Review of Literature. July 22, Compiled by: Dr. Sanjeev Tandon and Sundus Adhi at CDC/OSELS/PHSIPO

Transcription

1 Review of Literature July 22, 2013 Compiled by: Dr. Sanjeev Tandon and Sundus Adhi at CDC/OSELS/PHSIPO

2 Review of Literature Table of Contents: The Meaningful Use Regulation for EHRs Meaningful Use of Electronic Health Records NCHS Data Brief of EHR Adoption The Missing Pieces in Meaningful Use Minding the Public s Health IT The Ups and Downs of EMRs Compiled by: Dr. Sanjeev Tandon and Sundus Adhi at CDC/OSELS/PHSIPO Page 1

3 The NEW ENGLAND JOURNAL of MEDICINE Perspective august 5, 2010 The Meaningful Use Regulation for Electronic Health Records David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A. The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers decisions and patients outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice. But inevitability does not mean easy transition. We have years of professional agreement and bipartisan consensus regarding the potential value of EHRs. Yet we have not moved significantly to extend the availability of EHRs from a few large institutions to the smaller clinics and practices where most Americans receive their health care. Last year, Congress and the Obama administration provided the health care community with a transformational opportunity to break through the barriers to progress. The Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use EHRs privately and securely to achieve specified improvements in care delivery. Through HITECH, the federal government will commit unprecedented resources to supporting the adoption and use of EHRs. It will make available incentive payments totaling up to $27 billion over 10 years, or as much as $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician. This funding will provide important support to achieve liftoff for the creation of a nationwide system of EHRs. Equally important, HITECH s goal is not adoption alone but meaningful use of EHRs that is, their use by providers to achieve significant improvements in care. The legislation ties payments specifically to the achievement of advances in health care processes and outcomes. HITECH calls on the secretary of health and human services to develop specific meaningful use objectives. With the Centers for Medicare and Medicaid Services (CMS) in the lead, the Department of Health and Human Services (DHHS) has used an inclusive and open process to develop these criteria, providing an extensive opportunity for public and professional input. The department published proposed meaningful use requirements on January 16, The proposal prompted some 2000 comments. This week, the n engl j med 363;6 nejm.org august 5, The New England Journal of Medicine Downloaded from nejm.org at CDC Public Health Library & Information Center on September 17, For personal use only. No other uses without permission. Copyright 2010 Massachusetts Medical Society. All rights reserved.

4 PERSPECTIVE Meaningful Use Regulation for Ehrs DHHS is releasing a final regulation for the first 2 years (2011 and 2012) of this multiyear incentive program. Subsequent rules will govern later phases. Although the intent of our January proposals has been retained and indeed affirmed through the rule-making process, the final regulation also incorporates significant changes a response to the comments and experience that diverse stakeholders shared with us. In particular, concerns about the pace and scope of implementation of meaningful use led us to adopt a two-track approach regarding the objectives that allow practices and hospitals to qualify for incentive payments in the first 2 years of the program. The most important part of this regulation is what it says hospitals and clinicians must do with EHRs to be considered meaningful users in 2011 and In the original proposal, we identified a broad set of objectives, all of which would need to be met. This included 23 objectives for hospitals and 25 for clinicians. The DHHS received many comments that this approach was too demanding and inflexible, an all-or-nothing test that too few providers would be likely to pass. In the final regulation, we have divided these elements into two groups: a set of core objectives that constitute an essential starting point for meaningful use of EHRs and a separate menu of additional important activities from which providers Summary Overview of Meaningful Use Objectives.* Objective Measure Core set of objectives to be achieved by all eligible professionals, hospitals, and critical access hospitals to qualify for incentive payments Record patient demographics (sex, race, ethnicity, date of birth, preferred language, and in the case of hospitals, date and preliminary cause in the event of death) Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children) Maintain up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record smoking status for patients 13 years of age or older For individual professionals, provide patients with clinical summaries for each office visit; for hospitals, provide an electronic copy of hospital discharge instructions on request On request, provide patients with an electronic copy of their health information (including diagnostic-test results, problem list, medication lists, medication allergies, and for hospitals, discharge summary and procedures) Generate and transmit permissible prescriptions electronically (does not apply to hospitals) Computer provider order entry (CPOE) for medication orders Implement drug drug and drug allergy interaction checks Implement capability to electronically exchange key clinical information among providers and patient-authorized entities Implement one clinical decision support rule and ability to track compliance with the rule Implement systems to protect privacy and security of patient data in the EHR Report clinical quality measures to CMS or states Over 50% of patients demographic data recorded as structured data Over 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data Over 80% of patients have at least one entry recorded as structured data Over 80% of patients have at least one entry recorded as structured data Over 80% of patients have at least one entry recorded as structured data Over 50% of patients 13 years of age or older have smoking status recorded as structured data Clinical summaries provided to patients for over 50% of all office visits within 3 business days; over 50% of all patients who are discharged from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it Over 50% of requesting patients receive electronic copy within 3 business days Over 40% are transmitted electronically using certified EHR technology Over 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE Functionality is enabled for these checks for the entire reporting period Perform at least one test of EHR s capacity to electronically exchange information One clinical decision support rule implemented Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures 502 n engl j med 363;6 nejm.org august 5, 2010 The New England Journal of Medicine Downloaded from nejm.org at CDC Public Health Library & Information Center on September 17, For personal use only. No other uses without permission. Copyright 2010 Massachusetts Medical Society. All rights reserved.

5 PERSPECTIVE Meaningful Use Regulation for Ehrs Summary Overview of Meaningful Use Objectives (Continued.) Objective Measure Eligible professionals, hospitals, and critical access hospitals may select any five choices from the menu set Implement drug formulary checks Incorporate clinical laboratory test results into EHRs as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate Perform medication reconciliation between care settings Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period Over 40% of clinical laboratory test results whose results are in positive/ negative or numerical format are incorporated into EHRs as structured data Generate at least one listing of patients with a specific condition Over 10% of patients are provided patient-specific education resources Medication reconciliation is performed for over 50% of transitions of care Provide summary of care record for patients referred or transitioned to another provider or setting Submit electronic immunization data to immunization registries or immunization information systems Submit electronic syndromic surveillance data to public health agencies Record advance directives for patients 65 years of age or older Submit electronic data on reportable laboratory results to public health agencies Additional choices for hospitals and critical access hospitals Additional choices for eligible professionals Summary of care record is provided for over 50% of patient transitions or referrals Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions) Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) Over 50% of patients 65 years of age or older have an indication of an advance-directive status recorded Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) Send reminders to patients (per patient preference) for pre ventive and follow-up care Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies) Over 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders Over 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR * This overview is meant to provide a reference tool indicating the key elements of meaningful use of health information technology. It does not provide sufficient information for providers to document and demonstrate meaningful use in order to obtain financial incentives from the Centers for Medicare and Medicaid Services (CMS). The regulations and filing requirements that must be fulfilled to qualify for the Health IT financial incentive program are detailed at will choose several to implement in the first 2 years (see table). Core objectives comprise basic functions that enable EHRs to support improved health care. As a start, these include the tasks essential to creating any medical record, including the entry of basic data: patients vital signs and demographics, active medications and allergies, up-to-date problem lists of current and active diagnoses, and smoking status. Other core objectives include using several software applications that begin to realize the true potential of EHRs to improve the safety, quality, and efficiency of care. These features help clinicians to make better clinical decisions and avoid preventable errors. To qualify for incentive payments, clinicians must start employing such clinical decision support tools. They must also start using the capability that undergirds much of the value of EHRs: using records to enter clinical orders and, in particular, medication prescriptions. Only when providers enter orders electronically can the computer help improve decisions by applying clinical logic to those choices in light of all the recorded patient data. And to begin extending the benefits of EHRs to patients themselves, the meaningful use requirements will include providing patients with electronic versions of their health information. n engl j med 363;6 nejm.org august 5, The New England Journal of Medicine Downloaded from nejm.org at CDC Public Health Library & Information Center on September 17, For personal use only. No other uses without permission. Copyright 2010 Massachusetts Medical Society. All rights reserved.

6 PERSPECTIVE Meaningful Use Regulation for Ehrs In addition to the core elements, the rule creates a second group: a menu of 10 additional tasks, from which providers can choose any 5 to implement in This gives providers latitude to pick their own path toward full EHR implementation and meaningful use. For example, the menu includes capacities to perform drugformulary checks, incorporate clinical laboratory results into EHRs, provide reminders to patients for needed care, identify and provide patient-specific health education resources, and employ EHRs to support the patient s transitions between care settings or personnel. For most of the core and menu items, the regulation also specifies the rates at which providers will have to use particular functions to be considered meaningful users. Reflecting the views and experiences shared during the comment period, these rates will enable significant progress toward improving care but are also achievable by average practices and providers in the early years. The HITECH legislation further requires that meaningful use include electronic reporting of data on the quality of care. In the final regulation, we have simplified the January proposals for quality reporting, while still building toward a robust reporting capability that will inform providers about their own performance and will eventually inform the public as well. Clinicians will have to report data on three core quality measures in 2011 and 2012: blood-pressure level, tobacco status, and adult weight screening and follow-up (or alternates if these do not apply). Clinicians must also choose three other measures from lists of metrics that are ready for incorporation into electronic records. The meaningful use rule is part of a coordinated set of regulations to help create a private and secure 21st-century electronic health information system. On June 18, 2010, the DHHS issued a rule that laid out a process for the certification of electronic health records, so that providers can be assured they are capable of meaningful use. The department has also issued still another regulation that lays out the standards and certification criteria that EHRs must meet in order to be certified. Finally, realizing that the privacy and security of EHRs are vital, the DHHS has been working hard to safeguard privacy and security by implementing new protections contained in the HITECH legislation. The meaningful use rule strikes a balance between acknowledging the urgency of adopting EHRs to improve our health care system and recognizing the challenges that adoption will pose to health care providers. The regulation must be both ambitious and achievable. Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself. As part of this process, the DHHS is establishing a nationwide network of Regional Extension Centers to assist providers in adopting qualified EHRs and making meaningful use of them. The DHHS is committed to the support, collaboration, and ongoing learning that will mark our progress toward electronically connected, information-driven medical care. We hope that providers and consumers will now join us in the effort to assure that we make the best possible use of our most precious health care resource: information about the patients we serve. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. Dr. Blumenthal is the national coordinator for health information technology at the Department of Health and Human Services, and Ms. Tavenner is the principal deputy administrator of the Centers for Medicare and Medicaid Services both in Washington, DC. This article ( /NEJMp ) was published on July 13, 2010, at NEJM.org. Copyright 2010 Massachusetts Medical Society. 504 n engl j med 363;6 nejm.org august 5, 2010 The New England Journal of Medicine Downloaded from nejm.org at CDC Public Health Library & Information Center on September 17, For personal use only. No other uses without permission. Copyright 2010 Massachusetts Medical Society. All rights reserved.

7 COMMENTARY Meaningful Use of Electronic Health Records The Road Ahead Ashish K. Jha, MD, MPH ON JULY 13, 2010, THE DEPARTMENT OF HEALTH and Human Services released the final criteria defining meaningful use of electronic health records (EHRs). The aim behind these rules is to improve quality and efficiency of care by encouraging approximately clinicians and 5000 acute care hospitals to use EHRs. With approximately $30 billion in incentives and the threat of reduced payments for those that fail to comply, meaningful use may represent the single most potent federal effort to change health care delivery in the past 2 decades. For practicing clinicians, the origins and likely effects of this rule may be opaque. It would be helpful to understand the motivation behind the key components of the meaningful use rules, where they are likely to take the US health care system (and the obstacles along the way), and the benefits and risks of a rapid transformation from paper to electronic record systems. Why Meaningful Use? The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, part of the stimulus bill, allocates approximately $ for each practicing clinician and between $2 million and $10 million for each hospital that qualifies as a meaningful user of EHRs. Although efforts to tie financial incentives for meaningful use are not new (this was articulated in previous bills that did not pass), the current Congress was quite prescriptive about defining meaningful use, stipulating that it include electronic prescribing, health information exchange (sharing clinical data among clinicians and hospitals), and automated reporting of quality performance. The final meaningful use rule incorporates these 3 challenging requirements that clinicians and hospitals must meet to receive incentive payments. Other requirements include electronically recording key parts of a patient s history (detailed demographics, vital signs, active medication and problem lists, smoking status), creating care-summary documents, and implementing at least 1 clinical decision support tool. Functions that are optional (for now) include the ability to generate lists of patients with specific conditions, using EHRs to provide patients with educational materials, performing medication reconciliation, and submitting key data electronically to public health entities. Many clinicians and hospitals will struggle to achieve these goals in a timely fashion. Why did policy makers impose a high bar? Concerned by data showing that simply adopting EHRs was inadequate to substantially improve care, policy makers focused on scientific evidence supporting use of electronic prescribing, coupled with decision support, to improve quality 1 and widespread sharing of clinical data to lower costs. 2 In addition, Congress required automated reporting of quality performance to augment existing efforts to increase transparency. Each of these 3 required elements is difficult: implementing electronic prescribing can be highly disruptive and few EHR systems can currently support exchange of clinical data or automated gathering and reporting of quality measures. HITECH, Meaningful Use, and Adoption of EHRs When President Obama first declared the goal of near universal EHR use by 2014, approximately 10% of hospitals 3 and 20% of physicians 4 were using these systems, and even fewer could meet the preliminary definition of meaningful use. 5 Adoption of EHRs has been increasing at about 3% to 6% per year. 3,4 If HITECH incentives double or triple these rates (which is generous because adopting EHRs alone is not adequate to qualify for meaningful use), achieving universal EHR use by 2014 will remain difficult. The challenge is enormous: a majority of US physicians work in practices with fewer than 5 physicians and few currently use EHRs. 4 Without successfully converting these practices, widespread EHR use will be an elusive goal. Tracking their adoption rates over time will provide a critical early signal. Another hurdle is ensuring that clinicians and hospitals that disproportionately care for the poor do not fall behind; early data suggest that they have fewer electronic functionalities needed to meet meaningful use. 6 The HITECH Act allocated extra funding for these clinicians and hospitals, although Congress designated state Medicaid agen- Author Affiliations: Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; Division of General Medicine, Brigham and Women s Hospital, Boston; and VA Boston Healthcare System, Boston. Corresponding Author: Ashish K. Jha, MD, MPH, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA (ajha@hsph.harvard.edu) American Medical Association. All rights reserved. (Reprinted) JAMA, October 20, 2010 Vol 304, No

8 COMMENTARY cies as the vehicles for distributing funds to them (as well as to others, such as children s hospitals). Medicaid agencies are facing swelling ranks of patients due to the recession and the need to plan for the large Medicaid beneficiary expansion authorized by the Patient Protection and Affordable Care Act. There are concerns as to whether these agencies will be capable of effectively administering HITECH funds to qualifying clinicians and hospitals. 7 This problem is avoidable but states must act now to ensure timely provision of funds to those who disproportionately care for the poor. Meaningful Use and Health Care Quality and Costs Meaningful use provisions will help improve legibility of clinical records, reduce prescription errors, improve adherence to guidelines, improve patients access to their records, and ensure that clinicians and hospitals are capable of exchanging clinical data. These are essential first steps. However, for HITECH to be transformative, substantive payment system changes are needed. Although meaningful use makes greater integration and coordination of care feasible, hospitals and clinicians need incentives to actually integrate and coordinate care. Despite good intentions, the Accountable Care Act leaves intact a system that primarily rewards quantity over quality and fragmentation over integration, offering little hope that meaningful use will have more than a modest effect. The administration has hinted that starting in 2013, meaningful use may become more stringent, requiring clinicians and hospitals to demonstrate improved outcomes. A major concern is the speed at which Congress requires meaningful use of EHRs. Incentives began in fiscal year 2011 (which began October 1, 2010) and are front-loaded over the first 2 years. During this short time, hundreds of thousands of clinicians and hospitals will change the way they practice medicine, transitioning from paper-based records to EHRs. This will happen while knowledge of how to implement EHRs safely and effectively is in its infancy. 1 Many of these transitions will be poorly executed, some with serious consequences. Poorly designed or poorly implemented EHR systems can cause as much harm as good. 8,9 Reports of failed adoption and patient harm are likely to emerge. Keeping the frequency and impact of these failures low should be a top policy priority. One approach is to create systems to monitor errors from EHRs and their implementation and use these data to improve future systems. 10 Meaningful Use as a Harbinger of Change Meaningful use, coupled with large financial incentives, may signal the beginning of the end of health care as a cottage industry. Congress and the Obama administration have made plain that the practice of medicine needs to change. However, the challenges to a successful transition to 21st century medicine are substantial, including low baseline EHR adoption rates, lack of knowledge about how best to implement EHRs, groups of clinicians and hospitals vulnerable to falling behind, and lack of incentives for collaboration and integration. These barriers are not insurmountable but require dedication and buy-in both from patients and those who care for them. They also require a payment system that rewards quality and efficiency. The current health care system is failing and EHRs are essential to making substantive and lasting changes in health care delivery. Only time will tell if HITECH delivers on its promise to modernize US medicine into the high-quality, integrated system of care that all individuals deserve. Financial Disclosures: None reported. REFERENCES 1. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10): Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood). 2005(suppl Web Exclusives):W5-10-W Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress report on electronic health records in US hospitals [published online August 26, 2010]. Health Aff (Millwood). doi: /hlthaff Burt CW, Hing E, Woodwell DA. Electronic Medical Record Use by Office- Based Physicians: United States Hyattsville, MD: National Center for Health Statistics; Hogan SO, Kissam SM. Measuring meaningful use. Health Aff (Millwood). 2010; 29(4): Jha AK, DesRoches CM, Shields AE, et al. Evidence of an emerging digital divide among hospitals that care for the poor. Health Aff (Millwood). 2009; 28(6):w1160-w Finnegan B, Ku L, Shin P, Rosenbaum S. Boosting Health Information Technology in Medicaid: The Potential Effect of the American Recovery and Reinvestment Act. Washington, DC: George Washington University; July 7, Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10): Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6): Sittig DF, Classen DC. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA. 2010;303(5): JAMA, October 20, 2010 Vol 304, No. 15 (Reprinted) 2010 American Medical Association. All rights reserved.

9 NCHS Data Brief No. 98 July 2012 Physician Adoption of Electronic Health Record Systems: United States, 2011 Eric Jamoom, Ph.D., M.P.H., M.S.; Paul Beatty, Ph.D.; Anita Bercovitz, Ph.D., M.P.H.; David Woodwell, M.P.H.; Kathleen Palso, M.A.; and Elizabeth Rechtsteiner, M.S. Key findings Data from the 2011 Physician Workflow study In 2011, 55% of physicians had adopted an electronic health record (EHR) system. About three-quarters of physicians who have adopted an EHR system reported that their system meets federal meaningful use criteria. Eighty-five percent of physicians who have adopted an EHR system reported being somewhat (47%) or very (38%) satisfied with their system. About three-quarters of adopters reported that using their EHR system resulted in enhanced patient care. Nearly one-half of physicians currently without an EHR system plan to purchase or use one already purchased within the next year. One goal of the federal 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act is to advance the use of health information technology by providing Medicare and Medicaid incentives to physicians and hospitals that adopt and demonstrate meaningful use (MU) of electronic health record (EHR) systems (1,2). This report presents a nationally representative profile of physician use of EHR systems. Keywords: electronic health records health information technology National Ambulatory Medical Care Survey physician workflow Who adopts EHR systems? Fifty-five percent of physicians were adopters of EHR systems (see Definitions ). Among physicians under age 50, 64% were adopters. Figure 1. Percentage of electronic health record system adoption, by physician age, practice size, ownership, and specialty, 2011 All physicians Physician age Under age 50 Aged 50 and over Practice size Solo practitioner 2 physicians 3 10 physicians 11 or more physicians Ownership Physician owned HMO Community health center Academic health center Physician specialty Primary care Surgical Medical Percent 1 Differences in adoption between this category and all others are statistically significant (p < 0.01). 2 Significant difference between primary care and surgical specialists (p < 0.01). NOTES: Adoption consists of physicians who use a health record system that is all or partially electronic (excluding systems solely for billing). The sample includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists. HMO is health maintenance organization. SOURCE: CDC/NCHS, Physician Workflow study, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics

10 NCHS Data Brief No. 98 July 2012 About one-half of physicians aged 50 and over were adopters (Figure 1). Among solo practitioners, 29% were adopters of EHR systems. The proportion of physicians who were adopters increased as the size of the practice increased, with 60% of physicians in 2-physician practices, 62% of physicians in 3-to-10-physician practices, and 86% of physicians in practices with 11 or more physicians having adopted EHR systems (Figure 1). Only 50% of physicians in physician-owned practices were adopters, whereas virtually all physicians in health maintenance organizations, three-quarters of physicians in community health centers (74%), and 7 out of 10 physicians (70%) in academic health centers had adopted EHR systems (Figure 1). Primary care (58%) and medical care specialists (55%) did not significantly differ from each other in EHR adoption, yet a greater proportion of primary care specialists had adopted EHR systems compared with surgical specialists (48%) (Figure 1). No differences were observed in EHR adoption status by physician gender, race or ethnicity, or practice location in metropolitan statistical area (data not shown). What kinds of systems do EHR adopters use? About three-quarters of adopters (77%) have a system that currently meets the Centers for Medicare & Medicaid Services (CMS) MU criteria (see Definitions ), whereas 8% have a system that does not meet the CMS MU criteria. About 15% of respondents are uncertain whether their system meets MU criteria (Figure 2). Figure 2. Physicians electronic health record systems, by type and ability to meet meaningful use criteria, 2011 System design Stand-alone 1 59 Web-based 2 41 Meaningful use criteria 3 Meets 77 Does not meet 8 Uncertain Percent of physicians with EHR 4 systems Data and application functionality delivered on-site. 2 System hosted and data stored off-site. 3 Defined by Centers for Medicare & Medicaid Services. 4 Electronic health record. NOTES: Data represent physicians who reported having adopted EHR systems (55% of sample). The sample includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists. Missing values are excluded. Percentages may not sum to 100 because of rounding. SOURCE: CDC/NCHS, Physician Workflow study,

11 NCHS Data Brief No. 98 July 2012 More adopters have a stand-alone, self-contained system (59%) rather than a Web-based system design (41%) (see Definitions ) (Figure 2). Although 10% of adopters were in the process of implementing their EHR system, the vast majority of adopters (90%) reported actively using their EHR system (data not shown). How satisfied are EHR users with their systems? The majority of physicians who have adopted an EHR system (85%) were either very satisfied (38%) or somewhat satisfied (47%) with their system. About 15% of providers were either very dissatisfied (5%) or somewhat dissatisfied (10%) with their EHR system (Figure 3). Over two-thirds of adopters (71%) would purchase their EHR system again (data not shown). Figure 3. Percent distribution of electronic health record satisfaction among office-based physicians: United States, Very satisfied Very dissatisfied Somewhat satisfied Somewhat dissatisfied NOTES: Data represent office-based physicians who reported having adopted electronic health record systems (55% of sample). The sample includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists. Missing values are excluded. SOURCE: CDC/NCHS, Physician Workflow study,

12 NCHS Data Brief No. 98 July 2012 What are the benefits of having an EHR system? A majority of adopters reported having accessed a patient s chart remotely (74%) and having been alerted to critical lab values (50%) by using their EHR system within the past 30 days. A majority also reported that using their EHR system had resulted in enhanced overall patient care (74%) (Figure 4). Figure 4. Percentage of physicians whose electronic health records provided selected benefits: United States, 2011 Physician workflow Accessed patient chart remotely 74 Alerted to critical lab value 50 Alerted to potential medication error 41 Reminded to provide preventive care 39 Reminded to provide care meeting clinical guidelines 37 Identified needed lab tests 28 Facilitated direct communication with patient 25 Patient-related outcomes Enhanced overall patient care 74 Ordered more on-formulary medications 41 Ordered fewer tests due to lab results availability Percent of physicians who experienced benefit within past 30 days NOTES: Physicians with electronic health record (EHR) systems whose systems or scope of work did not include a specified capability responded not applicable. These responses are included in the denominator for percentages. Data represent office-based physicians who reported having adopted EHR systems (55% of sample). The sample includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists. SOURCE: CDC/NCHS, Physician Workflow study,

13 NCHS Data Brief No. 98 July 2012 Do physicians without an EHR system intend to purchase a system? Among nonadopters, about one-third reported having no intention to purchase an EHR system within 12 months (32%), and one-fifth reported being undecided about whether to purchase an EHR system in the next 12 months (20%). In addition, about one-half of nonadopters reported either intending to purchase an EHR system within 12 months (27%) or having already purchased one (21%) (Figure 5). Figure 5. Percent distribution of intent to purchase electronic health record system among physicians lacking a system: United States, Have purchased system 32 No intent to purchase within 12 months 27 In process of selecting system or intend to purchase within 12 months 20 Undecided on purchasing within 12 months NOTES: Data represent office-based physicians who reported not having adopted an electronic health record system (45% of sample). The sample includes nonfederal, office-based physicians and excludes radiologists, anesthesiologists, and pathologists. SOURCE: CDC/NCHS, Physician Workflow study,

14 NCHS Data Brief No. 98 July 2012 Summary Overall, in 2011, 55% of physicians in office-based practices had adopted EHRs and 45% had not. Differences were observed between physicians who were EHR adopters and nonadopters by age, physician specialty, practice size, and ownership. Generally, physicians under age 50 were more likely to adopt EHR systems than physicians aged 50 and over. The proportion of physicians who were adopters increased as the size of the practice increased. Compared with solo practitioners where fewer than one-third of physicians adopted EHR systems, those in 2-physician or 3-to-10-physician practices were twice as likely, and those in practices with 11 or more physicians were nearly three times as likely, to have adopted EHR systems. Only one-half of those in physician-owned practices were adopters, whereas physicians employed by community health centers, academic health centers, and HMOs were more likely to have adopted an EHR system. The majority of EHR adopters systems met CMS MU criteria, which would allow the practice to receive incentive payments authorized by the HITECH Act. A majority of EHR adopters had stand-alone systems rather than Web-based systems. Stand-alone systems offer faster response times than Web-based systems, and although stand-alone systems have higher initial cost, their maintenance costs are lower. Web-based systems have the advantage of being easy to access wherever the Internet is available, whereas stand-alone systems may have limited off-site access. The vast majority of physicians who use EHR systems (85%) reported being somewhat satisfied (47%) or very satisfied (38%) with their system. A majority would purchase their EHR system again (71%), suggesting that EHR adopters are generally positive about their current systems. Among EHR adopters, 74% believe that using their system enhanced overall patient care. Among nonadopters, about one-half reported either already having purchased a system or planning to adopt a system within 12 months. This finding suggests an increase in EHR adoption is likely to take place in 2012 among 2011 s nonadopters, potentially amplifying the impact of federal policy incentives. Definitions Physician office: A place where physicians not federally employed provide direct patient care in the 50 states and the District of Columbia; excludes radiologists, anesthesiologists, and pathologists. Demonstrating meaningful use (MU): To qualify for CMS incentive payments for MU, an eligible provider must use a certified EHR system demonstrating all 15 of the core set objectives and 5 of 10 menu set objectives through associated measures or by attestation in 2011 (2). Comparisons of several core objectives are available from the NAMCS supplemental EHR mail survey (3). Adopters and nonadopters of EHRs: Status is derived from office-based physicians who answered the EMR supplement question, Does this practice use electronic medical records or electronic health records (not including billing records)? Adopters are those who answered either yes, all electronic or yes, part paper and part electronic ; nonadopters answered no to using electronic medical records (EMRs) or EHRs. 6

15 NCHS Data Brief No. 98 July 2012 Stand-alone and Web-based EHR systems: A stand-alone, or client, server represents an EHR system that is self-contained, in which data and application functionality are delivered on-site. Web-based EHR systems include application service providers and browser-based systems, also called a cloud system. Web-based EHR system designs use a service provider to host the system and store data for the practice off-site, and the physician accesses the EHR system and data through the Internet (4). Data source and methods The data for this report are from the National Ambulatory Medical Care Survey (NAMCS) Physician Workflow mail survey. The Physician Workflow study, funded by the Office of the National Coordinator for Health Information Technology, is conducted by the National Center for Health Statistics (NCHS) as a NAMCS supplement. It represents a 3-year initiative to survey office-based physicians about their experiences in and perceptions of adopting and using EHR systems. Respondents will be followed annually over a 3-year period, beginning in 2011 and continuing through The sample for the 2011 Physician Workflow mail survey consisted of those physicians confirmed eligible (i.e., who treat ambulatory patients in a physician s office; see Definitions ) in the earlier 2011 NAMCS EMR mail survey. The 2011 EMR mail sample was a stratified sample of physicians with strata defined by state. Eligible physicians for whom EHR adoption status was not confirmed in the EMR survey were contacted to determine that status. Only those NAMCS eligible respondents were mailed Physician Workflow questionnaires within a 2-month period of determining whether they used an EHR system. Adopters received a different questionnaire than nonadopters (4,5). Eligibility status was determined for 8,164 of the 10,301 office-based physicians in the EMR mail survey sample, for an unweighted eligibility status rate of 79.3% (77.7% weighted). Of these 8,164 physicians, 5,232 were deemed eligible and mailed the Physician Workflow questionnaire, to which a total of 3,180 physicians responded for an unweighted response rate of 60.8% (59.0% weighted). The combined, overall unweighted response rate is based on multiplying the eligibility status rate by the workflow mail response rate among those deemed eligible. Therefore, the combined overall unweighted response rate is 48.2% (45.8% weighted). To be nationally representative and correct for nonresponse bias, survey weights were designed to use characteristics of late respondents (data obtained by phone) as a proxy for nonresponse. Those refusing to participate in the EMR survey were contacted to determine eligibility and included in the workflow survey if eligible. About 11% of workflow survey respondents had refused to participate in the EMR survey, with more of these respondents being nonadopters than adopters. For estimates from the EMR questionnaire (e.g., practice size or ownership), missing estimates include unit nonresponse among respondents who refused to take the EMR questionnaire. Among workflow survey respondents, the proportion that completed the EMR questionnaire was greater for EHR adopters than nonadopters. All reported comparisons are statistically significant unless otherwise indicated. Comparisons not mentioned may or may not be statistically significant. Data analyses were performed using the statistical packages SAS version 9.2 (SAS Institute, Cary, N.C.) and SUDAAN version 10.0 (RTI International, Research Triangle Park, N.C.). 7

16 U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics 3311 Toledo Road Hyattsville, MD FIRST CLASS MAIL POSTAGE & FEES PAID CDC/NCHS PERMIT NO. G-284 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 NCHS Data Brief No. 98 July 2012 About the authors The authors are with the Centers for Disease Control and Prevention s National Center for Health Statistics, Division of Health Care Statistics. Eric Jamoom, Paul Beatty, Anita Bercovitz, and David Woodwell are with the Ambulatory and Hospital Care Statistics Branch; Kathleen Palso and Elizabeth Rechtsteiner are with the Technical Services Branch. References 1. Blumenthal D, Tavenner M. The meaningful use regulation for electronic health records. N Engl J Med 363(6): Centers for Medicare & Medicaid Services. The official Web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Available from: [Accessed April 9, 2012]. 3. Hsiao CJ, Hing E, Socey TC, Cai B. Electronic health record systems and intent to apply for meaningful use incentives among office-based physician practices: United States, NCHS data brief, no 79. Hyattsville, MD: National Center for Health Statistics Available from: cdc.gov/nchs/data/databriefs/db79.pdf [Accessed April 9, 2012]. 4. Physician workflow supplement 2011 [EHR adopters], National Ambulatory Medical Care Survey. Hyattsville, MD: National Center for Health Statistics Available from: ahcd/2011_physician_workflow_supplement_for_ehr_adopters.pdf [Accessed April 9, 2012]. 5. Physician workflow supplement 2011 [EHR nonadopters], National Ambulatory Medical Care Survey. Hyattsville, MD: National Center for Health Statistics Available from: ahcd/2011_physician_workflow_supplement_for_ehr_non-adopters.pdf [Accessed April 9, 2012]. Suggested citation Jamoom E, Beatty P, Bercovitz A, et al. Physician adoption of electronic health record systems: United States, NCHS data brief, no 98. Hyattsville, MD: National Center for Health Statistics Copyright information All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. National Center for Health Statistics Edward J. Sondik, Ph.D., Director Jennifer H. Madans, Ph.D., Associate Director for Science Division of Health Care Statistics Clarice Brown, M.S., Director For updates on NCHS publication releases, subscribe online at: For questions or general information about NCHS: Tel: cdcinfo@cdc.gov Internet: ISSN (Print ed.) ISSN (Online ed.) CS DHHS Publication No. (PHS)

17 The Missing Pieces in Meaningful Use June 27, 2009 John Loonsk With the initial definition of "meaningful use" offered by the Health Information Technology Policy Council, we can finally see the broad contours of the administration's plan for the health IT portion of the economic stimulus legislation. In terms of promoting electronic health records, the influx of substantial funds and the advancement of privacy regulations are significant and welcome. But in terms of promoting the health outcomes that this investment should achieve, several pieces are still missing. One relates to the long recognized need to change the misaligned incentives in the health business environment that prevent health IT from taking off and supporting desired outcomes. While approaches now exist for allowing systems to work together (standards), and for testing systems to establish that they can work together (certification), and while funding exists for electronic medical records, none of these ensure that the people and organizations involved in health will actually make the systems work together to exchange information and support improved healthcare quality, access, efficiency and public health. As currently conceived, "meaningful use" will also not change the misaligned incentives that have been so problematic. Another missing piece, which no one should expect health reform to solve, is the need for the technology and policy engineering to guide the thousands of electronic medical record systems and participating organizations into becoming a coherent and secure infrastructure to support health and health reform. Previous incarnations of the national health IT agenda have included initial design and trial implementation of a coherent infrastructure (NHIN, NHII). But these efforts suffered from a lack of funds or incentives to refine and implement them. Now that there are funds, the national health IT agenda is no longer emphasizing proactive engineering. Instead, the focus is more narrowly on getting electronic medical records into practice settings, supporting the general idea of health information exchange, and hoping that the organic growth of the two solves the many needs of a nationwide infrastructure. The administration should reconsider this plan. The many parts and players in health information technology need aspects of proactive design, or "engineering" if they are to technically come together to support meaningful system outcomes. This engineering should not be confused with zealotry for any particular approach or with the development of any particular piece of software. It is about the development of the shared elements that will make for a coherent and secure health information system in the United States. Such a system will not happen organically anymore than pure organic growth would have created other systems we depend on daily. The postal system would not function if different addresses organically developed from every individual house, street and city. So, how can we expect a secure health infrastructure to function without a common way to electronically address the providers and patients that participate? 1

18 The air traffic control system would not function if different airports organically developed their own individual systems to guide planes. So, how can we expect myriad different health systems and information exchanges will function to secure and protect information being exchanged? The Internet would not have explosively developed nor function as it does if different approaches to managing web site names on the network were organically developed by every user and Internet Service Provider. So, how can we expect a "health Internet" to grow or function without engineering analogous approaches? None of these systems can also operate exclusively through the standards that individual participant systems use even if they are all tested to ensure their inclusion. Each system has required a core engineered approach. In the same way, solutions to common health infrastructure issues need to be engineered to meet the functional and policy problems of electronic health information. The product of this engineering then needs to be supported through the use of funds or regulation to make sure that it "sticks." Recognizing that there is a need to proactively engineer aspects of the infrastructure can allow the engineering to be strategic and minimalistic so that positive aspects of organic growth and entrepreneurship can build on it. Failure to recognize the need for engineering risks great inefficiencies in the use of HITECH funds and a "paving the cow paths" approach to the isolated health technologies that exist today which won't produce the system outcomes to accomplish the vision of electronic medical records or justify the investment. About the author: John Loonsk, MD FACMI, is chief medical officer for CGI. From , he was Director of Interoperability and Standards in the Office of the National Coordinator for Health Information Technology Source: 2

19 Minding the Public's Health IT June 23, 2010 John Loonsk The fervor over health insurance reform and electronic medical records in the HITECH Act seems to have sucked all the oxygen away from health information technology that is not about direct patient care. Public health, health research and other parts of the broader health system have less healthcare IT influence than ever in the face of market forces geared toward healthcare delivery and the push to demonstrate the accomplishments of health insurance reform accomplishments. Even less prominent now are the distinct IT needs of these vital other health areas. The irony is that much of the actual meaningful use of health IT comes from areas that are not exclusively about direct patient care. Many of the outcomes that can actually improve health depend on supporting broader public health requirements than those of just electronic medical records (EMRs). Yes, there are some public health meaningful use (MU) criteria. And, yes, there were some funds in the stimulus for public and population health. But consider their relative priorities: A back of the envelope calculation shows that only about 0.1 percent of HITECH funding is oriented to supporting public health IT. The Centers for Disease Control and Prevention has closed the National Center for Public Health Informatics and the Public Health Information Network (PHIN) initiative may be headed toward a similar fate. Even the actual text of the MU rule says that public health needs are being deferred until later years. For all who once worried that secondary use was too derogatory a term for public and population health IT activities, being only secondary must seem awfully attractive now. A narrow focus on healthcare delivery IT and the low priority given to public health IT is doubly difficult. Not only are public health needs not being engineered into the nascent healthcare IT infrastructure, government is not assuming its critical role of advancing complementary public health IT functions. In healthcare, much of the IT challenge relates to market forces that don t always drive the best implementations and outcomes. In public health, there are no major market forces driving IT at all. If government does not drive a public health IT agenda, does not set public health priorities for healthcare, and does not support a connected infrastructure between healthcare and public health, it simply will not get done. Some public health needs that do not seem to be even on the horizon include: Case reporting. There exists a fundamental, legally required (in every state) need for physicians to report to public health agencies on the occurrence of certain communicable diseases and conditions. Although inconvenient in discussions of patient confidentiality, this reporting is about specific cases and not aggregate data (as so-called syndromic surveillance is). Nowhere is there expressed a driver for EMR vendors to include public health case reporting in their products despite its legal status. 1

20 Disease investigation. Many of the most useful surveillance activities and shoe leather epidemiologic investigations require retrieving data types and data relationships that will not be routinely pushed-out or reported. Like many other population health needs, the investigation need is not supported by point-to-point data exchange and requires data look-up and query functions. Cross-organizational query capabilities, while useful for many other purposes like post market drug surveillance and medical errors determination, seem to be now largely defeated by ongoing data ownership issues and the reconsideration of health information exchange that has occurred at the federal level. Vital statistics. Demonstrating regional variations in health and healthcare is among the most compelling way of improving the quality of public health and healthcare. But it is highly dependent on getting consistent and clearly defined vital statistics data. Most behavioral risk data, for example, are manually collected and tend to be incomplete and relatively untimely. The advancement of an alternative electronic system will not be accomplished through a measure by measure application of MU criteria, but must be based on broader data aggregation and analysis. Prevention. Schedules and reminders for preventative services would seem to be very well aligned with decreasing healthcare costs, but specifications for the delivery of these materials into EMRs are not now a requirement. Nor is there any clear path to a consensus on developing these specifications, now that the Healthcare Information Technology Standards (HITSP) panel has been terminated by ONC. Integration with drug and immunization delivery. MU does include testing the ability to report routine immunizations, but broader supply chain management and delivery data are necessary for apportioning response countermeasures in emergency situations. There are also needs for tight coupling of drug and immunization delivery with surveillance systems to support active surveillance of side effects. Well standardized data exchange. Public health is inherently multi-organizational. While the HHS Standards Committee should be complimented for beginning to identify high level terminology standards for recording clinical data, the proposed standards do not go near the level of specification of the messages and unambiguous data sets necessary to reduce the costs of hooking-up multiple organizations for information exchange. Public health personnel will tell you that neglect of public health needs is a common phenomenon. It seems that it is only during health emergencies that attention is paid to the public health infrastructure. Then, in the emergency, there are inevitable questions asked about why the public health infrastructure is not more robust. Finally, after the emergency, sustained attention and funding is usually lost before there is time to implement lasting solutions. The H1N1 flu was the latest public health emergency, but it garnered little attention for public health IT infrastructure. Some have said that H1N1 actually showed the strength of the public health system to respond. In fact, H1N1 was so contagious it rapidly exceeded the ability of public health to contain it and led to fall back controls of encouraging hand washing and better sneezing etiquette rather than tracking and isolating active cases of the disease. What if SARS, Anthrax, drug resistant tuberculosis, or other diseases with greater morbidity were contained to the degree of H1N1? Health IT has been shown to be important in all modern health emergencies even with a very limited infrastructure. It would be ironic to perpetuate its problems because the latest emergency got out of hand too fast. Health insurance reform may have, or have the ability to deliver funds that can be used to help the public health IT infrastructure. To do so, there needs to be a broader recognition of the importance of the non-direct care aspects of health and a renewed focus on the importance of these areas in delivering broad meaningful use. -- Dr. John W. Loonsk is chief medical officer for CGI, an IT services firm. Previously, he was director interoperability and standards in the Office of the National Coordinator for Health Information Technology (ONC) and was associate director for informatics at the Centers for Disease Control and Prevention. Source: 2