Headline Continued Progress

Headline Continued Progress Hospital Use of Information Technology 2007

Summary of Findings Hospitals realize the promise of health information technology (IT) to improve quality of care. Despite the financial and implementation challenges of health IT adoption, hospitals continue to accelerate their use of health IT, with 68 percent reporting fully or partially implemented electronic health records (EHRs) in. To gauge the extent of health IT use among U.S. hospitals and better understand the barriers to further adoption, the American Hospital Association (AHA) surveyed hospitals in fall. The results provide the most complete picture of hospital IT use currently available. The survey asked about use of EHRs and other specific kinds of health IT, financing of health IT systems, barriers to greater use, and involvement in arrangements to share clinical information. More than 1,500 community hospitals about 31 percent of all U.S. community hospitals responded to the survey. This sample fairly represents all community hospitals by size, location, and teaching status. This is the AHA s second survey of hospital health IT use; the first was conducted in spring. Key findings include: Over two-thirds of hospitals (68 percent) had either fully or partially implemented EHRs in. 1 The 11 percent with fully implemented EHRs were more likely to be large, urban, and/or teaching hospitals. Health IT use is growing. In, 46 percent of community hospitals reported moderate or high use of health IT, compared to 37 percent in. Health IT use was determined by the number of clinical IT functions such as medication order-entry, test results review, or clinical alerts a hospital had fully implemented. Computerized physician order-entry (CPOE) is gaining traction. In 10 percent of hospitals, physicians routinely ordered medications electronically at least half of the time in. For laboratory and other tests, physicians routinely placed orders electronically at least half of the time in 16 percent of hospitals. Hospitals reported dramatic increases in the use of computerized alerts to prevent negative drug interactions. In, 51 percent of hospitals were using real-time drug interaction alerts, up from 23 percent in. Certain kinds of hospitals are further ahead in adoption of health IT. Larger hospitals, those in urban areas, teaching hospitals, and hospitals with positive margins used more health IT. In addition, large and urban hospitals also showed greater rates of growth in IT use than their smaller and rural counterparts. Hospital spending on health IT is high and increasing. Not surprisingly, therefore, the most commonly cited barrier to further IT adoption continued to be cost. About one-half of hospitals shared electronic patient data with others in both (53 percent) and (49 percent). Their most common partners included private-practice physician offices, laboratories, payers, and other hospitals. The data show continued progress in health IT adoption in hospitals, but we remain far from the goal of universal adoption. The patterns displayed in the survey data suggest that certain kinds of hospitals generally those with greater financial resources are gaining ground faster than others. Accelerating adoption among all kinds of hospitals will require a shared investment between providers, payers, and purchasers. Hospitals currently bear almost all the costs of IT investment, with no increase in payment for the use of these new technologies. However, many of the financial benefits of IT such as decreased need for repeat tests, lower readmission rates, and shorter lengths of stay accrue to those who pay for care. When looking at how to finance health IT adoption, policymakers should give special attention to hospitals with less stable finances, smaller hospitals and rural hospitals. Other barriers to IT use, such as lack of systems that share data easily, challenges in managing work process changes, and lack of trained IT staff also must be addressed by policymakers and the hospital field.

Introduction The potential of health information technology (IT) to improve the care patients receive and the overall efficiency of the health care system has become a central part of the national health care debate. Many hospitals and health systems have embarked on the challenging journey of IT adoption. However, use of health IT is not yet universal due to financial, technical, implementation, and policy barriers. To further develop our understanding of the level of health IT use by hospitals and the barriers to further adoption, the AHA conducted a second survey of hospitals in the fall of (a previous survey was fielded in the spring of ). The survey asked about the use of specific technologies, such as electronic health records (EHRs) and computerized physician order-entry (CPOE), as well as other clinical and non-clinical applications, such as administrative and department-specific information systems. The survey also asked about financing for IT, barriers to use, and efforts to exchange clinical information with others. The AHA surveyed all U.S. community hospitals both members and non-members to ensure as complete a picture as possible. More than 1,500 community hospitals about 31 percent of all U.S. community hospitals responded to the survey. This sample fairly represents all hospitals by size, location, and teaching status. The technical appendix contains more details on the survey methodology. This report provides a comprehensive picture of hospital IT use. It first discusses adoption of the most comprehensive clinical IT tools EHRs and CPOE. It then explores the evolutionary nature of clinical IT adoption, which often involves implementation over time of separate systems in different departments of the hospital, such as the pharmacy or laboratory, that provide data to the EHR. The report places hospitals along a spectrum of IT adoption and considers the factors that drive greater IT use. It then looks at the use of other supportive technologies, such as bar-coding and telemedicine. The final sections examine the barriers to adoption and increasing efforts to share clinical data with others.

Hospitals are adopting electronic health records Among other technologies, the survey asked hospitals about their use of EHRs, defined as systems that integrate electronically originated and maintained patient-level clinical health information, derived from multiple sources, into one point of access. An EHR replaces the paper medical record as the primary source of patient information. More than two-thirds of hospitals had fully or partially implemented EHRs Percent of hospitals reporting EHRs*, Sixty-nine percent of hospitals reported having either fully or partially implemented an EHR. Larger hospitals, those in urban areas, and teaching hospitals were more likely to be among the 11 percent with fully implemented EHRs. Fully implemented 11% No EHR 32% Hospital size bears a systematic relationship to progress on EHR implementation; as bed size increases, so does use of EHRs. While 23 percent of responding hospitals with 500 or more beds have a fully implemented EHR and 92 percent have a fully or partially implemented EHR only 3 percent of hospitals with fewer than 50 beds have fully implemented EHRs. Among the smallest hospitals, 55 percent have no EHR. Given that larger organizations are more likely to have EHRs, and a larger share of all hospitalizations occur in large hospitals, more than 11 percent of patients with a hospital stay in likely had an EHR as their primary medical record. For example, in, 23 percent of hospital admissions occurred in hospitals with 500 or more beds, compared to 4 percent in hospitals with fewer than 50 beds. EHR implementation also varies by hospital location. Urban hospitals are three times more likely to have a fully implemented EHR than their rural counterparts (16 percent versus 5 percent). Among rural hospitals, 43 percent have no EHR. The advantage held by urban hospitals remains, but is lessened, when partial implementation is also considered (77 percent versus 58 percent). Partially implemented 57% Percent of hospitals reporting EHRs by bed size, 92% 87% 79% 46% 43% 3% <50 beds *NOTE: This question was first asked in. Larger hospitals more likely to have EHRs than smaller hospitals 63% 56% 7% 50-99 beds 66% 13% 100-299 beds Fully implemented 64% 23% 300-499 beds 69% 23% 500+ beds Partially implemented

Teaching hospitals are almost twice as likely to have fully implemented EHRs as non-teaching facilities (17 percent versus 9 percent). When both fully and partially implemented systems are considered, the gap remains, but narrows (81 percent versus 65 percent). Urban hospitals more likely to have EHRs than their rural counterparts Percent of hospitals reporting EHRs by location, Hospitals without an EHR were primarily small, rural, non-teaching, and did not belong to a health system: 71 percent had fewer than 100 beds (compared to 48 percent of all community hospitals); 61 percent were rural (compared to 41 percent of all community hospitals); 88 percent were non-teaching (compared to 78 percent of all hospitals); and 63 percent were not system members (compared to 45 percent of all hospitals). 58% 53% 5% Rural Fully implemented 77% 61% 16% Urban Partially implemented While these hospitals are certainly committed to EHR adoption, they face considerable financial and other barriers. Teaching hospitals more likely to have EHRs than their non-teaching counterparts Percent of hospitals reporting EHRs by teaching status, 81% 65% 64% 56% 9% Non-teaching Fully implemented 17% Teaching Partially implemented

Hospitals are moving toward computerized physician order-entry Computerized physician order-entry systems allow physicians to electronically order medications, tests, and consultations. They also provide advice on best practices and alerts to the possible adverse consequences of a therapy, such as an allergy or a harmful combination of drugs. Numerous studies have shown that CPOE can lead to fewer adverse drug events and other quality improvements, leading organizations such as the Leapfrog Group to call for universal CPOE adoption. However, successful CPOE implementation can be difficult to achieve, since it requires significant changes to work processes and the active support of busy clinicians. Hospitals often phase-in CPOE systems, starting with physician technology champions in one or two departments. Consequently, not all physicians in a hospital may be entering orders electronically. To gauge CPOE use across hospitals, the survey asked about the share of treating physicians placing orders electronically. In 10 percent of hospitals, more than half of the physicians routinely ordered medications electronically in, while at least some physicians were doing so in 27 percent of hospitals. Use of CPOE was more common among hospitals with fully implemented EHRs. In about 25 percent of those facilities, at least half of the physicians routinely ordered medications electronically. In about half of the hospitals with fully implemented EHRs, some physicians were routinely ordering medications electronically. 2 Physician order-entry was slightly more common for laboratory and other tests than for medications. Among survey hospitals, 16 percent reported that treating physicians routinely ordered tests electronically at least half of the time. In another 37 percent of hospitals, electronic ordering was done by at least some physicians. Among hospitals with fully implemented EHRs, almost 60 percent had at least some physicians ordering laboratory tests electronically, with 28 percent reporting that 50 percent or more of the physicians did so. As with adoption of EHRs, CPOE use was more common in larger, urban, and teaching hospitals. In 27 percent of hospitals with 500 or more beds, almost all physicians (75-100 percent) routinely ordered medications electronically. In 32 percent of those hospitals, almost all physicians (75-100 percent) routinely ordered laboratory and other tests electronically. Percent of hospitals Percent of hospitals In 10 percent of hospitals, more than half of treating physicians routinely ordered medications electronically Share of physicians ordering medications electronically, 73% None 63% None 14% 1-24 percent 17% 1-24 percent 3% 25-49 percent 4% 25-49 percent 2% 50-74 percent 4% 50-74 percent 8% 75-100 percent In 16 percent of hospitals, more than half of treating physicians routinely ordered tests electronically Share of physicians ordering tests electronically, 12% 75-100 percent

Use of health IT is evolutionary Implementing EHRs with CPOE systems requires significant changes to hospital workflow. Beyond the technological changes, physicians, nurses, and other hospital staff must incorporate new ways of processing, storing, and retrieving the information they use every minute of every day. Not all implementations are successful, and failure is very expensive. Given the large-scale changes and large-scale costs of these kinds of systems, many hospitals are taking an incremental approach. For example, they may implement IT systems in individual departments, working over time to connect them. Hospitals also may prioritize their implementation of health IT systems according to their quality improvement goals. To capture the diversity and incremental nature of health IT use among hospitals, the survey asked about distinct clinical IT functions. In both and, the survey asked about implementation of: Access to current medical records. Access to medical history. Access to patient flow sheets. Access to patient demographics. Order-entry of laboratory tests. Results review for laboratory tests. Order-entry of radiology procedures. Results review for radiology images, including picture archiving and communications systems (PACS). Results review of radiology reports. Order-entry of medications. Real-time drug interaction alerts. Back-end drug interaction alerts. Clinical guidelines and pathways. Patient support through home monitoring, selftesting, and interactive patient education. In, the survey also included two additional functions use of other clinical alerts and patient access to electronic records in order to complete the picture of decision-support functions and capture the new trend toward consumer access to EHRs. Laboratory, radiology, and pharmacy functions Much of the care provided in the hospital involves ordering and receiving tests and medications from Hospitals used many electronic laboratory, radiology, and pharmacy functions Percent of hospitals reporting that they have fully or partially implemented various clinical IT functions Results review, Lab Order-entry, Lab Order-entry, Radiology Results review, Radiology report Results review, Radiology images Order-entry, Pharmacy 66% 66% 64% 64% 64% 60% 62% 60% 62% 59% 59% 62% 59% 65% 65% 62% 60% 60% 65% 60% 47% 47% 41% 47% 46% 48% 66% 48% 17% 19% 15% 14% Fully implemented 12% 11% 11% 9% 64% 60% 61% 62% 12% 11% 72% 73% 70% 71% 78% 75% 12% 77% 12% 72% Partially implemented 6

ancillary departments such as the laboratory, radiology, and pharmacy. Physicians typically generate these orders, which are communicated to the relevant department on paper or electronically. The results of tests must be communicated back to treating physicians, and medications must be delivered to the bedside. Therefore, information systems in these areas are a focus for many hospitals. Indeed, the Centers for Disease Control and Prevention estimate that laboratory results produce 70 percent of the information in a patient s medical record. Laboratory information systems are widely used, with 78 percent of hospitals having electronic results review either fully or partially implemented in (an increase over ), and 72 percent having electronic order-entry systems (either by the physician or within the lab). Reports summarizing the results of X-rays, CT scans, and other radiology procedures were available electronically in 77 percent of hospitals, while the actual images were computerized in 64 percent of hospitals. In 70 percent of hospitals, orders for radiology procedures were entered electronically (either by the physician or within the radiology department). Sixty one percent of hospitals had fully or partially implemented electronic order-entry for the pharmacy (either by the physician or pharmacist) in, about the same number as in. Decision-support systems Within the pharmacy, witnessed a remarkable increase in use of drug interaction alerts. In more than half of hospitals, either real-time or back-end drug interaction alerts were being used. These systems are key elements of improving medication safety. Thirty-six percent of hospitals had fully or partially implemented electronic clinical guidelines and pathways that support physicians in making clinical decisions, such as which Hospitals increased use of decision-support functions Percent of hospitals reporting that they have fully or partially implemented various decision-support functions Real-time drug alerts 10% 31% 13% 23% 20% 51% Back-end drug alerts 14% 37% 13% 27% 19% 56% Clinical guidelines and pathways 10% 9% 26% 26% 36% 35% Other clinical alerts 17% 26% 43% Fully implemented Partially implemented

diagnostic tests or medications may be appropriate for a given condition. Other types of electronic clinical alerts were fully or partially implemented in 43 percent of hospitals. Medical record and other functions Hospitals reported high use of IT systems for maintaining patient demographic information (79 percent in ). However, electronic access to current and historic medical records was less common, but still available in more than 60 percent of hospitals, a small improvement over. Functions that allow patients to access their own EHRs and support patients through home monitoring were much less common. Access to patient demographics Hospitals increased use of electronic record management functions Percent of hospitals reporting that they had fully or partially implemented various EHR functions 68% 11% 79% 62% 12% 74% Access to current medical records Access to medical history Access to patient flow sheets Results review - Consultant report 32% 32% 64% 30% 30% 60% 34% 30% 64% 29% 30% 59% 27% 24% 51% 21% 24% 45% 43% 19% 62% 45% 16% 61% Patient support through home-monitoring, etc. 2% 9% 11% 2% 11% 13% Patient access to EHRs* 1%4% 5% Fully implemented Partially implemented *NOTE: This question was first asked in.

Hospitals fall along a spectrum of health IT use The evolutionary nature of health IT adoption means that hospitals fall at different places along the adoption curve. To assess differences in the level of IT use among hospitals, the AHA created four usage groups based on the number of clinical IT functions that were reported to be fully implemented at each surveyed hospital, ranging from just getting started to having almost all of the functions in place. 3 Spectrum of IT use Level of Use Getting Started 0-3 Functions (0-25%) Fully implemented Low 4-7 Functions (26-50%) Fully implemented Moderate 8-11 Functions (51-75%) Fully implemented High 12-15 Functions (76-100%) Fully implemented Functions Access to current medical records Access to medical history Access to patient flow sheets Access to patient demographics Order-entry - lab Results review - lab Order-entry - radiology Results review - radiology images (incl. PACS) Results review - radiology report Results review - consultant report Order-entry - pharmacy Real-time drug interaction alerts Back-end drug interaction alerts Clinical guidelines and pathways Patient support through home monitoring, self-testing, and interactive patient education Hospitals continue to progress in the use of health IT. In, 46 percent of hospitals reported moderate to high clinical IT use, a considerable increase over when just 37 percent of hospitals fell into these groups. Sixteen percent of hospitals had implemented almost all of the functions in, up from 10 percent in. Hospitals used more health IT in Distribution of hospitals by level of health IT use 32% 22% 30% 16% Despite this growth in the upper end of the spectrum, more than half of hospitals were still in the getting started or low use groups in. 36% 27% 27% 10% Getting started Low Moderate High

The extent of health IT use varied with many different hospital characteristics, including number of beds, location, teaching mission, and membership in a hospital system. The patterns displayed in the survey data suggest that certain kinds of hospitals generally those with greater financial and technical resources are gaining ground faster than others. Of all the characteristics considered, the size of the hospital bore the strongest relationship to health IT use. Of the largest hospitals those with 500 or more beds 74 percent reported moderate or high health IT use in. In contrast, only 23 percent of hospitals with 50 or fewer beds were in the top two levels of IT use. In between these extremes, health IT use increased with hospital size. In addition to having greater health IT use, larger hospitals saw a much greater increase in use from to than did smaller hospitals. In general, larger hospitals have greater revenues, greater access to capital, and more staff resources to support IT adoption. Fifty-six percent of hospitals in urban areas reported moderate or high health IT use in compared to 33 percent of rural hospitals. Both groups experienced increases from. Among rural hospitals, 46 percent reported just getting started with adoption of health IT in, down from 50 percent in. Teaching hospitals used more health IT than their nonteaching counterparts in, with 59 percent reporting moderate or high use compared to 42 percent of nonteaching hospitals. However, both groups saw increased use from to. Being part of a hospital or health system can mean that hospitals have access to greater financial and technical resources for health IT adoption. Among system hospitals, 51 percent reported moderate or high health IT use, compared to 42 percent of non-system hospitals in. Both groups reported increases across years. Implementing and maintaining health IT systems requires significant financial resources. Not surprisingly, financial status also helps determine a 6% 10% 18% 66% Larger hospitals used more health IT and saw greater growth from to 5% 18% 19% 58% Distribution of hospitals across levels of health IT use by bed size 7% 18% 27% 48% 11% 21% 26% 42% 12% 31% 34% 23% < 50 beds 50-99 beds 100-299 beds 300-499 beds 500+ beds 21% 37% 23% 19% 13% 45% 31% 11% Getting started Low Moderate High 24% 47% 18% 11% 13% 61% 19% 7% 34% 40% 20% 6% 10

hospital s health IT use: hospitals with better financial standing generally have greater IT use. Having positive margins gives hospitals the funds needed to make the large capital investments necessary to implement health IT and covers the increased operating costs Urban hospitals used more health IT than rural hospitals, but both groups increased use 7% 18% 25% 50% Levels of health IT use by location 11% 22% 21% 46% 12% 36% 30% 22% 20% 36% 22% 22% Rural Urban Getting started Low Moderate High that come along with investment in health IT systems. Among those with negative margins, 43 percent of hospitals are just getting started with health IT investments, compared to 29 percent of those with positive margins. Teaching hospitals used more health IT than non-teaching hospitals, but both groups increased use 13% 43% 29% 15% Levels of health IT use by teaching status 19% 40% 23% 18% 9% 24% 26% 41% 15% 27% 21% 37% Teaching Non-teaching Getting started Low Moderate High Hospitals that were members of systems used more health IT than those that were not, but both groups increased use 14% 32% 26% Levels of health IT use by system status 19% 32% 18% 7% 23% 28% 14% 28% 24% Hospitals with positive margins used more health IT in both and Level of use of fully implemented IT systems by margin level 11% 17% 6% 11% 29% 22% 32% 24% 26% 22% 28% 22% 28% 31% 42% 34% 32% 29% 46% 43% System Non-system Getting started Low Moderate High 11 Positive Margin Negative Margin Getting started Low Moderate High

Other supportive IT applications Hospitals use IT systems for clinical and nonclinical purposes. The survey asked about use of a select group of applications that support the care process, but are not a direct part of the EHR. These technologies included bar-coding, which has multiple clinical and administrative functions, telemedicine, and administrative systems. The survey revealed that more than half of all hospitals have adopted bar-coding technologies for at least one purpose. Bar-coding technologies have created significant safety benefits by matching patients and their drugs before they are administered to ensure that the right medication is given to the right patient, in the right dose, and at the right time. Twenty-six percent of those surveyed had fully or partially implemented bar-coding for pharmaceutical administration in, a small increase over. Hospitals also reported increased use of bar-coding for labeling lab specimens, identifying patients, and tracking pharmaceuticals throughout the facility. The survey also found that some hospitals are beginning to use radio frequency identification (RFID), a new technology for identifying and tracking items. This technology is at an early stage, with almost 10 percent of hospitals having fully or partially implemented it in both and. Telemedicine technology allows remote health care facilities to consult with physicians and medical personnel at other hospitals or central facilities, such as regional medical centers, through the use of highresolution cameras, digital-imaging equipment, and high-speed connectivity. This technology can reduce the need to transfer patients and possibly save lives. Hospitals increased use of bar-coding Percent of hospitals with fully or partially implemented bar-code systems Lab specimens 38% 35% 18% 19% 53% 57% Patient ID 20% 25% 17% 17% 37% 42% Supply chain management 16% 16% 24% 24% 40% 40% Tracking pharmaceuticals 14% 12% 18% 19% 30% 33% Pharmaceutical administration 12% 14% 11% 12% 23% 26% Fully implemented Partially implemented 12

More than half of hospitals in both urban and rural areas used telemedicine in both and. Some physicians have found that using hand-held electronic devices such as personal digital assistants (PDAs) to access patient information and medical references, and enter orders, can improve their workflow. According to survey results, about 30 percent of hospitals had fully or partially implemented this technology in both and. Administrative tasks also are becoming increasingly electronic, with almost all hospitals using IT systems for patient accounts, about three-fourths using electronic patient scheduling systems, and about 70 percent using IT systems to manage their pharmaceutical and medicalsurgical supply chains in. Hospitals adopting telemedicine and other technologies Percent of hospitals with fully or partially implemented systems Telemedicine Physician use of personal 8% digital assistance (PDAs) 9% Radio frequency 3% 9% 12% identification (RFID) 2% 8% 10% Fully implemented 24% 24% 23% 31% 21% 34% 30% 37% 58% Partially implemented 61% Hospitals using administrative systems Percent of hospitals with administrative systems, Patient accounts 97% Patient scheduling 75% Pharmaceutical supply chain management Medical-surgical supply chain management 71% 70% 13

Health IT is expensive Hospitals spend large sums on health IT. The level of health IT spending will depend on both hospital size and the technologies deployed. Hospitals use many sources to finance IT, but rely primarily on capital and operating budgets. Capital budgets cover investments in buildings and medical equipment, as well as health IT systems, while operating budgets cover staff, supplies, and other daily expenses of running a hospital. Operating costs are generally higher than capital spending in a given year and represent ongoing costs, such as upgrades, maintenance, and interfaces to ensure that various applications work together. To ensure a common comparison across large and small hospitals, health IT spending was scaled by the number of beds in the hospital, reporting spending per bed. Among the hospitals surveyed in, the median capital spending per bed for health IT was $5,556. This is a one-year snapshot of capital spending, and does not reflect the full spending for multi-year IT installations. For operating costs, the median amount per bed was $12,060. Thus, a 200-bed hospital at the median spending level for health IT would have invested $1.1 million in capital for health IT and spent $2.4 million on related operating costs in. On average, hospitals spent more on health IT in than in. Notably, the median operating cost per bed was 4.5 percent higher in. The median capital spending per bed was 1 percent higher. Spending on health IT is high and increasing Median one-year spending per bed $11,538 $12,060 $5,500 $5,556 Capital spending Operating costs 14

Cost is the greatest barrier to greater adoption Hospitals are showing progress in health IT use, but adoption is still not as widespread as it should be. The survey asked hospitals about the many different barriers to use, including the initial costs of deploying IT, personnel needs, and the need to devote resources to other priorities, such as meeting federal privacy and security requirements. Respondents identified the initial and ongoing costs of deploying and maintaining IT systems as the greatest barriers to IT use. In, 94 percent of hospitals saw the initial costs of adoption as a significant barrier or somewhat of a barrier, compared to 95 percent in. In both years, 87 percent of hospitals saw ongoing costs as a barrier. In general, smaller hospitals were more likely to see the initial and ongoing costs of IT implementation as a significant barrier, but the largest hospitals (those with 500 or more beds) also struggle to afford health IT. The availability of well-trained staff to implement technology both technical and clinical is also an issue. Hospitals also struggle with the lack of interoperability among systems and finding technology that really meets their needs. There were some changes in the percent of hospitals identifying each barrier between and, but the ordering of barriers remained consistent, with cost being of greatest concern. Hospitals continued to report cost as greatest barrier to IT adoption Percent of hospitals indicating barrier is a significant barrier or somewhat of a barrier Initial costs 54% 59% 40% 36% 94% 95% Ongoing costs 32% 33% 55% 54% 87% 87% Interoperability with current systems 27% 25% 52% 52% 79% 77% Acceptance by clinical staff 23% 24% 59% 58% 82% 82% Availability of well-trained IT staff 16% 15% 51% 49% 67% 54% Inability of technology to meet needs 11% 12% 51% 48% 62% 60% Significant barrier Somewhat of a barrier 15

While a barrier for all, smaller hospitals were most likely to see ongoing costs as significant barrier Percent of hospitals indicating ongoing costs are a significant barrier or somewhat of a barrier by bed size, <50 beds 42% 49% 91% 50-99 beds 36% 55% 91% 100-299 beds 28% 59% 87% 300-499 beds 25% 61% 86% 500+ beds 38% 45% 83% Significant barrier Somewhat of a barrier Rural hospitals more likely to see ongoing costs as significant barrier Percent of hospitals indicating ongoing costs are a significant barrier or somewhat of a barrier by location, Initial Costs Rural Urban 60% 51% 42% 36% 96% 93% Ongoing Costs Rural Urban 38% 30% 52% 56% 90% 86% Significant barrier Somewhat of a barrier 16

Hospitals are sharing clinical data Among survey hospitals, about half reported sharing electronic patient-specific health information with local or regional partners. This information exchange can take many forms. Examples include: Web portals giving physicians access to hospital information systems; Sharing electronic data with other hospitals or facilities within a system; Sharing data with a laboratory; Electronic reporting to public health departments; and Planned or nascent projects to share information through a regional health information network. Hospitals reported that they most commonly share electronic patient information with private-practice physician offices and laboratories. The percent of hospitals sharing data with various partners changed slightly from to, but the general order remained consistent. Hospitals most commonly shared electronic patient information with physician offices Most commonly reported organizations for sharing of electronic patient health care information among hospitals that shared data Private-practice physician office 67% 66% Laboratories 40% 46% Payers Other hospitals 42% 39% 39% 38% Public health department Long-term care facilities 31% 28% 23% 27% 17

Policy implications From to, hospitals showed progress in health IT adoption. However, use varied, with some hospitals just getting started while others had fully implemented EHRs and routinely used CPOE. The survey results indicate that hospitals are committed to moving forward. However, adoption will be evolutionary, as hospitals implement systems that meet their needs. Acceleration of the adoption process will require addressing the barriers identified in the survey, beginning with the high cost of implementing and maintaining IT systems. Hospitals are making investments in health IT because they see the quality and safety gains that can be realized. However, others who share in the benefits of a wired health system, such as payers and purchasers, must share in that investment. Certain types of hospitals such as those that are struggling financially, smaller facilities, and those in rural areas may need more help than others. 18

End notes 1 An EHR was defined as a system that integrates electronically originated and maintained patient-level clinical health information, derived from multiple sources, into one point of access. An EHR replaces the paper medical record as the primary source of patient information. This question was not asked in. 2 AHA first asked this question in. No trend data are available. 3 To compare data across years, only those functions that were included in both surveys were used in creating the groups. 19

Technical appendix The survey instrument was designed with the assistance of the AHA Member Advisory Group on Information Technology, a group of about 20 hospital chief executive officers and chief information officers. AHA fielded the survey from October to November. All community hospitals not just AHA members were asked to respond. Survey instruments were sent to hospital CEOs by both e-mail and fax. Respondents could either respond via an on-line Web portal or fax back a paper copy. We made special efforts to ensure that hospitals of all types and from all parts of the country responded. Hospital CEOs received multiple reminders about the survey through e-mail, fax, and newsletters. We are thankful to the many state, metropolitan, and regional hospital associations that helped recruit respondents, and to the College of Healthcare Information Management Executives for assistance with survey review and recruitment of respondents. The following table compares the survey hospitals to U.S. hospitals by bed size, location, teaching status, and other variables. The comparison statistics come from the AHA Annual Survey. Comparison of sample to universe Characteristic Universe (%) Sample (%) Bed size < 50 beds 28.4 29.1 50-99 beds 20.3 18.6 100-299 beds 35.4 33.0 300-499 beds 11.0 12.6 500+ beds 4.9 6.7 Location Urban 59.3 53.5 Rural 40.7 46.5 Teaching status Non-teaching 78.3 80.4 Teaching 21.7 19.6 Region New England 4.2 5.0 Mid-Atlantic 9.6 11.6 South Atlantic 15.1 13.2 East North Central 15.1 14.5 East South Central 8.9 7.7 West North Central 13.7 18.7 West South Central 15.0 12.8 Mountain 7.4 7.6 Pacific 11.1 8.6 Ownership Non-profit 59.9 62.5 Investor owned 17.6 9.7 State/local government 22.5 27.7 System Membership Member 55.0 41.7 Non-member 45.0 58.3 Note: Universe includes all 4,936 community hospitals in the AHA Annual Survey. Sample includes 1,543 community hospitals responding to the AHA Health IT Survey. 20

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