Catherine DesRoches, DrPH

To examine whether physicians using health information technology and participating in new models of payment and delivery were more likely to perform care processes associated with improved care delivery.

Nationally representative, cross-sectional data on US office-based physicians from the 2012 National Ambulatory Medical Care Survey Physician Workflow Survey.

Multivariate regression analysis of whether physicians routinely performed 14 specific care processes in 4 categories: population management, quality measurement, patient communication, and care coordination. Key independent measures were electronic health record (EHR) use and accountable care organization (ACO) or patient-centered medical home (PCMH) participation.

A majority of physicians reported routinely conduct at least 1 care process related to care coordination (89%), patient communication (69%), and population management (67%); less than half reported performing at least 1 quality measurement process routinely (44%). EHR use and ACO or PCMH participation were independently associated with a higher likelihood of performing care processes. Physicians who were using EHRs in combination with participation in ACO or PCMH initiatives had the highest likelihood of routinely performing the care processes: physicians who used an EHR and participated in ACO or PCMH initiatives were between 6 and 22 percentage points more likely to routinely perform the care processes than physicians with EHRs alone.

 In 2012, physicians using EHRs and participating in ACO or PCMH initiatives were more likely than other physicians to be routinely engaging in care processes expected to improve healthcare outcomes. Yet, many US physicians were not performing these processes routinely. This analysis highlights several specific areas where more work is necessary to facilitate wider adoption of these activities.

National policies are supporting the use of health information technology (IT) and testing new models of payment and delivery, such as accountable care organizations (ACO) and patient-centered medical homes (PCMH). This study examined whether use of health IT and participation in new models of care are associated with improved care delivery.

		In 2012, physicians using electronic health records (EHRs) and participating in ACO or PCMH initiatives were more likely to routinely perform population management, quality measurement, patient communication, and care coordination processes; yet, many physicians were not performing these processes routinely.

		There are several areas where EHRs may be important to facilitate wider adoption of these activities.

There is wide consensus that changes are necessary in the way healthcare is delivered in the United States in order to realize reductions in healthcare spending and improvements in population health outcomes.

 National policies currently support 2 programs that may substantially change the way care is delivered; one related to health information technology (IT) adoption and the other related to payment reform and the use of new care delivery models.

The Health Information Technology Act (HITECH) Act of 2009 was designed to provide the infrastructure necessary for improvements in care delivery by supporting greater adoption of IT tools, including electronic health records (EHRs), which can facilitate high-quality care.

 The HITECH Act authorized the Medicare and Medicaid EHR Incentive Programs, which provide financial assistance to eligible professionals for the “meaningful use” (MU) of certified EHRs with functionalities associated with enhanced quality of care, such as electronic prescribing and medication alerts.

Concurrently, the 2010 Affordable Care Act (ACA) is supporting the development and implementation of new delivery and payment models, such as patient-centered medical homes (PCMHs) and shared savings arrangements like accountable care organizations (ACOs). Although EHRs are not required for participation in all types of PCMH or ACO programs, it is widely believed that providers need a robust health IT infrastructure to be fully successful in these payment and delivery arrangements.

Early indicators suggest strong physician participation in initiatives to support health IT adoption and to reform healthcare payment and delivery.

 However, evidence on whether provider participation in these initiatives has translated to better care delivery is just beginning to emerge.

 Areas identified as priorities for improvement include care processes, such as population management and prevention, quality measurement and reporting, care coordination, and patient engagement.2 Although studies prior to HITECH and the ACA found health IT and external reporting or payment incentives to be associated with a higher likelihood of performing these care processes, they are performed at low rates even when these factors are in place.

 At least 1 study of primary care physicians found evidence that those in PCMH practices using EHRs had greater quality improvements and changes in utilization over time on some measures than those in non-PCMH practices with or without EHRs.

We examined 4 main questions about the relationship between EHR use, participation in new payment and delivery models, and the extent to which physicians perform care processes that may lead to improved outcomes. First, how routinely did US physicians perform population management, quality measurement, patient communication, and care coordination processes? Second, were physicians using EHRs and participating in ACO or PCMH initiatives more likely than other physicians to perform these 4 types of care processes? Third, given that health IT and new payment models often are envisioned to work symbiotically to improve care,

 were physicians using EHRs and participating in ACO or PCMH initiatives more likely to routinely perform these types of care processes than those using EHRs alone? Finally, since previous studies have shown room for improvement in the extent to which EHR adopters use their EHRs to engage in these care processes,

 were certain EHR-related factors associated with use of computerized tools to routinely perform these processes? The results of this study may be useful to policy makers and researchers concerned with the level of adoption of these advanced care processes and the potential policies and tools to support their greater diffusion.

We used data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Workflow Survey, the second wave of a panel survey conducted by the National Center for Health Statistics to collect nationally representative information on physicians’ attitudes toward and experiences with EHRs.

 The first wave of the Physician Workflow Survey was conducted in 2011 as a follow-up to the 2011 NAMCS Electronic Health Records Survey.

The sample for the 2012 NAMCS Physician Workflow Survey came from the 2011 NAMCS Electronic Health Records Survey (ie, nonfederal office-based physicians, excluding radiologists, anesthesiologists, and pathologists). Eligibility status was determined for 8198 of the 10,302 physicians sampled, and those deemed eligible were mailed the Physician Workflow questionnaire. In 2012, 2567 physicians responded for an unweighted response rate of 45%. There were no significant differences in characteristics between responders and nonresponders.

The 2012 NAMCS survey included 14 separate items that queried physicians on 14 specific care processes in 4 categories: population management, quality measurement, patient communication, and care coordination. For each care process, the survey asked “Is this done routinely?” (yes/no) and then “Is this process computerized?” (yes, usually/yes, sometimes/no).

Use of care processes. In the multivariate analyses described below, we used 2 sets of dependent variables. First, to examine factors associated with routinely performing the care processes overall, we assigned the dependent variables a value of 1 if the physician reported routinely performing each process, and 0 otherwise. Second, to examine EHR-related factors associated with routinely performing the care processes using computerized tools, we assigned the dependent variables a value of 1 if the physician reported the process was performed routinely and the process was computerized (either usually or sometimes), and 0 otherwise. Missing responses, which ranged from 2% to 11% across the items, were assigned the value of 0.

For ease of communicating results across the 14 processes queried in the survey, we also created 1 measure for each of the 4 categories indicating whether at least 1 of the processes in the category was performed routinely. We reported multivariate results for these category-level measures in the main text and reported multivariate results for all 14 individual processes in the 

]). The results for the category-level measures were substantively similar to the results for the individual process measures.

EHR use and characteristics. We measured EHR use based on the question, “Which of the following best describes [your primary practice] location’s current EHR adoption status?” with response options: 1) “We do not have an EHR system,” 2) “We are not actively using an EHR system but have one installed,” and 3) “We are actively using an EHR system.” Our main measure of EHR use assessed whether or not the physician reported their primary practice location was actively using an EHR. We also reported the percent of physicians who responded, “We are not actively using an EHR system but have one installed” or answered yes to another question, “At the reporting location, are there plans for installing a new EHR system within the next 12 months?”

We examined 3 EHR-related characteristics among physicians using EHRs: whether the EHR met MU criteria, the length of EHR experience, and the receipt of technical assistance for initial EHR implementation. Physicians who answered “yes” to the question, “Does your current system meet meaningful use criteria as defined by the Centers for Medicare & Medicaid Services (CMS)?” were considered to have EHRs that met MU criteria. Length of EHR experience was calculated based on the difference between year of the survey (ie, 2012) and year reported in response to the item: “In which year did you install your EHR system?” Receipt of technical assistance was based on questions about whether the physician’s primary practice location received assistance “in implementing an EHR system” (yes/no/uncertain) and “with training staff in using your EHR system” (yes/no/uncertain).

ACO or PCMH participation. We measured participation in ACO or PCMH arrangements based on responses to 2 questions: 1) “Does [your primary practice location] participate in an 

 or similar arrangement by which you may share savings with insurers (including private insurance, Medicare, Medicaid, and other public options)?” and 2) “Does [your primary practice location] receive any additional compensation beyond routine visit fees for offering 

 (PCMH)-type services or does [the location] participate in a certified PCMH arrangement?”

In multivariate analyses (described below), we used a measure of whether or not the physician reported participating in either an ACO or PCMH arrangement. Results of sensitivity analyses examining ACO and PCMH participation as separate variables were similar to results from the combined variable (results not shown but are available on request). 

We first conducted univariate and bivariate descriptive statistics of the key independent and dependent variables. We then performed multivariate logistic regression to examine the relationship between EHR use, ACO or PCMH participation, and routinely performing the care processes while controlling for other physician and office characteristics. We estimated 18 logistic regression models (1 for each of the 14 individual process measures and the 4 category-level measures), regressing the dependent variable (whether or not the physician routinely performed the process of interest) on whether the physician used any EHR, whether the physician participated in an ACO or PCMH, and an interaction between the EHR use and ACO/PCMH participation variables. The models also included physician and practice characteristics as control variables: physician age, physician specialty, practice size, practice ownership, practice specialty, county metropolitan status, and region (eAppendix Table 1).

To assess whether EHR use and ACO or PCMH participation were independently associated with routinely performing the care processes, we used the logistic regression results to calculate the average incremental effects of EHR use and ACO or PCMH participation. To assess whether physicians using EHRs and participating in ACO or PCMH initiatives are more likely to routinely perform these care processes than those using EHRs alone, we used the regression results to calculate predicted probabilities for combinations of the interaction. 

Finally, we conducted multivariate logistic regression to assess whether, among EHR adopters, certain EHR-related factors were associated with a higher likelihood that EHR users routinely perform the care processes using computerized tools. The analysis sample for these regressions was the subset of office-based physicians who were using an EHR. We estimated 18 logistic regression models (1 for each of the 14 individual process measures and the 4 summary measures), regressing the dependent variable (whether or not the physician routinely performed the process of interest using computerized tools) on the 3 EHR-related characteristics: met MU criteria, EHR installation year, and staff received EHR training. The models also included the same control variables as above and the ACO or PCMH participation variable. We used the regression results to calculate the average incremental effects of the EHR related factors.

All analyses were conducted using Stata 11.2 (StataCorp LP, College Station Texas), using weights to account for nonresponse and adjusting standard errors for the complex survey design. We used a regression model that predicts the likelihood of responding to the survey, to develop weights to ensure that our survey was nationally representative.

EHR Use and Participation in ACO or PCMH Initiatives

In 2012, a majority of office-based physicians were using an EHR (62%), with about half of all physicians using an EHR that was certified to meet MU criteria (48%) (

). Over 1 in 5 physicians (22%) were participating in either an ACO (16%) or PCMH (9%) (Figure 1)—4% reported participating in both models, 13% in ACO only, and 6% in PCMH only (data not shown). A majority of physicians participating in these models used an EHR certified for MU (Figure 1). Overall, 18% of physicians reported using an EHR and participating in an ACO or PCMH. Additionally, 44% of physicians reported using an EHR but not participating in one of these care delivery models, and the remaining 38% of physicians did not use an EHR.

The majority of physicians reported performing at least 1 care process routinely in the categories of care coordination (89%), patient communication (69%), and population management (67%) (

). Less than half (44%) reported performing quality measurement processes routinely. There was variation in the extent to which physicians routinely performed specific processes within each category (eg, the population management processes ranged from 13% for creating lists of patients by lab results to 58% for providing patients with reminders for follow-up or preventive care). Among physicians who routinely performed a given process, the majority reported that the process was computerized.

Relationship Between EHR Use, Participation in ACO or PCMH Initiatives, and Performance of Care Processes

Physicians using EHRs were significantly more likely to perform care processes across all 4 categories (

). For example, physicians using EHRs were 15 percentage points more likely than physicians without EHRs to routinely perform at least 1 population management process. Similarly, physicians participating in new delivery models were significantly more likely to routinely perform these processes. The magnitude of the incremental effects for EHR use and ACO or PCMH participation were similar (ie, there were no statistically significant differences between the incremental effects [test not shown]).

Physicians who were using EHRs in combination with participation in ACO or PCMH initiatives had the highest likelihood of routinely performing the care processes (

). Among physicians not participating in either type of initiative, using an EHR was associated with a 14 to 27 percentage point greater likelihood of routinely performing at least 1 care processes in 3 of the 4 categories (not care coordination). However, across all categories, physicians who had an EHR and participated in ACO or PCMH initiatives were between 6 and 22 percentage points more likely to routinely perform the care processes than physicians with EHRs alone. The same results were found in analyses of the individual care processes in each category (eAppendix Table 3).

Relationship Between EHR-Related Factors and Performance of Care Processes Among Physicians Using EHRs

Among the 62% of physicians using an EHR in 2012, those with EHRs certified to meet MU criteria were significantly more likely to routinely perform at least 1 care process in a computerized manner across all 4 categories (

). For example, physicians using EHRs certified to meet MU criteria were 15 percentage points more likely than physicians using other EHRs to routinely perform at least 1 population management process in a computerized manner. The same results were found in analyses of the individual care processes in each category

Physicians at practices with longer experience with their current EHR were more likely to routinely perform 1 or more processes in a computerized manner across all categories. Assistance with initial EHR implementation and assistance with training staff to use the EHR were not significantly associated with the likelihood of routinely performing any care process in a computerized manner in the categories.

The National Quality Strategy has prioritized several areas for improvement, including population management and prevention, quality measurement and reporting, care coordination, and patient engagement.

 This study finds that US physicians’ rates of performing these care processes varied; although a majority reported routinely conducting at least 1 care process related to care coordination, patient communication, and population management, less than half reported performing at least 1 quality measurement process routinely.

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In 2012, electronic health record use and participation in accountable care organization or patient-centered medical home initiatives were associated with performing care processes expected to improve healthcare outcomes.

The Role of Health IT and Delivery System Reform in Facilitating Advanced Care Delivery

To update the status of electronic health record (EHR) adoption in US hospitals and assess their readiness for “Meaningful Use” (MU).

 We used data from the 2010 American Hospital Association Annual Information Technology Survey. The survey was first conducted in 2007 and is made available both online and through the mail to all non-federal acute-care hospitals in the United States.

We measure the percentages of applicable hospitals that have adopted “basic” and “comprehensive” EHRs as defined in previous literature. Additionally, we report the percentage of hospitals planning to apply for MU in the near term, and assess hospitals’ readiness for the program and how readiness varies by key characteristics.

 We received responses from 2902 hospitals (64% of all non-federal acute-care hospitals). More than 15% have adopted at least a “basic” EHR, representing nearly 75% growth since 2008. Approximately two-thirds plan to apply for MU before 2013; however, only 4.4% had implemented each of the “core” MU functionalities we measured. Hospitals closer to achieving MU are more likely to be larger non-profits (P <.001) and vary by other key characteristics. Certain functionalities included in MU, such as computerized provider order entry, electronic generation of quality measures, and electronic access to records for patients are proving more challenging to implement for all hospitals.

 Broad enthusiasm exists among hospitals for participation in MU. However, adoption will have to accelerate above its current pace for readiness to match intention. Gaps in adoption show bringing all hospitals along is the key policy challenge.

(Am J Manag Care. 2011;17(12 Spec No.):SP117-SP124)

	The data show adoption of electronic health records among hospitals has increased steadily in recent years. In addition, the vast majority of hospitals intend to apply for “Meaningful Use” (MU) in the near term, although challenges still remain:

		 More than two-thirds of non-federal acute-care hospitals intend to apply for MU in 2011 or 2012. However, very few can meet the program criteria now. We found that fewer than 5% of hospitals had implemented all the “core” MU functionalities we measured.

		 Hospital readiness for achieving MU varies based on key characteristics such as size, ownership status, location, and presence of teaching programs. Bringing all hospitals to MU is a key policy challenge.

		 Certain MU functionalities are more difficult to implement than others. Even hospitals that have implemented many of the “core” criteria we measured report difficulties with generating quality measures and patient problem lists.

	Over the past 2 years, the federal government has initiated an unprecedented effort to reform the healthcare system and promote the “Meaningful Use” (MU) of health information technology (HIT). Federal standards have been developed to define MU (the criteria for receiving financial incentives under Health Information Technology for Economic and Clinical Health [HITECH] Act) and to encourage providers to implement electronic health records (EHRs). Regular assessments of the readiness of the nation’s hospitals to achieve MU are critical, given that the incentives are front-loaded: hospitals that are slow to adopt and meaningfully use EHRs will receive considerably smaller amounts of incentives (with future federal subsidies highly unlikely). Further, Congress has authorized penalties for providers who are not meaningful users before 2015, raising the ante for hospitals and other providers to seriously consider the adoption and use of these systems.

	The early data on EHR adoption among US hospitals have been sobering. In 2008, approximately 9% of US hospitals had a basic EHR,

 a number that grew by just 3% in 2009.2 However, despite the ongoing policy interest in this area, the most recent published data on adoption come from a survey administered well before the delineation of the MU rules, and the questions within it were not well aligned with the MU criteria. In 2010, we modified the national hospital EHR survey administered by the American Hospital Association to ask a series of specific questions pertaining to MU.

	Using the 2010 survey data, which was administered during the time that the MU rules were being finalized, we sought to answer 3 questions: (1) What proportion of US hospitals have a basic or comprehensive EHR or could meet MU in 2010, the last year prior to the onset of incentives? (2) How many hospitals intend to apply for MU and how realistic is it that they are likely to be able to meet the standards? and (3) What are the major barriers holding hospitals back from adoption and from meaningfully using EHRs?

	We used data from the American Hospital Association annual surveys of HIT adoption from 2008, 2009, and 2010. The approach to the 2008 and 2009 surveys has been described previously and our approach in 2010 was very similar. 

 The American Hospital Association sent the survey, as a supplement to its annual survey, to the chief executive officer (CEO) of each short-term acute-care hospital in the United States, asking the CEO to assign the survey to the most knowledgeable member of his or her staff (typically the chief information officer or equivalent). All non-respondents received multiple mailings and phone calls in follow-up to try to achieve a high response rate. The 2010 survey was in the field between May and October 2010. Of note, 60% of our respondents completed the survey prior to the publication of the final rule defining MU, meaning that they were reporting their intention to apply for MU based on the proposed rule and their view of how the final rule might differ from it. Respondents were given the option of responding online or by mail; as with the 2 previous surveys, the vast majority completed their responses online.

	We updated the 2010 survey instrument to better assess hospital readiness and plans to meet the criteria for MU.

 Under the MU regulation, non-federal acute-care hospitals are eligible for Medicare and Medicaid payment incentives when they meet specified goals for information technology use.

 To qualify for Stage 1 of the program, hospitals must meet 14 “core” requirements and no fewer than 5 of 10 capabilities chosen from a “menu.” We updated the instrument to incorporate many of the additional functionalities included in the MU criteria. We also measured whether hospitals planned to apply for the program, and, if so, in what year. The questions and response categories used are included in the eAppendices A-C.

	We used definitions of a “basic” and “comprehensive” EHR that were previously developed by a consensus panel of HIT experts.

 A “basic” EHR is defined as the full implementation in at least 1 clinical unit of computerized system(s) for patient demographics, physician notes, nursing assessments, patient problem and medication lists, laboratory and radiologic reports, diagnostic test results, and order entry for medications. A “comprehensive” EHR must include all the functionalities of a “basic” system and 14 additional functionalities.

 In addition, a “comprehensive” record requires full implementation in all clinical units. Although many functions included in these definitions are requirements of MU, others are not. Thus, these measures do not fully capture hospital readiness for the incentive program. Therefore, we constructed an additional measure to assess hospital adoption of “core” criteria. Of the 14 “core” criteria that apply to hospitals, we had reasonable proxies for 12 (eAppendices A-C). The survey also did not include items measuring possession of an EHR that has been certified through a new federal process or use of specific standards for collecting and transmitting data, which are both requirements to be eligible for incentives.

	Because the MU criteria require that electronic functions support the care of a certain percentage of patients, we considered a positive response of either “full implementation in at least 1 clinical unit” or “full implementation in all clinical units” as achieving the MU criteria. The standard of implementing in “at least 1 unit” is too generous for the bar set by MU, while requiring implementation in “all units” is too restrictive. Therefore, we present the proportion that had met all 12 criteria in “at least a single unit” as our MU upper- bound estimate and, in an attached appendix, show the proportion that met all 12 criteria in “all units” as our lowerbound estimate.

	Consistent with previous years, we compared the characteristics of non-federal acute-care hospitals responding to the survey to all hospitals in that category. Not surprisingly, we found modest but statistically significant differences (

). As a result, we weighted all results for potential non-response using commonly used methods.

	We calculated the proportion of US hospitals that had adopted “basic” and “comprehensive” EHRs as of 2010 and plotted the trends in these proportions from 2008 to 2010. We used the same approach to calculate the proportion of US hospitals that had adopted all 12 of the “core” functionalities of MU that we had been able to capture on the survey. To assess how far along other hospitals were, we also calculated the proportion that had adopted 9 to 11 of the core functions, those that adopted 5 to 8, those that had adopted 1 to 4, and those that had adopted none of the 12 functions.

	To assess hospitals’ future plans to apply for MU, we examined the proportion that reported planning to apply in 2011 or 2012, those planning to apply in 2013 or later, and those unsure about whether or when they might apply. We examined the responses to this question both overall, as well as stratified by the number of core functions available.

	Finally, we categorized the cohort of US hospitals into 2 groups: (1) those that were further along and may be able to meet MU in 2011 or 2012, and (2) those that were highly unlikely to meet MU in the first 2 years of the program. We defined those hospitals further along who had 9 or more of the “core” functions fully implemented in at least 1 unit and refer to them as “closer to MU” hospitals and those with fewer than 9 functions “farther from MU.” For these 2 cohorts of hospitals, we assessed the functionalities they were still missing and the barriers they identified to meeting MU.

	The American Hospital Association received responses from 3635 hospitals. After excluding federal hospitals, those located outside of the 50 states and the District of Columbia, and non-medical or surgical institutions, 2902 hospitals remained for analysis (64% of non-federal acute-care hospitals). This was comparable to the response rates in 2008 (63%) and 2009 (69%). Because there were modest but significant differences between responders and the entire census of US hospitals (Table 1), as described above, all results were statistically adjusted for potential non-response.

Changes in Adoption of EHRs in US Hospitals

	We found that in 2010, the proportions of non-federal acute-care hospitals reporting the presence of “basic” and “comprehensive” EHR systems continued to increase compared with previous years. In 2010, 3.6% of non-federal acutecare US hospitals had a comprehensive EHR, compared with 2.7% in 2009 and 1.5% in 2008. The proportion of hospitals reporting just a “basic” system was 11.5%, compared with 9.2% in 2009 and 7.2% in 2008 (

 characteristics of hospitals associated with a greater likelihood of having at least a basic EHR included larger size, being a non-profit or public (as opposed to for-profit), being a major or minor teaching hospital, being a member of a system, or being located in an urban area (

 <.001 for all comparisons; see Table 1).

	We found only 4.4% of eligible US hospitals had each of the 12 available “core” functionalities of MU fully implemented in at least 1 unit (

). This declined to 2.8% using “full implementation in all clinical units” as the standard (

). An additional 42.6% of hospitals had 9 or more of the functions in place in at least 1 unit (see last column, 

). Nearly 25% of hospitals had less than a third of the 12 “core” functions implemented in even a single unit of the hospital.

	We found that 66% of eligible US hospitals planned to apply for federal MU incentives in 2011 or 2012 (Table 2, last row). More than 3 in 4 of these hospitals reported they intended to apply for incentives administered both through Medicare and the Medicaid programs while 22% intended to apply for the Medicare incentives only. Of hospitals that were intending to apply in 2011 or 2012, 5.7% had all 12 core functions implemented in at least 1 unit while an additional 48.2% had 9 to 11 core functions implemented in at least 1 unit (Table 2, second column). Hospitals intending to apply in 2011 or 2012 were further along in their adoption of the MU functions than those intending to apply in 2013 or those unsure about applying for MU.

Characteristics of Hospitals With More MU Functions

	Hospitals that had adopted 9 or more “core” functions were,compared with hospitals who had adopted fewer core functions, larger, located in the Northeast, and less often forprofit (

). They were also more likely to be major teaching hospitals (30% vs 18%, 

<.001), members of hospital systems (60% vs 53%,

 <.001), and with coronary care units (38% vs 26%, 

 <.001) than other hospitals. These hospitals with more MU functions in place were less likely to be located in a rural part of the country (37% vs 51%,

Functions Missing From More Advanced Hospitals

	Of the hospitals with 9 or more core functions in place, or “closer to MU” hospitals, 32% could automatically generate numerators and denominators for quality measurement, 56% were able to electronically provide patients access to their own records, 59% had implemented computerized provider order entry (CPOE) in at least 1 unit, and 79% had electronic problem lists. The “farther from MU” hospitals, with 8 or fewer core functions, were missing these key functions far more frequently (see 

	“Closer to MU” hospitals differed from the “farther from MU” hospitals in the difficulties they identified to meeting MU. The “closer to MU” hospitals were more likely to report the following as challenges to achieving MU: generating problem lists (16% vs 10%) and automated quality measures (31% vs 20%). Conversely, they were less likely to report CPOE (44% vs 55%) or clinical decision support implantation as a challenge (21% vs 28%; see Table 4).

	We found modest but significant increases in EHR adoption among non-federal acute-care hospitals in 2010, with just over 15% of acute-care hospitals in the United States having at least a basic EHR. The increase between 2009 and 2010 was similar, when the adoption rate of a basic EHR increased from 9% to 12%. While most hospitals reported that they intend to apply for MU, only 4.4% of US hospitals could meet all 12 of the 14 “core” measures, pointing to the difficult road ahead. While a substantial minority of hospitals had 9 to 11 of the “core” measures implemented, many lacked CPOE, arguably the most difficult technology implementation challenge.

 Finally, a sizable minority of hospitals had very few of the functions needed. Small hospitals, those located in the South, and for-profit institutions lagged behind others in their adoption of functions needed to meet MU. It is unclear why there are differences by region or ownership and understanding the factors that underlie these differences will be helpful in ensuring equitable adoption.

	These data, the last set before incentives begin to be distributed, represent the national baseline for assessing the impact of HITECH. They suggest that US hospitals continue to be on a slow but incremental path toward adopting EHRs. The challenges they face are real: EHR systems are expensive, often disruptive to implement, and there can be significant pushback from physicians and other healthcare providers. However, the benefits of these EHR systems are considerable: they can dramatically reduce medication errors, increase adherence to evidence-based care processes, and, if implemented well, can lead to overall gains in patient outcomes.

 The current reimbursement system, which primarily rewards hospitals for volume over quality, creates little financial incentive for hospitals to adopt these systems. Whether the MU regulations can overcome these barriers by providing direct incentives to providers for adopting and meaningfully using EHRs needs to be monitored closely.

Broad enthusiasm exists among hospitals for participation in Meaningful Use. However, many hospitals have a long road ahead to implement the advanced systems required for the program.

Catherine DesRoches, DrPH

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