Report: Health IT Adoption in U.S. Sees Steady Increase, HIE Growing Pains Remain

Unprecedented federal financial support for HIT drives system change; proportion of hospitals with electronic health records nearly triples since 2010; 30 percent of hospitals send and receive data through HIE

Driven by major federal investments in health information technology over the last several years, hospitals, physicians and other providers have made significant strides in the adoption of Health Information Technology (HIT), according to the Robert Wood Johnson Foundation’s annual report, “Health Information Technology in the United States: Better Information Systems for Better Care, 2013.” The report, co-authored by Mathematica Policy Research and the Harvard School of Public Health, finds that in 2012, 44 percent of hospitals reported having a basic electronic health record (EHR) system, up 17 percentage points from 2011. Since 2010, when health care providers began receiving federal funding to encourage EHR adoption, the proportion of hospitals with at least a basic EHR has nearly tripled. Physicians have also made substantial progress, with 38.2 percent reporting the adoption of basic EHR functionalities in 2012.

“Hospitals, physicians and other health care providers are clearly taking advantage of recent incentives to embrace the promise of technology,” said John R. Lumpkin, MD, MPH, senior vice president at the Robert Wood Johnson Foundation.

“It’s particularly encouraging to see that more doctors and hospitals are using electronic health records, which contribute to better care at the bedside. But there is still a significant amount of work to be done to ensure that our health care system is as up-to-date as it can be. These kinds of technologies can lead to safer, higher-quality care.”


However, one of the findings was that only 5 percent of hospitals could meet all 16 core objectives for stage 2 meaningful use; however, 63 percent reported meeting 11-15 of the functionalities, suggesting a large proportion of hospitals are close to meeting these objectives. The functions least likely to be implemented are functions that require health information exchange and patient access to health information. Still in 2012, 42 percent of hospitals reported implementing all 14 core functionalities for stage 1 meaningful use, a substantial increase from 4 percent in 2010 and 18 percent in 2011. Like those most likely to have a basic EHR, hospitals meeting stage 1 meaningful use objectives are large, major teaching, private nonprofit hospitals located in urban areas.

Chapter 4 of the report presents data from a national survey of health information exchange (HIE) efforts and describes the progress, gaps, and barriers to nationwide HIE in the United States. This chapter includes policy recommendations to spur the implementation of HIE throughout the United States. The report shows that health care providers are increasingly connecting their EHR initiatives with broader HIT partnerships in their communities. Twenty-seven percent of hospitals are now participating in HIE initiatives, up from 14 percent in 2010. HIEs enable different care providers to securely share patient information with each other. Ten percent of ambulatory practices were engaged in one of the nation’s 119 HIEs, up from 3 percent in 2010. In addition, 32 percent of the HIEs reported supporting Accountable Care Organizations, while 45 percent are supporting Patient-Centered Medical Homes.

Some key findings from chapter four include:

  • Hospitals and ambulatory practices were most common participants in HIE efforts. Thirty percent of U.S. hospitals and 10 percent of ambulatory practices send and receive data through HIE efforts.
  • Test results and patient summary care records were the most common type of data exchanged (in 82% and 79% of HIE efforts, respectively), while public heath reports were the least common type of data exchanged (30%).
  • Most HIE efforts reported using a query model as their technical approach, where users actively search for available data. Other common technical approaches include a push model, where data is actively sent out to users; end-to-end integration, where data is included in the user’s electronic system; and Direct, which facilitates point-to-point transport of health information.
  • The majority of HIE efforts enabled participants to meet the core stage 1 meaningful use criteria of demonstrating the capability to exchange key clinical information electronically. The two public health-related stage 1 meaningful use criteria (syndromic surveillance and reportable lab results) were least likely to be supported by the HIE efforts. A small subset of HIE efforts supported all six HIE-related meaningful use functionalities.
  • HIE efforts continue to struggle with financial viability, with 74 percent of efforts identifying that developing a sustainable business model was a moderate or substantial barrier. Currently, grants and contracts are the most substantial source of support for the majority of operational HIE efforts.

The report was discussed, along with other health IT related papers as a Health Affairs “web-first” report on Tuesday, July 9 during a Health Affairs briefing at the National Press Club in Washington, D.C. These papers are open access for only two weeks, so I suggest you download them now. Speakers at the event included:

The technology can help make for safer and higher quality care, but more must be done to make that happen, said Michael Painter, MD, senior program officer with the Robert Wood Johnson Foundation. “The federal incentives to drive the implementation of the electronic health records are working,” he said. “But we have big, big challenges ahead of us.” In addition, he said the U.S. still falls behind other countries in the adoption of electronic records.

“Although the rural hospitals are challenged, they’re accelerating faster than some of the urban hospitals,” Painter said. “Everybody wants to get on board while the money is available and before the disincentives kick in.”

“While we still have some ways to go, these findings, taken together, suggest that incentives, when thoughtfully targeted can have a profound impact on the healthcare marketplace,” said Dr. Ashish Jha, co-author of Office-Based Physicians Are Responding To Incentives And Assistance By Adopting And Using Electronic Health Records. The paper points out the surprising fact that as of 2012, physicians in rural areas had higher rates of adoption than those in large urban areas, and physicians in counties with high rates of poverty had rates of adoption comparable to those in areas with less poverty. However, small practices continued to lag behind larger practices. “Rural practices are more likely to be in smaller practices and they have lower rates,” he said.

“The news here is mostly good, but we shouldn’t declare victory yet,” Jha said. “In other industries it takes about 10 years after technology is adopted to see real efficiencies. My hope is we’ll see that more quickly in health care. We don’t have 10 years to waste.”

“It’s the right incentives at the right time,” Jha said. “Doctors and hospitals have been thinking about buying electronic health records [systems] for some time. This is where our society is moving. But the finances have been a challenge. The federal incentives have been very well targeted. They were well designed to help push hospitals and doctors to adopt EHRs.”

Jha added that penalties for failure to act on electronic health records should not be underestimated as a motivating factor. “They are signaling if you don’t do it, a few years down the road we’re going to start paying you less,” he said. “That motivates people to say, ‘whoa, I’d better get on board.'”

Farzad Mostashari, MD, the National Coordinator for Health Information Technology and co-author of two of the papers in Health Affairs, said that while we haven’t slain all the dragons, we are making progress, but true transformation would likely take a decade. One of the key requirements for stage 2 meaningful use is the ability for patients to view online, download, and transmit their own health information. Certified EHR technology will have this capability in 2014. However, in 2012 very few hospitals met this requirement. Enabling this functionality will not only meet the meaningful use requirements, but hopefully also begin a greater degree of patient engagement.

There is a great stream of tweets from the briefing using the hashtag #HA_HealthIT and I encourage you to read through them. A few of my favorites are:






“We saw a tremendous amount of activity throughout all subtypes of hospitals,” said co-author of Adoption Of Electronic Health Records Grows Rapidly, But Fewer Than Half Of US Hospitals Had At Least A Basic System In 2012 Catherine DesRoches, a senior scientist at Mathematica Policy Research. “The rate at which they are adopting has increased quite a bit.”

The next step, in which health data is shared between providers, will be key to realizing the true potential of EHRs, DesRoches said. “It also has the potential to help with costs,” she said. “If you’re a patient and you get to your appointment and the specialist can see all of the tests that have already been ordered, they’re not going to order duplicate tests or order medications that might be contraindicated. The information’s right there in the record.”

Julia Adler-Milstein, PhD, Assistant Professor, University of Michigan, Health Management and Policy, and lead author, along with Jha and  DesRoches, of Operational Health Information Exchanges Show Substantial Growth, But Long-Term Funding Remains A Concern points out that 74 percent of the health information exchange programs reported that they’re struggling to develop a sustainable business model. Often times, organizations have closed their doors when grants ended. According to Adler-Milstein one reason is that “health care providers are not willing to pay for the service at the level needed. They don’t see enough value, and that’s because much of it doesn’t accrue to them. It goes to patients and to health insurance companies. The central challenge is that the incentives and the business model are not aligned yet for this to really work,” she said.

“What we’ve seen is this federal money really has made a big difference. What hasn’t really moved, though, is the perception that the organizations haven’t figured out how to fund themselves, which will be a big problem after the government grant money runs out in January 2014,” she said.

“One piece of data that makes me a little bit hopeful is that many of these organizations are trying to figure out the broader role they can play in efforts to improve healthcare delivery,” she said. “They’re realizing that the data they have is very valuable for research and performance reports.”

Exchange efforts could also aid in the establishment of accountable care organizations. “If these accountable care organizations are going to be successful, they need to know what care patients are receiving,” Adler-Milstein said. “If you want to know how things are going from a quality perspective, that requires data. It’s a broader effort that’s really about aligning incentives for healthcare, but underneath it all is health information exchange.”

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Brian Ahier

Brian Ahier is a national expert on health information technology with a focus on health data exchange. He is President of Advanced Health Information Exchange Resources, LLC, which has provided consulting services to a variety of industry clients as well as the Office of the National Coordinator at HHS. Brian sits on the Consumer Technology Workgroup of the HIT Standards Committee which makes recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information consistent with the implementation of the Federal Health IT Strategic Plan. Brian is a founding Board member of DirectTrust, and also serves on the Board of HIMSS Oregon and Q-Life., an intergovernmental agency providing broadband capacity to the region. Brian helped found Gorge Health Connect, Inc. (GHC) a health information exchange organization in the Columbia River Gorge where they implemented one of the first Direct Project pilots. Brian worked at Mid-Columbia Medical Center for eleven years, most recently as Health IT Evangelist. He served four years as a City Councilor in The Dalles, Ore., and on the Board for Mid-Columbia Council of Governments. Brian helped develop the Oregon strategic and operational plans for implementing State-Level HIE under the State Health Information Exchange Cooperative Agreement. After the plan was approved by the ONC he was appointed by the State of Oregon Health Information Technology Oversight Council (HITOC) as Chairperson of the Technology Workgroup responsible for developing a framework and providing input for technology goals, including deliverables and objectives, standards, and definition of central services. Brian has worked on a number of workgroups and committees within the Standards and Interoperability Framework and continues to work on the Direct Project.