characteristics. The authors merge in responses on years of EHR experience from a survey called, “Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey.” The authors obtained data on the year of PCMH adoption from the Health Resources and Services Administration (HRSA). Additional data on local labor market conditions such as number of physicians per capita are extracted from the Area Health Resource File collected by HRSA. The final sample size was 750 unique CHCs, or 5250 CHC-year observations.

Using a pooled longitudinal sample, the authors use a fractional multinomial logit model to estimate the change in proportion of staffing across four categories of medical staff (i.e., physicians, advanced level providers, nurses, and other medical personnel) as a function of year of EHR adoption and year of PCMH adoption controlling for facility and patient characteristics, and market conditions. The authors find that that adoption of EHR is associated with a significant reduction in the share of primary care physicians on staff, but significantly increase the share of advanced level providers and nurses. PCMH did not have a significant impact on the change the staffing mix of providers over the time period. The authors conclude that EHRs significantly shift the staffing models of CHCs toward a less skilled workforce. CHCs that adopted PCMH may not have needed to make additional changes after EHR adoption, although changes in roles may be undetected.