Michael F. Furukawa, PhD

To assess physician attitudes on ease of use of electronic health record (EHR) functionalities related to “Meaningful Use” (MU) and whether perceived ease of use was associated with EHR characteristics, including meeting MU criteria, technical assistance from EHR vendors or regional extension centers, and the amount of clinical staff training. 

A cross sectional analysis of the 2011 Physician Workflow study, nationally representative of US office-based physicians. 

Cross-sectional data were used to examine physician attitudes on ease of use of 14 EHR functionalities related to MU, among physicians with any EHR system. 

For 11 of the 14 EHR functions examined, physicians with EHRs that met MU criteria were significantly more likely than physicians that also utilized EHR systems to report that EHR functions were easy to use. For 8 of the functions examined, physicians receiving technical assistance from a vendor or regional extension center were significantly more likely to report that the EHR function was easy to use. 

Our study of a nationally representative survey of office-based physicians found that physicians’ adoption and perceived ease of use of EHR functionalities related to MU was generally high.

	Physician attitudes on ease of use of electronic health record (EHR) functionalities were generally positive. 

		Among a nationally representative sample of office-based physicians, EHR adoption and perceived ease of use of EHR functionalities related to Meaningful Use (MU) were relatively high. 

		Physicians using an EHR that met MU criteria were much more likely to report that EHR functionalities were easy to use. 

		Technical assistance and training were associated with ease of use for some but not all EHR functionalities.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 created incentives and provided technical assistance to spur widespread adoption of electronic health records (EHRs) in the United States. HITECH was designed to support greater use of health information technology in order to improve the efficiency and quality of patient care. Among its many provisions, HITECH authorized the Medicare and Medicaid EHR Incentive Programs, which began providing incentive payments to physicians and hospitals that demonstrated “Meaningful Use” (MU) of EHRs in 2011. HITECH also established a national EHR Certification Program to ensure that certified EHR technology included specific functionalities that meet MU criteria. In 2011, more than half of office-based physicians had adopted some type of EHR system, and about three-fourths of these physicians reported that their EHR was certified to meet MU criteria.

To achieve the aims of HITECH, it is important to understand physician attitudes toward the use of EHRs after adoption. A key factor in physician acceptance of EHRs is the extent to which users perceive the technology to be easy to use and useful in enhancing patient care.

 Since certification requires that functionalities meet technical standards, physician attitudes toward newer, more robust EHRs that meet MU criteria may differ from older systems. Attitudes may also depend on EHR implementation, such as receipt of technical assistance and amount of training.

 Anecdotal reports suggest growing physician dissatisfaction with the usability of EHRs,

 and physician difficulties in using EHR systems may lead to unintended consequences such as new work and safety issues.

 Thus, understanding the factors related to physician attitudes on ease of use of specific EHR functions has important clinical and policy implications.

Prior research on physician attitudes regarding EHRs has focused on the barriers and benefits of EHR adoption,

 and influences of EHR use on professional and workplace satisfaction.

 Fewer studies have focused on the association of EHR characteristics with ease of use related to specific EHR functions.

 Physician surveys from single states have found relationships between EHR robustness and physician satisfaction with EHRs overall,

 and a recent study using national data found that physicians using certified EHRs were more likely to report clinical benefits.

 However, these studies were limited to EHR robustness in relation to perceptions of satisfaction and usefulness, but not ease of use. Important gaps remain in our understanding of the associations between EHR characteristics with perceived ease of use, particularly for newer functionalities, such as secure messaging and public health reporting.

This study used nationally representative survey data from 2011 to examine physician attitudes on the ease of use of EHR functionalities related to MU. We also assessed whether perceived ease of use varied by EHR characteristics, including EHR certification, receipt of technical assistance from vendors or regional extension centers, and the amount of clinical staff training. Findings have important policy implications for the potential role of robustness and implementation support to influence physician attitudes on usability of some EHR functions.

The data source was the 2011 National Ambulatory Medical Care Survey (NAMCS) Physician Workflow study, the first wave of a longitudinal panel survey of US office-based physicians.

 The Physician Workflow study was conducted by the National Center for Health Statistics and collected information on physicians’ attitudes toward and experiences with EHRs across many domains. Survey content was developed with the guidance of an expert advisory panel, and separate questionnaires were developed for physicians using an EHR and physicians who had not yet adopted an EHR. Questions about ease of use of specific EHR functionalities were included on the EHR adopter questionnaire only.

The sample for the Physician Workflow study was a subset of physicians who were contacted to participate in the 2011 NAMCS Electronic Health Records Survey (NEHRS). The target universe for the NAMCS was nonfederal, office-based physicians in the United States, excluding radiologists, anesthesiologists, and pathologists. A total of 5232 physicians were sampled for the Physician Workflow study; the response rate for the 2011 survey was 61%, yielding a final sample size of 3180. This analysis was limited to respondents who used an EHR at their primary practice location in 2011 (n = 1793). Information on adoption of specific EHR functions was obtained from corresponding respondents of the 2011 NEHRS. Additional information on the survey methods is available elsewhere.

Rates of Adoption and Physician Attitudes on Ease of Use of Specific EHR Functions

We examined rates of adoption and physician attitudes on the ease of use of EHR functionalities related to MU. Adoption of specific EHR functions was measured using a NEHRS question asking whether the physician’s reporting location had computerized capabilities for each function. Fourteen of the 16 EHR functions listed in the Physician Workflow study mapped to MU Stage 1 or Stage 2 core or menu requirements; we focused our analyses on these 14 functions.

Perceived ease of use was measured from physician responses to the question: “Please indicate your level of ease or difficulty for each EHR function.” Response categories included: “very easy,” “easy,” “difficult,” “very difficult,” and “not applicable.” Physicians were instructed to select “not applicable” if they did not have or did not use a particular EHR function. Physicians were considered as having adopted and been using a specific function if they had a response other than “not applicable” for the question about ease of use of the function. We reported on physicians’ perceived ease of use of EHR functionalities, conditional on their adoption and use of that specific function. To report on ease of use, we used dichotomous variables that combined the “very easy” and “easy” responses into 1 group and combined “difficult,” “very difficult,” and missing responses in the comparison group. Missing responses across items ranged between 1% and 13% of physicians. Because we coded missing responses as “difficult” or “very difficult” in the analysis, rather than excluding them from the denominator, the estimates of ease of use may be conservative. Results were not sensitive to the exclusion of missing responses.

EHR Characteristics Associated With Perceived Ease of Use

The study hypothesized that EHR characteristics, including certification and implementation support, would be positively associated with perceived ease of use.

To measure EHR certification, we created a dichotomous variable indicating whether or not the respondent’s EHR was certified to meet the Stage 1 MU criteria. This variable was created based on responses to the question: “Does your current system meet Meaningful Use criteria as defined by the Centers for Medicare & Medicaid Services (CMS)?” Response categories were “yes,” “no,” and “uncertain.” Physicians who answered “yes” were considered to have EHRs that met MU criteria. Of the entire sample, 8.4% answered “no,” 14.4% answered “uncertain,” and 1.4% did not answer the question. Sensitivity analyses using an alternative measure of whether physicians had 9 of the 15 computerized capabilities that compose the core MU requirements yielded similar results to the main analysis.

To measure EHR implementation support, we created variables for technical assistance from EHR vendors or regional extension centers and the amount of clinical staff training. Receipt of technical assistance was measured using the questions: “Did you receive help from EHR vendors in analyzing your practice work flow?” and “Did you receive help from regional extension centers (RECs) in analyzing your practice work flow?” Since respondents may have received assistance from both vendors and RECs, we combined “yes” responses to either question as having received technical assistance. The amount of clinical staff training was determined using the question: “How many hours, on average, did clinical staff spend in training to implement your practice’s EHR system?” To balance cell sizes, we created 3 categories for the amount of training as 0 to 8 hours (combining responses “1 to 8 hours” and “did not receive training”), 9 to 40 hours, and 41 or more hours (combining “41 to 80 hours” and “over 80 hours”).

In multivariate analyses, we included additional controls for physician (age, specialty) and office characteristics (size [number of physicians], ownership, practice type, metropolitan status, region) that have been associated with EHR adoption and physician attitudes toward EHRs in previous research (listed in 

Univariate descriptive statistics were calculated to describe the percent of physicians that adopted specific EHR functions, and among EHR adopters, the percent of physicians who reported the EHR function was easy to use (either “very easy” or “easy”). Multivariate logistic regression analyses were used to examine whether perceived ease of use varied by EHR characteristics while controlling for other physician and office characteristics. All analyses were conducted using Stata version 11.2 software (StataCorp LP, College Station, Texas) using weights to account for nonresponse and adjusting standard errors for the complex survey design of the data.

EHR Characteristics Among Physicians With Any EHR

Using a nationally representative sample of EHR adopters, more than three-fourths (76%) reported that their EHR met MU criteria (

). Fewer than half (45%) of EHR adopters reported the receipt of technical assistance with analyzing practice work flow from EHR vendors or RECs. About 1 in 5 (22%) physicians with any EHR received 41 or more hours in clinical staff training to implement their EHR system.

Adoption and Perceived Ease of Use of EHR Functionalities Related to Meaningful Use

Among physicians that had adopted an EHR, physicians’ rate of adopting and using 14 EHR functions related to MU ranged from 98% (recording a comprehensive list of medications and allergies) to 40% (public health reporting) (

). Overall, at least 75% of EHR adopters reported adopting and using 9 of the 14 EHR functions we examined. Functions related to documentation had the highest rates of adoption and use; exchanging secure messages with patients and public health reporting had the lowest adoption rates.

Among physicians who reported adopting and using a given EHR function, the percent who reported the function was easy to use ranged from 91% (viewing laboratory results) to 49% (public health reporting). At least 75% of EHR adopters considered 10 of the 14 functions we examined as easy to use; this included functions related to documentation, ordering, viewing results, decision support, patient engagement, and clinical data exchange.

In general, the percent of physicians who considered a particular EHR function to be easy to use was higher for more commonly adopted EHR functions and lower for less commonly adopted EHR functions. For example, the percent of physicians who considered the least commonly adopted functions as easy to use, were relatively low; these included public health reporting (49%), viewing data on quality measures (63%), secure messaging with patients (68%), and reminders based on guidelines (69%).

EHR Characteristics and Perceived Ease of Use of Specific EHR Functions

Physician attitudes on ease of use of specific EHR functions varied according to some EHR characteristics (

]). For 12 of the 14 functions examined, physicians with EHRs that met MU criteria had 56% to 196% higher odds of reporting the EHR function was easy to use. EHR certification had the strongest association with perceived ease of use in providing reminders for guideline-based interventions or screening tests (+196% difference in the odds of ease of use) and providing patients with a clinical summary for each visit (+176%). EHR functions related to documentation and viewing clinical data showed smaller differences based on whether physicians’ EHRs met MU criteria. For example, EHR certification had no significant effect on ease of use for recording a comprehensive list of medication and allergies or viewing imaging reports.

Receipt of technical assistance from EHR vendors or RECs had some association with perceived ease of use (Table 4). For 8 of the 14 functions examined, physicians receiving technical assistance had 55% to 174% higher odds of reporting that the EHR function was easy to use. Technical assistance had the strongest relationships with ease of use of EHR functions related to public health reporting (+174%), viewing data on quality of care (+101%), and exchanging secure messages with patients (+98%).

The amount of clinical staff training had little association with perceived ease of use (Table 4). Relative to 0 to 8 hours, clinical staff training of 9 to 40 hours had no effect on perceived ease of use for any EHR functions. Training of 41 or more hours was associated with 51% to 60% lower odds of reporting that the EHR function was easy to use for 4 functions: viewing imaging reports, recording clinical notes, providing patients with clinical summaries, and recording problem lists.

Physician and Office Characteristics Associated With Perceived Ease of Use of Specific EHR Functions

With the exception of practice ownership, we found little association of physician and office characteristics with perceived ease of use that was consistent across the 14 EHR functions (see eAppendix Table). For 9 of the 14 functions examined, physicians in practices owned by a health maintenance organization (HMO) or other healthcare corporation had 125% to 494% higher odds of reporting the EHR function was easy to use compared with physicians working in physician-owned practices.

Using a nationally representative survey of office-based physicians conducted in 2011,

 in this study, we provide one of the first studies on the association of EHR characteristics with physician attitudes on ease of use of EHR functionalities related to MU.

 We found that both adoption of specific EHR functions and perceived ease of use were relatively high. In 2011, at least three-fourths of EHR adopters reported adopting and using 9 of 14 EHR functions related to MU; furthermore, at least 3 of 4 EHR adopters considered 10 of the 14 EHR functions as easy to use. However, we found that physicians considered less commonly available EHR functions as less easy to use.

We also found that some EHR characteristics were associated with physicians’ ease of using EHR functions. For 12 of the 14 EHR functions we examined, physicians with EHRs that met MU criteria were significantly more likely than physicians with other EHRs to report that EHR functions were easy to use. Technical assistance during EHR implementation played a significant, though less important, role in perceived ease of use compared with EHR certification. More clinical staff training was associated with lower ease of use for a few EHR functions. This finding might be due to the complexity of implementation, concomitant changes to practice work flow, or the possibility that physicians with less experience with EHRs required more initial training.

Our findings suggest that EHR certification and implementation support might play a role in physician attitudes toward EHRs. Although concern has been expressed that EHR vendors have developed poorly designed systems,

 our findings offer preliminary evidence that EHR certification is associated with perceived ease of use. The MU criteria were selected with the goal of enabling EHRs to support improved safety, quality, and efficiency of patient care.

 MU criteria require that EHRs have the capabilities to enable the collection of important patient data, in addition to computerized ordering and clinical decision support capabilities considered critical to improving quality of care.

 Our findings are consistent with prior studies that found higher EHR satisfaction and greater reporting of EHR benefits among physicians using EHRs that were relatively robust or met MU criteria.

 Since the advent of HITECH, the number of certified EHR vendor products has increased dramatically.

 The role of certification in influencing physician attitudes toward EHRs warrants further examination.

We did find variation in perceived ease of use across EHR functions, with more physicians reporting that less common EHR functions were more difficult to use. Prior research has found that perceptions of EHR usefulness improved as users moved beyond the implementation stage and acquired more EHR experience.

 Physicians may have less experience with more novel and advanced EHR functions that involve more complex work flow such as decision support, engagement with patients, or clinical data exchange with outside providers. Perceived ease of use was lowest for EHR functions requiring external coordination, including public health reporting, secure messaging with patients, and viewing data on quality measures. Improvements in the adoption and ease of use of public health reporting functions of EHRs may hinge on improvements in state and local public health systems’ capacity to exchange data with physicians.

 Our findings suggest that technical assistance from EHR vendors or RECs may play a role in improving ease of use of some EHR functions.

Articles

We assessed physician attitudes on ease of use of electronic health record (EHR) functionalities related to “Meaningful Use” and whether ease of use was associated with EHR characteristics.

Physician Attitudes on Ease of Use of EHR Functionalities Related to Meaningful Use

The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted to increase electronic health record (EHR) adoption by providers and hospitals. Experts expressed skepticism about whether the program would indeed hasten adoption and could be implemented in time for the initial reporting period. Could EHR vendors meet the certification requirements, and could the industry innovate to meet small-practice needs? This study, in addition to documenting increased provider adoption, provides the first evidence of increased competitiveness and innovation in the EHR industry spurred by HITECH. For example, the number of EHR vendors certified for e-prescribing with Surescripts increased from 96 to 229 over the program's first 3 years. We also find that prescribers in small practices increasingly adopted lower-cost, Web-based e-prescribing and EHR applications at significantly higher rates (15%-35%) than did large practices (3%-4%), which generally have more human and capital resources to make significant investments. These findings suggest that EHR vendors were highly responsive to HITECH requirements and have been adapting their strategies to meet nuanced market needs, providing reason to be optimistic about the Programs’ future.

	• The HITECH Certification Program has driven fundamental market changes that increase the likelihood that physician use of HIT as a clinical tool will become a central component of medical practice.

	• Proliferation of E*HR vendors under HITECH has spurred increased competition and business model innovation.

	• Innovation has improved the match between physician market needs and industry offerings.

Our study addresses questions about how the Health Information Technology for Economic and Clinical Health (HITECH) program has affected innovation and competition in the electronic health record (EHR) market. We provide the first empirical evidence that demonstrates:

The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted by Congress in 2009 to promote the adoption and meaningful use of certified electronic health record (EHR) technology.

 A number of factors contributed to the particularly low adoption rates among providers in small practices prior to HITECH, including limited access to capital, lack of perceived benefits, and hesitation to adopt significant work flow changes.

 Establishing different programmatic tactics was required to address these various barriers to adoption.

HITECH authorizes significant financial incentives to offset EHR adoption costs for eligible healthcare providers if they demonstrate “meaningful use” of certified EHR technology. Regional Extension Centers (RECs) were created to disseminate best practices and technical assistance for small office practices, critical access hospitals, and other providers in rural areas.

 A health information technology (HIT) certification program was established to assess EHR vendor compliance with certification criteria and standards, to provide assurance to eligible providers that such products could support Meaningful Use (MU) measures.

The HITECH Act required a substantial and multifaceted approach to implementation. Furthermore, the relatively short time between the law’s passage and the deadline for program implementation added significant challenges.

 The impact of these combined issues on providers and EHR vendors created uncertainties and risks for both.

 For example, prior to the final rule for MU measures, all parties had uncertainty about what types of standard functionality would be required to meet MU, how eligible professionals could qualify for MU, what EHR vendors needed to do to become certified, and what the certification criteria and process would be.

Many have noted the myriad challenges associated with implementing HITECH. Potential problematic questions

 raised include: would financial incentives be enough to prompt providers to adopt EHRs

; should the federal government push for more stringent and faster compliance with standards

; would the federal government directly or indirectly pick “winners” and “losers” in the EHR industry

; and would the EHR industry consolidate or expand to meet different provider market needs?

Early evidence suggests that HITECH is addressing these challenges: CMS had paid $9 billion to more than 177,000 eligible professionals and hospitals as of December 2012.

 Given this significant uptake, important questions remain about the impact of HITECH on competitiveness and innovation in the EHR market. For example, a decreasing number of EHR vendors with certified products over the long term could indicate that certain aspects of the certification process are too challenging or costly, or that market forces are naturally leading to consolidation; alternatively, an increase in the number of EHR vendors with certified products could indicate increased competition, greater alignment with market needs, and evidence that the certification process is providing value to both vendors and purchasers.

To understand the EHR market and the implications of HITECH, we investigated several key measures prior to and during HITECH’s implementation, including: 1) the number of providers who have adopted EHR; 2) the number of certified EHR vendors; 3) market concentration ratio among the top 10 EHR vendors; 4) type of technology adopted by physician market segments; and 5) whether there is a difference in market focus by vendor, using vendor technology type as a predictor.

The study data were obtained from the Surescripts network, which electronically connects and certifies systems used by prescribers, pharmacies, payers, and pharmacy benefit managers. The network connects more than 40 payers and pharmacy benefit managers, more than 62,000 community pharmacies, and roughly 490,000 prescribers using more than 250 e-prescribing and EHR systems representing over 400 applications.

E-prescriptions generated by a provider using a “Surescripts-certified” system are processed by Surescripts and routed electronically to a community pharmacy. Surescripts estimated that, as of the end of 2012, more than 50% of all eligible prescriptions in the United States were electronically routed through its network.

 Others have validated the use of Surescripts data to track EHR adoption.

 We tested the credibility of using Surescripts data for this study by comparing EHR and eprescribing vendors certified on the Surescripts network against a list of vendors certified by the Office of the National Coordinator (ONC).

 First, we used a VLOOKUP function in Microsoft Excel to find exact matches of vendor names provided by Surescripts and Data.Gov; second, we manually reviewed the unmatched vendors and searched ONC’s Certified Health IT Products List website for instances in which the vendor’s product classification was “Modular EHR” and used a Surescripts-certified vendor for e-prescribing.

 We were able to find a positive Surescripts vendor match for 97.3% of ONC-certified vendors, as outlined in the 

We measured the number of active prescribers and Surescripts-certified vendors on the Surescripts’ network during the first quarter of each year on a longitudinal basis using data from 2008 to 2012. We calculated the number of vendors as those with active prescribers in any measurement period, as this is best proxy for the number of active vendors in the marketplace at any one time. A prescriber is characterized as “active” if he or she has written and routed at least 1 prescription electronically in a 30-day period.

To determine industry competitiveness, we conducted 2 calculations during each measurement period: collective market share of vendors (grouped by 10) by share of active prescribers; and the Herfindahl-Hirschman Index (HHI), which provides insight into industry competitiveness and is used by the Federal Trade Commission (FTC) for the purpose of measuring market concentration in antitrust cases. We calculated HHI index by determining market share of each EHR vendor, as established by share of active prescribers.

To assess innovation occurring in the market and industry, we measured the type of EHR technology—as defined in dichotomous terms as either Web-based or traditional software&mdash;adopted by different market segments (defined here as physician practice size). We chose these 2 measures because Web-based technology tends to allow for more rapid technology innovation and deployment and more flexible business models than traditional software. Because we could not positively identify all vendor applications by type, we categorized applications into either 1) Web-based, 2) traditional software, or 3) unclear. We present a range of results based on possible variations of inclusion and exclusion in the “unclear” category. In addition, we matched Surescripts provider data to data from SK&A, the large healthcare information solutions firm, to obtain and verify practice-size information. We categorized EHR providers by the sizes of the practices they serve. For the purpose of tracking EHR application type by practice size, these sizes were defined as small (1-5 providers), medium (6-25 providers), and large (more than 25 providers).

Early data indicate that a substantial number of EHR vendors have successfully completed the ONC certification process—396 as of September 2012, each of which had at least 1 eligible professional who has successfully attested to MU requirements.

 shows that the number of certified vendors on the Surescripts network increased by 133 from the first quarter of 2009 (when HITECH became law) to the first quarter of 2012, from 96 to 229. Notably, the number of new vendor entrants in the industry increased each year, with 58 entering between 2011 and 2012; this is more than the total number of vendors, 52, in 2007. (Also of note is that several of the Surescripts-certified vendors partner with and provide e-prescribing services to many ONCcertified vendors, which explains the difference in vendor numbers between Figure 1 and Table 1.) Prescriber adoption increased at a rapid pace as well in the 3-year period following HITECH, from 40,759 in early 2008 to 401,651 in early 2012, reflecting a compound annual growth rate of 58%. The number of new adopters increased each year, from approximately 70,000 in the year immediately following HITECH’s adoption to nearly 140,000 between Q1 2011 and Q1 2012. Reflecting the rapid growth, 74% of active e-prescribers on the Surescripts network as of the first quarter in 2012 had adopted EHRs post HITECH.

Among the top 10 vendors (as measured by market share) during this same 3-year period, the average number of active e-prescribers per vendor increased from 7864 in 2009 to 31,120 in the first quarter of 2012; the average vendor’s e-prescriber base increased from 1078 users to 1754 during that time (

). A top-10 vendor in early 2012 was 75 times larger than the average vendor, up from 27 times the size of the average vendor in early 2009.

Despite the top 10 vendors’ faster growth rate, however, they did not collectively gain market share: the top 10 EHR/e-prescribing vendors had 72.4% market share in Q1 2008, 76.0% in 2009, and 77.5% in Q1 2012—relatively stable growth (

). The HHI index for the EHR/e-prescribing industry increased from 814 in Q1 2008 to 1022 in Q1 2009 before decreasing again to 876 in Q1 2012. Based on the definition provided by the FTC, this suggests that the EHR industry remained a “highly competitive” industry throughout the study period.

We have seen evolution in the types of HIT providers have adopted. In early 2008, the majority of providers (59%) across practice settings had chosen stand-alone e-prescribing systems. By early 2009 (when HITECH was signed into law), the numbers had changed significantly, with the majority (54%) of providers choosing EHRs.

Among providers who adopted an EHR in 2008, very few (3.6%-6.2%) opted for Web-based EHRs. Adoption of Web-based EHRs was highest among small office providers (6.0%-11.7%) and lowest among providers working in large practices (1.8%-2.9%), as noted in 

. The overall prevalence of Web-based EHRs increased to between 9.9% and 19.5% among providers who adopted in 2011. Web-based EHRs were most popular with small office practice providers, with between 15.0% and 34.5% of this cohort selecting Web-based applications in 2011. During the same period, providers in medium and large practices increasingly selected traditional software-based EHRs.

There are several limitations to our study. First, the comparison of EHR vendors was based on measuring EHR and e-prescribing vendors with at least 1 active prescriber on the Surescripts network and at least 1 eligible professional who successfully attested for the EHR incentive program. While we believe this type of comparison is the most valid way to compare data between Surescripts and ONC/CMS, it is possible that a comparison of all vendors certified by each organization (regardless of whether they have demonstrated market viability) may yield different results.

Second, we had a limited ability to positively identify applications as either Web-based or traditional software; while (Surescripts) certifies vendors and applications, we do not collect information during the certification process as to whether the technology is Web-based or software. During the course of our study, between 42% and 49% of new physician users each year selected an application we were unable to positively identify here as either Web-based or traditional. While we are confident in the remaining data as representative of market trends, our findings as presented in Figure 4 should therefore be considered directional only at this point.

Third, because this study uses e-prescribing data from the Surescripts network, it is important to note that our visibility to EHR users is limited to providers who not only adopt an EHR but also e-prescribe through Surescripts. While the majority of providers nationwide were actively e-prescribing through Surescripts as of the study period, it is possible that our study may underrepresent certain market segments or EHR vendors.

Finally, our study should be considered within the broader context and timeline of implementation of the HITECH Act and MU stages. We have reviewed industry and market data through the first quarter of 2012, which provides insight only through the very beginning of MU Stage 1. Given the more rigorous technical interoperability requirements moving forward, our data and findings should be viewed as representative only of early-stage progress.

Policy makers enacted HITECH to spur physician adoption of HIT, believing it a significant step towards facilitating increased care coordination, improving outcomes, and empowering providers and patients by giving them access to more information. HITECH authorized a multipronged approach to support this effort, including financial incentives, the establishment of a certification program, funding for health information exchanges, regional extension centers to provide education and support services, and grants to advance test specific use cases for HIT, such as to improve care coordination. These provisions, designed to remove barriers to adoption, also created an initial environment of uncertainty among providers and EHR vendors.

Despite that uncertainty, however, the results from this study suggest that HITECH is driving fundamental market and industry changes that we believe increase the likelihood that physician use of EHRs will become a central component of how medicine is practiced. For example, the proliferation of EHR vendors since HITECH was enacted in 2009—from 96 to more than 229 as of early 2012&mdash;suggests that the legislation has spurred increased competition among these vendors. During the same time, we have seen business-model innovation from EHR vendors to attract small office practices; this seems to be resonating in the marketplace, as evidenced by the proportion (15%-35%) of small office prescribers now adopting Web-based applications. In addition, as the final barometer of success, the number of prescribers using an EHR to e-prescribe increased close to 300%, from 103,458 to 401,651, in the 3 years between HITECH’s enactment and the end of the study period.

We believe there have been 3 key components to HITECH’s success in driving substantial industry and market changes thus far. First, the Act provides financial incentives for providers, which puts the market (not the federal government) in the position of determining which vendors most effectively meet provider needs. Additionally, we believe these financial incentives created a catalyst for the EHR industry to compete for market segments that were previously economically unappealing.

 New market segments attracted private capital and increased competition, which spurred industry business model innovation that appears to be resonating with small practices.

Second, the Act called for a certification process for EHR vendors, which reduced provider uncertainty by establishing an unbiased validation service to ensure that certain functionality is available. Equally important, ONC was able to quickly determine the certification criteria and implement them within a very short time frame by establishing a novel public-private approach that leveraged existing expertise within the federal government (National Institute of Standards and Technology) with private entities possessing HIT certification expertise.

Third, the Act requires providers to meaningfully use certified EHR technology. By staging the requirements to meet MU, CMS has set the expectation that providers must commit to the continued use of EHR technology over a period of years. While debates continue over the measurement thresholds and programmatic timelines, the basic premise of MU requires that both sides—physician market and EHR industry&mdash;work together to improve care delivery.

We believe it is premature to judge HITECH’s overall impact since its numerous programs will continue to evolve and shape the healthcare landscape for many years. This study documents, for the first time, that in addition to provider adoption, there is change occurring in the EHR industry that has matched the pace of market changes. Tracking market behavior and EHR vendor activity over time may provide clues about the program’s lasting impact. We are encouraged by its findings and therefore hopeful that as HITECH’s programs continue, we will see the market continue to respond to greater demands for interoperability and patient engagement.

 Surescripts, Arlington, VA (SJ, MS, MAC); Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD (MFF); Office of National Coordinator for Health Information Technology, Department of Health and Human Services, Washington, DC (MFF, SP).

The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (SJ, MS, MFF); acquisition of data (SJ, MS); analysis and interpretation of data (SJ, MS, MFF); drafting of the manuscript (SJ, MS, MAC); critical revision of the manuscript for important intellectual content (SJ, MS, MFF, SP); administrative, technical, or logistic support (MAC).

 Mary Ann Chaffee, MS, MA, Surescripts, 2800 Crystal Dr, Arlington, VA 22202. E-mail: 

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http://www.aao.org/yo/newsletter/201001/article01.cfm

. Published January 2010. Accessed December 2012.

8. Testimony of Glen Tullman, Before the House Committee on Energy and Commerce Subcommittee on Health; Implementation of the Health Information for Economic and Clinical Health (HITECH) Act; July 27, 2010. 

http://democrats.energycommerce.house.gov/sites/default/files/documents/Testimony-Tullman-Health-Implementation-HITECH-Act-2010-7-27.pdf

9. Gold M, Hossain M, Charles DR, Furukawa MF. Evolving vendor market for HITECH-certified ambulatory EHR products. 

10. Madeleine Konig, Sheera Rosenfeld, Sara Rubin, Scott Weier; Avalere Health LLC. Stimulus spending: will the EHR incentives work? 

http://www.avalerehealth.net/research/docs/hit_stimulus_spending_slides.pdf

This is the first empirical evidence to demonstrate increased competition and innovation in the EHR industry as a result of the HITECH program.

HITECH Spurs EHR Vendor Competition and Innovation, Resulting in Increased Adoption

The ambitious goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act require rapid development and certification of new ambulatory electronic health record (EHR) products.

To examine where the vendor market for EHR products stands now and the policy issues emerging from the market’s evolution.

 We had 3 main sources of information: (1) documents describing this evolving market, which is not well represented in peer-reviewed literature; (2) operational data on certified ambulatory EHR products and their use by Medicareeligible professionals attesting for meaningful use payments from January 2011 to October 2012; and (3) telephone interviews with 10 vendors that account for 57% of the market.

 Those attesting for Medicare meaningful use payments used ambulatory EHRs from 353 different vendors, although 16 firms accounted for 75% of the market. The Herfindahl-Hirschman Index showed the ambulatory EHR market to be highly competitive, particularly for practices of 50 or fewer professionals. The interviewed vendors and the external analysts agreed that stage 1 requirements set a relatively low bar for market entry, but that likely will change as requirements get more demanding.

The HITECH Act met its initial goals to motivate growth of diverse ambulatory EHR products. A market shakeout may emerge, though current data reveal no signs of it. Policy makers can influence the shape and value of such a shakeout, and the extent of disruption, through their approach to certification and “usability” and “interoperability” strategies and requirements.

Am J Manag Care. 2013;19(11 Spec No. 10):SP353-SP361

This study examines the evolving vendor market for ambulatory electronic health records (EHRs) as implementation of the Health Information Technology for Economic and Clinical Health Act proceeds. It analyzes:

		The market share of Medicare-eligible attesting providers and the extent of competition across the 353 ambulatory EHR vendors.

		How ambulatory EHR vendors handle product distribution and pricing, implementation and maintenance support, and support for a meaningful use attestation.

		The policy issues that arise with the rapid growth of ambulatory EHR products.

The Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009 set ambitious goals for using health information technology (HIT) to improve healthcare delivery. Critical first steps for success involve rapid nationwide adoption of electronic health records (EHRs) and electronic health information  exchange to support delivery improvements. In previous work, we examined critical drivers of adoption and exchange, finding that some of these drivers were not directly under HITECH or government control.

 In this study, we examine in more depth the evolution of one such driver: the availability of vendor products offering EHRs to eligible professionals, especially in office-based practice. (Other drivers of adoption are affordability, practice integration, and provider attitudes.)

Availability is particularly relevant to ambulatory care. Before HITECH, use of EHRs in office-based practice was much less developed than in the inpatient environment; products serving smaller office-based practices were particularly limited in both number and functionality.

 While the percentage of office-based physicians making any use of an EHR has risen over time,

 adoption rates are uneven, with uptake substantially lower for certified products that meet uniform nationwide standards. The HITECH objective was to combine such standards with meaningful use incentives and regional extension center support for high-priority  roviders to accelerate development of a strong vendor market with certified EHR products suitable to ambulatory and inpatient settings.

This study sought to further our understanding of the industry, which is evolving to meet the demand for HITECH-relevant ambulatory EHRs. It addressed 3 questions:

	1. How has the vendor market for ambulatory products evolved with the implementation of HITECH?

	2. What role do vendors play in the market, and how do they function currently?

	3. How will the market evolve in the future, and what tools do policy makers have to shape it?

Because the vendor market is relatively new, there is not a welldeveloped, peer-reviewed literature on the industry and many available sources are proprietary. To begin filling this gap, we used available information to answer these 3 questions. Three main sources of information were used:

		Documents, including available industry reports and information on company websites (the “grey literature”).

		Operational data that federal agencies have developed in the context of certifying vendor products and reviewing applications from eligible professionals for meaningful use payments.

		Telephone interviews with 10 diverse vendors in the ambulatory EHR market in March and April 2012.

Lacking an established sample frame, we used information in the trade press to identify a mix of vendors active in the ambulatory market that were diverse in company origins (hospital industry versus others), age, target market, and product design features as reflected in trade publications. Before finalizing our recommendations, we discussed them with Office of the National Coordinator staff, including high-level leadership familiar with the industry. Interviews were guided by a semistructured protocol covering topics relating to market position, marketing and provider support, certification, meaningful use requirements, interaction with federal programs, and future directions and issues. We asked to speak for 45 minutes with each firm’s most senior executive(s) who had strategic and operational oversight of product development, sales, and provider support of certified electronic medical record product(s). To encourage cooperation, we assured interviewees that their comments would be confidential and not reported by firm.We also elicited the cooperation of the Healthcare Information and Management Systems Society Electronic Health Record Association, which then encouraged its members to respond. (The Electronic Health Record Association had no role in choosing interviewees or topics covered and played no role in the analysis.) Interviews were conducted in March and April 2012; 10 of 11 solicited vendors responded. Our lead author conducted each interview, and a research associate participated in the call, taking detailed notes to support analysis.

 shows selected characteristics of the vendors we interviewed. While most were relatively large, their gross revenues ranged from the low millions to billions, sometimes including revenue from a parent company. Most currently are publicly traded, sometimes as subsidiaries of larger parent companies such as General Electric and Quest Diagnostics. Epic, founded in 1979, remains a private, employee-held company. e-MDs is privately held, as is Practice Fusion, a start-up firm founded with capital from Silicon Valley entrepreneurs. The origins of the 10 vendors also differ. Some were founded by clinicians for ambulatory uses (Greenway,e-MDs), and others added EHRs to existing product lines that tend to emphasize practice management products (athenahealth, NextGen, Cerner) or HIT in support of laboratory testing (MedPlus). Vendors also differed in the emphases of their marketing (see the Company Public Tag Line column, Table 1).

Given their small number, interviewees obviously did not represent all vendors; however, they did represent a sizable share of the market (57% of all eligible professionals receiving stage 1 payments by October 2012). Interviewee responses also reflected the vendor perspective and should be understood  in this context. We relied on vendor reports to describe the way the industry functions but applied a critical eye in assessing the policy implications.

The market for ambulatory EHR products is potentially quite large. Frost and Sullivan estimated that the US market was likely to double, from $1.3 billion to an estimated $2.6 billion in revenue between 2009 and 2012, peaking at $3 billion in 2013 before falling off as saturation occurred.

 These are large numbers. Customers for ambulatory products are diverse, including not only new practices but also those looking to replace existing systems with new certified options that better position them to meet increasingly stringent meaningful use requirements in HITECH stages 2 and 3.

 One analysis found that 35% of practices considering acquisitions were replacing their existing products (vs buying new ones), with replacement particularly likely in larger practices.

As intended, HITECH appears to have contributed to a  rapid growth in the vendor market for certified ambulatory products. Almost 800 vendors had such products in late 2012, including 666 with ambulatory products only and 129 that also had inpatient products.

  Some products predated HITECH and were adapted, as needed, to meet its requirements; others were new products from both new and established vendors.

 shows the vendors used by eligible professionals who attested by October 31, 2012, that they successfully met stage 1 meaningful use requirements for Medicare. These data show a broad market, with 353 vendors selling certified complete products used by at least 1 eligible attesting provider. (The analysis was restricted to eligible professionals attesting for Medicare payments who used 1 vendor with 1 complete EHR. These included 93% of those attesting under Medicare [100,877 of 107,907 eligible professionals who qualify for Medicare and Medicaid must decide which program to use]. We cite Medicare figures because they are collected centrally and are more current and complete.) The number of vendors continues to grow, although at a slower rate than in 2011 (data not shown). Although there are many vendors, 16 firms account for 75% of the market. They include relatively established hospital vendors (Allscripts, CCS, and Sage) and newer vendors based mainly in the ambulatory market (eClinicalWorks, NextGen, and Greenway). Some (eg, athenahealth, Practice Fusion) offered products on a widespread basis only after HITECH was enacted, reflective of significant market entry coinciding with HITECH. However, most vendors showed only a small reach to date (271 had fewer than 100 attestations; 127 of these had 10 or fewer attestations).

The Herfindahl-Hirschman Index is a commonly accepted measure of market concentration.

 (This index is calculated by summing the squares of the market share of each firm in an industry. The maximum score is 10,000. Markets with between 1500 and 2500 are considered to be moderately concentrated; those with higher scores are considered to be highly concentrated.) On this metric, the vendor market for ambulatory products was relatively competitive, with low concentration nationwide and across market sectors (

). The main exception involved the largest practices (

51 professionals). Other analyses also show greater diversity in vendor mix among  the smallest practices (1-3 professionals) than among the largest (

 these data provide no evidence that this consolidation has begun, as the index reported here was relatively unchanged from that calculated at the end of 2011 (data not shown).

Industry reviews highlight the relevance of particular vendors to different sized practices.

 The attestation data show most large vendors used by practices across the size spectrum. Epic users are almost all professionals in the largest practices or multiple practice settings. Conversely, half or more of Practice Fusion, Eyefinity, Compulink, Biomedix, and Amazing Charts users are in the smallest settings (

Studies show higher rates of attestation among primary care professionals than specialists.

 Our analysis showed somewhat more dispersion in vendors used by specialists than by primary care physicians (Tables 2 and 3). However, there were no striking differences in the vendor mix by individual specialty (data not presented). (Eyefinity/OfficeMate and Biomedix Vascular Solutions are exceptions.) Thus, both our analysis and industry sources suggest that most of the largest vendors aim to satisfy a wide audience.

All of the vendors with whom we spoke were actively soliciting new business. They commonly used a variety of sales channels, varying the emphasis with their target market. One vendor relied almost exclusively on online marketing and social media to attract large numbers of new but small practices. Another relied heavily on word of mouth to attract largescale customers best positioned to take advantage of its product. Another vendor, part of a parent firm with other lines of health business, solicited new business from its existing clients using other firm products.

Most of the vendors had relationships with multiple regional extension centers funded by HITECH to assist highpriority providers.

 Some of their clients also worked with a center. Vendors differed in the number of regional extension centers with which they worked and the conditions of the work, often reflecting differences in vendor marketing strategies. Some said they were motivated to pursue such arrangements as a possible source of new business. However, they generally were disappointed because extension centers produced limited new business.

Most vendors priced their products on a license or subscription basis, with monthly fees covering the specified services. One vendor linked payments to revenues generated, mirroring its pricing for existing practice management products. Another charged nothing, instead relying on advertising revenue, which a practice could remove for a monthly payment.

Some built incentives into the pricing. For example, one company ran demonstration projects in multiple states (now nationwide), offering vendor-financed grants/donations to reduce the product price. Two others offered some form of guarantee that practices would get their money back if they were  not successful in obtaining meaningful use payments. One of them limited such incentives to Medicaid practices, linking payments to initial adoption but not to meaningful use. The other included practices regardless of whether they were attesting for Medicaid or Medicare.

Implementation of EHRs requires practices to secure access to any hardware and complementary software the EHR product requires, train practice staff in product use, integrate EHR functionalities into practice work flow, and use the product to improve care for individual patients and the practice population overall. To access meaningful use payments, practices also must generate and submit metrics demonstrating compliance with requirements.

Balancing competing goals of innovation and regulatory oversight will influence the evolution of the vendor market for certified ambulatory electronic health record products.

Evolving Vendor Market for HITECH-Certified Ambulatory EHR Products

 To provide national estimates of physician capability to electronically share clinical information with other providers and to describe variation in exchange capability across states and electronic health record (EHR) vendors using the 2011 National Ambulatory Medical Care Survey Electronic Medical Record Supplement.

Survey of a nationally representative sample of nonfederal office—based physicians who provide direct patient care.

The survey was administered by mail with telephone follow-up and had a 61% weighted response rate. The overall sample consisted of 4326 respondents. We calculated estimates of electronic exchange capability at the national and state levels, and applied multivariate analyses to examine the association between the capability  to exchange different types of clinical information and physician and practice characteristics.

 In 2011, 55% of physicians had computerized capability to send prescriptions electronically; 67% had the capability to view lab results electronically; 42% were able to incorporate lab results into their EHR; 35% were able to send lab orders electronically; and, 31% exchanged patient clinical summaries with other providers. The strongest predictor of exchange capability is adoption of an  EHR. However, substantial variation exists across geography and EHR vendors in exchange capability, especially electronic exchange of clinical summaries.

In 2011, a majority of office-based physicians could exchange lab and medication data, and approximately one-third could exchange clinical summaries with patients or other providers. EHRs serve as a key mechanism  by which physicians can exchange clinical data, though physicians’ capability to exchange varies by vendor and by state.

Physicians’ ability to access key clinical information electronically in a timely manner can potentially improve the safety, quality, and efficiency of patient care.

		Our findings indicate that the majority of US physicians have the capability to exchange laboratory and pharmacy data electronically.

		One-third of physicians are capable of exchanging clinical summaries with patients or other providers.

		Electronic health records (EHRs) could serve as a primary means for exchange of clinical information, but there is variation in exchange capability among EHR products.

The capability to electronically share and view clinical data has the potential to enable clinical information to follow patients wherever they go to seek care and thereby improve the safety, quality, and efficiency of healthcare.

 Despite promising benefits, historically physicians have not exchanged clinical information  electronically due to the high costs associated with implementation and limited incentives for data sharing.

 Exchange activity has largely been confined to regions of the country where there are operational health information organizations that support clinical data exchange within their community.

 Furthermore, physicians have typically had to use stand-alone e-prescribing systems or proprietary portals that  support the exchange of specific types of clinical data (eg, viewing lab data), which can be costly, difficult to incorporate into their clinical work flow, and possess limited capability to support integrated data as with an electronic health record (EHR).

A number of federal programs and other initiatives are under way to help address some of these barriers. The Health Information  echnology for Economic and Clinical Health (HITECH) Act of 2009 includes up to $22.5 billion in financial incentives for eligible professionals who demonstrate “meaningful use” of interoperable EHRs capable of electronic exchange. HITECH also awarded more than $540 million to the Office of the National Coordinator for Health Information Technology (ONC) State Health Information Exchange (HIE) Program, which provides support for state-designated entities to ensure mechanisms are in place to enable providers to exchange clinical information.

 Furthermore, ONC’s Health Information Technology Certification Program seeks to ensure that EHR products include functionality that enables electronic exchange.

 In addition to the HITECH incentives and programs, a public-private initiative provides relatively simple technical solutions to enable directed exchange between 2 known providers.

We assessed physicians' capability to electronically share clinical information with other providers and describe variation in exchange capability across states and electronic health record vendors.

Michael F. Furukawa, PhD

Articles

Physician Attitudes on Ease of Use of EHR Functionalities Related to Meaningful Use

HITECH Spurs EHR Vendor Competition and Innovation, Resulting in Increased Adoption

Evolving Vendor Market for HITECH-Certified Ambulatory EHR Products

Physician Capability to Electronically Exchange Clinical Information, 2011