This study examines adoption of electronic health records and participation in health information exchange by New York state nursing homes over time.
Published Online: January 21, 2015
Erika L. Abramson, MD, MS; Alison Edwards, MS; Michael Silver, MS; Rainu Kaushal, MD, MPH; and the HITEC investigators
Only being part of a nursing home chain was significantly associated with having an EHR (odds ratio [OR] = 1.9; 95% CI, 1.0-3.4) (Appendix Table 1). Being affiliated with a hospital (OR = 2.4; 95% CI, 1.2-4.8), having an EHR (OR = 2.2; 95% CI, 1.5-3.2), and being a private nonprofit nursing home versus a for-profit nursing home (OR = 1.8; 95% CI, 1.3-2.7) were all significantly associated with HIE participation.
We also looked specifically at the 141 nursing homes that did not have EHRs in 2012 to identify any characteristics that distinguished the 2013 adopters (n = 45) from those who remained nonadopters (n = 96). We found no difference in facility characteristics between these 2 groups; however, among recent adopters we saw a significant increase in the use of many available computerized functionalities, a change we did not see among nonadopters. This was true for 16 of 23 functionalities, including 4 of 6 administrative functionalities, all documentation functionalities, all order entry functionalities, and consult viewing.
Similarly, we looked specifically at the 129 nursing homes that did not participate in HIE in 2012. We compared characteristics of those that participated in HIE in 2013 (n = 60) to nonparticipants both years (n = 69). We found that more of the facilities that newly engaged in HIE were medium-size (P = .02). In addition, there was significantly greater adoption in those facilities of several computerized functionalities—specifically medical history documentation (P = .04), allergy documentation (P = .04), and electronic laboratory results viewing (P = .01).
Barriers to EHR Adoption
The top barriers to EHR adoption among nursing homes without an EHR were stated to be: a) initial cost of HIT investment (67.9%, n = 133), b) lack of technical IT staff (46.4%, n = 91), and c) lack of fiscal incentives (45.8%, n = 88). Significantly more nursing homes without an EHR identified these as major barriers compared with those that had an EHR (P = .001, P <.0001, P = .03, respectively) (eAppendix Table 2).
To our knowledge, this study represents the only large-scale study to track EHR adoption and HIE participation by nursing homes over time. Our results show that there was a 7.7 percentage point increase in EHR adoption among NYS nursing homes between 2012 and 2013, and rates of HIE participation remained stagnant. These results provide important information about the pace of HIT adoption in nursing homes that can help guide policy discussions. Our results suggest that nursing homes are not keeping pace with the achievements in HIT acquisition seen among office-based providers and hospitals. National data from the CDC show that adoption of any EHR system (defined similarly to our study) by office-based physicians increased from 71.8% to 78.4% between 2012 and 2013.20 While this is also a 6.6 percentage point change, rates of overall EHR adoption by providers are much higher. Between 2011 and 2012, the adoption of EHR grew from 51.7% to 71.8%.2 Prior to the start of incentive payments, rates of adoption were increasing only 4% per year.
Among hospitals nationally, rates of adoption of at least a basic EHR system have nearly tripled since 2010, increasing by 15 percentage points from 2012 to 2013.21 While this comparison differs slightly in that we assessed adoption of any EHR system, not utilizing the stricter criteria for a basic EHR system as defined by the Office of National Coordinator for Health Information Technology in the above report, it is worth noting that 87% of all hospitals in 2013 reported receiving at least 1 meaningful use incentive payment (and thus, by definition, must have an EHR).3 Prior to 2010, rates of EHR adoption were increasing only 3% per year among US hospitals. Also of note, in NYS, we did a similar cross-sectional survey of hospitals assessing adoption of any EHR and participation in HIE, and found that as of 2012, 97% of hospitals had adopted an EHR and 79% were engaging in HIE with other partners (manuscript in press).
Among nursing homes with EHRs, the proportion of computerized functionalities available significantly increased for many functions between 2012 and 2013. Unfortunately, 2 areas where this did not occur were order entry and clinical tools. These areas are generally more difficult to implement; however, their use is likely necessary to achieve maximal quality and safety benefits. Such gains have already been seen in the nursing home setting. For example, several dozen nursing homes in California reduced their rates of pressure ulcers by 42% to 55% through use of clinical decision support embedded in EHRs.22
Our data suggest that the pace of HIT adoption will be much slower in healthcare sectors not receiving financial incentives, such as nursing homes. Indeed, 2 of the top barriers to adoption identified in our survey were the initial cost of HIT investment and lack of fiscal incentives. This is supported by research in other sectors excluded from the EHR Incentive Program. For example, a recent national study examining EHR adoption among non-acute care hospitals not eligible for federal incentives found that only 6% of long-term care hospitals, 4% of rehabilitation hospitals, and 2% of psychiatric hospitals have at least a basic EHR system.23 By comparison, among office-based physicians eligible for EHR incentives, top barriers to adoption often center around work flow challenges, lack of interoperability of EHR systems, and the costs of purchasing and maintaining EHRs.24
In contrast to EHR adoption, there was no change in HIE participation between 2012 and 2013. Among the nursing homes we surveyed, 50.5% engaged in HIE with providers within their care system and 27.2% engaged in HIE with providers outside their care system. By comparison, among hospitals nationally as of 2012, 65% were participating in HIE with hospitals inside their organization and 58% were exchanging data with providers outside their organization.25 Similar to hospitals, having an EHR system significantly increases the likelihood of HIE participation in our sample of nursing homes.25 Meaningful use of Stage 2 criteria requires that eligible hospitals who transition patients to another care setting provide a care summary, electronically or via exchange, for a percentage of patients. Perhaps this is helping to facilitate some HIE between nursing homes and hospitals.1 However, there are many challenges to HIE beyond lack of technology, including required collaboration between competitors and lack of sustainable business models.26 These may explain why EHR adoption is increasing, even if slowly, while HIE rates remain unchanged.
There are several limitations to our study. First, our results may be subject to nonresponse biases, although we achieved a 74.9% response rate and there were no differences between respondents and nonrespondents. Our study sample was drawn exclusively from NYS, limiting generalizability. However, as NYS is a leader in HIT investment, it seems likely that rates of EHR adoption and participation in HIE would be lower among nursing homes in other states, underscoring the need for policy focused in this setting. Lastly, we asked about the availability of computerized functions but did not assess usage.
This survey provides important information about the pace of EHR adoption and HIE participation over time among nursing homes in NYS with the largest statewide investment in HIT. We found a 7.7 percentage point increase in rates of EHR adoption between 2012 and 2013, while rates of HIE participation remained stagnant. HIT adoption by nursing homes appears to be lagging compared with other healthcare sectors in which federal policies are incentivizing adoption. To ensure that nursing homes keep pace with the rest of healthcare, it seems critical that public policy should specifically focus on helping nursing homes overcome barriers to EHR adoption and encourage broad participation in HIE.
The authors would like to thank the HITEC investigators and the leadership of the Continuing Care Leadership Coalition, LeadingAge New York, and New York State Health Facilities Association for their support of this project.
Department of Pediatrics and Department of Medicine (ELA, RK), Department of Healthcare Policy and Research, Weill Cornell Medical College and Center for Healthcare Informatics and Policy (ELA, AE, MS, RK), New York, NY; NewYork-Presbyterian Hospital, New York, NY (ELA, RK); and Health Information Technology Evaluation Collaborative, New York, NY (ELA, AE, MS, RK).
Source of Funding:
This project was supported by the New York State Department of Health, contract C025877.
The authors report no relationship or financial interest with any entity that may pose a conflict of interest with the subject of this paper.
Concept and design (ELA, RK); acquisition of data (ELA, RK); analysis and interpretation of data (ELA, AE, MS, RK); drafting of the manuscript (ELA, RK); critical revision of the manuscript for important intellectual content (ELA, AE, MS, RK); statistical analysis (AE, MS); obtaining funding (RK); and supervision (ELA, RK).
Address correspondence to:
Erika L. Abramson, MD, MS, Assistant Professor of Pediatrics and Healthcare Policy and Research, Weill Cornell Medical College of Cornell University, 525 E 68th St, Rm M-610A, New York, NY 10065. E-mail: firstname.lastname@example.org
1. Office of the National Coordinator for Health Information Technology; HHS. Health information technology: standards, implementation specifications, and certification criteria for electronic health record technology, 2014 edition; revisions to the permanent certification program for health information technology. US Government Publishing Office website. http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf
. Published September 4, 2012. Accessed July 21, 2014.
2. Hsiao CJ, Jha AK, King J, Patel V, Furukawa MF, Mostashari F. Office-based physicians are responding to incentives and assistance by adopting and using electronic health records. Health Aff (Millwood)
3. Harvard School of Public Health, Mathematica Policy Research, Robert Wood Johnson Foundation. Health information technology in the United States 2013: better information systems for better care, 2013. Robert Wood Johnson Foundation website. http://www.rwjf.org/content/dam/farm/reportzs/reports/2013/rwjf406758
. Published 2013. Accessed July 21, 2014.
4. Kramer A, Kaehny M, Richard A, May K; HHS. Survey questions for EHR adoption and use in nursing homes: final report. HHS website. http://aspe.hhs.gov/daltcp/reports/2010/ehrques.htm
. Published January 5, 2010. Accessed July 21, 2014.
5. Resnick HE, Manard BB, Stone RI, Alwan M. Use of electronic information systems in nursing homes: United States, 2004. J Am Med Inform Assoc
6. Minnesota e-Health factsheet: nursing homes–adoption and use of EHRs and health information exchange. Minnesota Department of Health website. www.health.state.mn.us/e-health/summaries/factnursinghome2011.pdf
. Published February 6, 2012. Accessed July 22, 2014.
7. Hudak S, Sharky S; Health information technology: are long term care providers ready? California HealthCare Foundation website. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HITNursingHomeReadiness.pdf
. Published April 2007. Accessed July 22, 2014.
8. A snap-shot of the use of health information technology in long term care. American Health Care Association, National Center for Assisted Living website. http://www.amda.com/news/othernews/2007/ahca_hit_longtermcarewhitepage1206.pdf
. Published December 2006. Accessed May 22, 2012.
9. Information technology in long term care–state of the industry: multi-facility research report. American Health Care Association, National Center for Assisted Living website. http://www.ahcancal.org/facility_operations/hit/Documents/InformationTechnologyinLong-TermCare.pdf
. Published April 2007. Accessed May 22, 2012.
10. Cherry B, Carter M, Owen D, Lockhart C. Factors affecting electronic health record adoption in long-term care facilities. J Healthc Qual
11. Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: early adopters in long-term care facilities. Health Care Manage Rev
12. FastStats: nursing home care. CDC website. http://www.cdc.gov/nchs/fastats/nursing-home-care.htm
. Updated May 14, 2014. Accessed July 23, 2014.
13. Levinson DR. Adverse events in hospitals: national incidence among Medicare beneficiaries. HHS website. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
. Published November 2010. Accessed July 23, 2014.
14. Office of the National Coordinator of Health Information Technology. Health IT in long-term and post acute care: issue brief. HealthIT.gov website. http://www.healthit.gov/sites/default/files/pdf/HIT_LTPAC_IssueBrief031513.pdf
. Published March 15, 2013. Accessed July 23, 2014.
15. Abramson EL, McGinnis S, Moore J, Kaushal R. A statewide assessment of electronic health record adoption and health information exchange among nursing homes. Health Serv Res
. 2014;49(1, pt 2):361-372.
16. Office of Health Information Technology Transformation. New York State Department of Health website. http://www.health.ny.gov/technology/
. Revised October 2014. Accessed July 30, 2014.
17. Abramson E, Barrón Y, Quaresimo J, Kaushal R. Electronic prescribing within an electronic health record reduces ambulatory prescribing errors. Jt Comm J Qual Patient Saf
18. Nursing home compare: downloadable database. CMS website. http://www.medicare.gov/NursingHomeCompare/Resources/Downloadable-Database.aspx
. Published August 28, 2012. Accessed July 30, 2014.
19. Nursing homes in New York state – regional offices. New York State Department of Health website. http://www.health.ny.gov/facilities/nursing/regional_offices.htm
. Published August 28, 2012. Accessed July 30, 2014.
20. Hsiao CJ, Hing, E. National Center for Health Statistics Data Brief No. 143: use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013. NCHS website. http://22.214.171.124/nchs/data/databriefs/db143.pdf
. Published January 2014. Accessed August 4, 2014.
21. Charles D, Gabriel M, Furukawa MF; Office of the National Coordinator for Health Information Technology. ONC Data Brief No. 16: adoption of electronic health record systems among U.S. non-federal acute care hospitals: 2008-2013. HealthIT.gov website. http://www.healthit.gov/sites/default/files/oncdatabrief16.pdf
. Published May 2014. Accessed August 4, 2014.
22. Hudak S, Sharkey S. Trendspotting: how IT triggers better care in nursing homes. California Healthcare Foundation website. http://www.chcf.org/publications/2011/09/trendspotting-it-nursing-homes
. Published September 2011. Accessed August 4, 2014.
23. Wolf L, Harvell J, Jha AK. Hospitals ineligible for federal meaningful- use incentives have dismally low rates of adoption of electronic health records. Health Aff (Millwood).
24. Wright A, Henkin S, Feblowitz J, McCoy AB, Bates DW, Sittig DF. Early results of the meaningful use program for electronic health records. N Eng J Med
25. Furukawa MF, Patel V, Charles D, Swain M, Mostashari F. Hospital electronic health information exchange grew substantially in 2008-12. Health Aff (Millwood)
26. Vest JR, Gamm LD. Health information exchange: persistent challenges and new strategies. J Am Med Inform Assoc