Quantitative Research

jha_et_al_2009.pdf

Home >Human Resource Management homework help >Quantitative Research

special article

T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 360;16 nejm.org april 16, 20091628

Use of Electronic Health Records in U.S. Hospitals

Ashish K. Jha, M.D., M.P.H., Catherine M. DesRoches, Dr.Ph., Eric G. Campbell, Ph.D., Karen Donelan, Sc.D., Sowmya R. Rao, Ph.D.,

Timothy G. Ferris, M.D., M.P.H., Alexandra Shields, Ph.D., Sara Rosenbaum, J.D., and David Blumenthal, M.D., M.P.P.

From the Department of Health Policy and Management, Harvard School of Pub- lic Health (A.K.J.); the Division of General Medicine, Brigham and Women’s Hospi- tal (A.K.J.); the Veterans Affairs Boston Healthcare System (A.K.J.); and the Insti- tute for Health Policy (C.M.D., E.G.C., K.D., S.R.R., T.G.F., A.S., D.B.) and the Biostatistics Center (S.R.R.), Massachu- setts General Hospital — all in Boston; and the Department of Health Policy, George Washington University, Washing- ton, DC (S.R.). Address reprint requests to Dr. Jha at the Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115, or at ajha@hsph.harvard.edu.

This article (10.1056/NEJMsa0900592) was published at NEJM.org on March 25, 2009.

A b s t r a c t

Background

Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals.

Methods

We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hos- pital characteristics and factors that were reported to be barriers to or facilitators of adoption.

Results

On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hos- pitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited cap- ital requirements and high maintenance costs as the primary barriers to implemen- tation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems.

Conclusions

The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care per- formance goals that depend on health information technology. A policy strategy fo- cused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

Use of Elec tronic He a lth R ecor ds in U.S. Hospita l s

n engl j med 360;16 nejm.org april 16, 2009 1629

The U.S. health care system faces chal-lenges on multiple fronts, including rising costs and inconsistent quality.1-3 Health in- formation technology, especially electronic health records, has the potential to improve the efficiency and effectiveness of health care providers.4,5 Meth- ods to speed the adoption of health information technology have received bipartisan support among U.S. policymakers, and the American Recovery and Reinvestment Act of 2009 has made the promotion of a national, interoperable health information sys- tem a priority. Despite broad consensus on the po- tential benefits of electronic health records and other forms of health information technology, U.S. health care providers have been slow to adopt them.6,7 Using a well-specified definition of elec- tronic health records in a recent study, we found that only 17% of U.S. physicians use either a min- imally functional or a comprehensive electronic- records system.8

Prior data on hospitals’ adoption of electronic health records or key functions of electronic rec- ords (e.g., computerized provider-order entry for medications) suggest levels of adoption that range between 5%9 and 59%.10 This broad range reflects different definitions of what constitutes an elec- tronic health record,10,11 use of convenience sam- ples,12 and low survey response rates.13 To provide more precise estimates of adoption of electronic health records among U.S. hospitals, the Office of the National Coordinator for Health Informa- tion Technology of the Department of Health and Human Services commissioned a study to measure current levels of adoption to facilitate tracking of these levels over time.

As in our previous study,8 we identified key clinical functions to define the minimum func- tionalities necessary to call a system an electronic- records system in the hospital setting. We also defined an advanced configuration of functional- ities that might be termed a comprehensive elec- tronic-records system. Our survey then determined the proportion of U.S. hospitals reporting the use of electronic health records for either of these sets of functionalities. We hypothesized that large hos- pitals would have a higher prevalence of adoption of electronic health records than smaller hospitals. Similarly, we hypothesized that major teaching hospitals would have a higher prevalence of adop- tion than nonteaching hospitals and private hos- pitals a higher prevalence than public hospitals.

Finally, to guide policymakers, we sought to iden- tify frequently reported barriers to adoption and potential mechanisms for facilitating it.

M e t h o d s

Survey Development

We developed our survey by examining and syn- thesizing prior hospital-based surveys of electronic- records systems or related functionalities (e.g., computerized provider-order entry) that have been administered in the past 5 years.9,13,14 Working with experts who had led hospital-based surveys, we developed an initial draft of the instrument. To get feedback, we shared the survey with chief information officers, other hospital leaders, and survey experts. We then obtained input from a consensus panel of experts in the fields of health information technology, health services research, survey research, and health policy. Further survey modifications were approved by our expert pan- el. The final survey instrument was approved for use by the institutional review board of Partners HealthCare.

Survey Sample and Administration

We collaborated with the American Hospital As- sociation (AHA) to survey all acute care general medical and surgical member hospitals. The sur- vey was presented as an information technology supplement to the association’s annual survey of members, and like the overall AHA questionnaire, was sent to the hospital’s chief executive officer. Hospital chief executive officers generally assigned the most knowledgeable person in the institution (in this case, typically the chief information of- ficer or equivalent) to complete the survey. Non- responding hospitals received multiple telephone calls and reminder letters asking them to com- plete the survey. The survey was initially mailed in March 2008, and our in-field period ended in September 2008.

Survey Content

We asked respondents to report on the presence or absence of 32 clinical functionalities of an elec- tronic-records system and on whether their hos- pital had fully implemented these functionalities in all major clinical units, had implemented them in one or more (but not all) major clinical units, or had not yet fully implemented them in any unit

T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 360;16 nejm.org april 16, 20091630

in the hospital. We asked respondents to identify whether certain factors were major or minor bar- riers or were not barriers to the adoption of an electronic-records system and whether specific pol- icy changes would have a positive or negative ef- fect on their decision to adopt such a system. The questions and response categories used are listed in the Supplementary Appendix, available with the full text of this article at NEJM.org.

Measures of Electronic-Records Use

The Institute of Medicine has developed a com- prehensive list of the potential functionalities of an inpatient electronic health record,15 but there is no consensus on what functionalities constitute the essential elements necessary to define an elec- tronic health record in the hospital setting. There- fore, we used the expert panel described earlier to help define the functionalities that constitute comprehensive and basic electronic-records sys- tems in the hospital setting. The panel was asked to identify whether individual functionalities would be necessary to classify a hospital as having a comprehensive or basic electronic health record. With the use of a modified Delphi process, the panel reached a consensus on the 24 functions that should be present in all major clinical units of a hospital to conclude that it had a comprehensive electronic-records system.16 Similarly, the panel reached a consensus on eight functionalities that should be present in at least one major clinical unit (e.g., the intensive care unit) in order for the hospital to be classified as having a basic electronic- records system. Because the panel disagreed on the need for two additional functionalities (physicians’ notes and nursing assessments) to classify a hos- pital as having a basic system, we developed two definitions of a basic electronic-records system, one that included functionalities for nursing assess- ments and physicians’ notes and another that did not. We present the results with the use of both definitions.

Statistical Analysis

We compared the characteristics of respondent and nonrespondent hospitals and found modest but significant differences. We estimated the propen- sity to respond to the survey with the use of a lo- gistic-regression model that included all these characteristics and used the inverse of this pro- pensity value as a weight in all analyses.

We examined the proportion of hospitals that had each of the individual functionalities and sub- sequently calculated the prevalence of adoption of an electronic-records system, using three defini- tions of such a system: comprehensive, basic with physicians’ and nurses’ notes, and basic without physician and nursing notes. For all subsequent analyses, we used the definition of basic electronic health records that included clinicians’ notes.

We explored bivariate relationships between key hospital characteristics (size, U.S. Census region, ownership, teaching status, urban vs. rural loca- tion, and presence or absence of markers of a high- technology institution) and adoption of a basic or comprehensive electronic-records system. We con- sidered the use of various potential markers of a high-technology institution, including the pres- ence of a dedicated coronary care unit, a burn unit, or a positron-emission tomographic scanner. Be- cause the results were similar for each of these markers, we present data based on the presence or absence of only one — a dedicated coronary care unit. We subsequently built a multivariable model to calculate levels of adoption of electronic- records systems, adjusted according to these hos- pital characteristics. We present the unadjusted results below and those from the multivariate mod- els in the Supplementary Appendix.

Finally, we built logistic-regression models (ad- justing for the hospital characteristics mentioned above) to assess whether the presence or absence of electronic health records was associated with respondents’ reports of the existence of specific barriers and facilitators of adoption. Since the number of hospitals with comprehensive elec- tronic-records systems was small, we combined hospitals with comprehensive systems and those with basic electronic-records systems and com- pared their responses with those from institutions without electronic health records. In all analyses, two-sided P values of less than 0.05 were consid- ered to indicate statistical significance.

R e s u l t s

We received responses from 3049 hospitals, or 63.1% of all acute care general hospitals that were surveyed. After excluding federal hospitals and those located outside the 50 states and the Dis- trict of Columbia, we were left with 2952 institu- tions. There were modest differences between re-

Use of Elec tronic He a lth R ecor ds in U.S. Hospita l s

n engl j med 360;16 nejm.org april 16, 2009 1631

spondents and nonrespondents (Table 1), and all results reported below have been adjusted for po- tential nonresponse bias.

Adoption of Clinical Functionalities in Electronic Format

We found large variations in the implementation of key clinical functionalities across U.S. hospi- tals. Only 12% of hospitals had instituted electron- ic physicians’ notes across all clinical units, and computerized provider-order entry for medications was reported as having been implemented across all clinical units in 17% of hospitals (Table 2). In contrast, more than 75% of hospitals reported adoption of electronic laboratory and radiologic reporting systems. A sizable number of hospitals reported having implemented several key func- tionalities in one or more (but not all) units, having begun such implementation, or having identified resources for the purpose of such im- plementation. These functionalities included phy- sicians’ notes (among 44% of the hospitals) and computerized provider-order entry (38%).

Adoption of Electronic Records

The presence of certain individual functionalities was considered necessary for an electronic-records system to be defined as comprehensive or basic by our expert panel (Table 3). On the basis of these definitions, we found that 1.5% (95% confidence interval [CI], 1.1 to 2.0) of U.S. hospitals had a comprehensive electronic-records system imple- mented across all major clinical units and an ad- ditional 7.6% (95% CI, 6.8 to 8.1) had a basic sys- tem that included functionalities for physicians’ notes and nursing assessments in at least one clinical unit. When defined without the require- ment for clinical notes, a basic electronic-records system was found in 10.9% of hospitals (95% CI, 9.7 to 12.0). If we include federal hospitals run by the Veterans Health Administration (VHA), the proportion of hospitals with comprehensive elec- tronic-records systems increases to 2.9% (95% CI, 2.3 to 3.5), the proportion with basic systems that include clinicians’ notes increases to 7.9% (95% CI, 6.9 to 8.8), and the proportion with basic systems that do not include clinicians’ notes increases to 11.3% (95% CI, 10.2 to 12.5).

Hospitals were more likely to report having an electronic-records system if they were larger insti- tutions, major teaching hospitals, part of a larger

hospital system, or located in urban areas and if they had dedicated coronary care units (Table 4); these differences were small. We found no rela- tionship between ownership status and level of adoption of electronic health records: the preva- lence of electronic-records systems in public hos- pitals was similar to that in private institutions. Even when we compared for-profit with nonprofit (public and private) institutions, there were no significant differences in adoption. In multivari- able analyses, each of these differences diminished

Table 1. Characteristics of Responding and Nonresponding U.S. Acute Care Hospitals, Excluding Federal Hospitals.*

Characteristic Respondents

(N = 2952) Nonrespondents

(N = 1862)

percent

Size

Small (6–99 beds) 48 50

Medium (100–399 beds) 43 43

Large (≥400 beds) 10 7

Region

Northeast 14 12

Midwest 33 24

South 37 41

West 17 22

Ownership status

For-profit hospital 14 22

Private nonprofit hospital 62 55

Public hospital 24 23

Teaching status

Major teaching hospital 7 4

Minor teaching hospital 16 16

Nonteaching hospital 77 80

Member of hospital system

Yes 43 47

No 57 53

Location

Urban 62 60

Nonurban 38 40

Dedicated coronary care unit†

Yes 35 25

No 65 75

* P<0.05 for all comparisons. Numbers may not add to 100 because of rounding. † The presence of a coronary care unit is a marker of technological capability.

T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 360;16 nejm.org april 16, 20091632

further and was less consistently significant (see the Supplementary Appendix).

Barriers to and Facilitators of Electronic- Records Adoption

Among hospitals without electronic-records sys- tems, the most commonly cited barriers were in- adequate capital for purchase (74%), concerns about maintenance costs (44%), resistance on the part of physicians (36%), unclear return on investment (32%), and lack of availability of staff with ade-

quate expertise in information technology (30%) (Fig. 1). Hospitals that had adopted electronic- records systems were less likely to cite four of these five concerns (all except physicians’ resistance) as major barriers to adoption than were hospitals that had not adopted such systems (Fig. 1).

Most hospitals that had adopted electronic- records systems identified financial factors as hav- ing a major positive effect on the likelihood of adoption: additional reimbursement for electronic health record use (82%) and financial incentives

Table 2. Selected Electronic Functionalities and Their Level of Implementation in U.S. Hospitals.

Electronic Functionality

Fully Implemented in All Units

Fully Implemented

in at Least One Unit

Implementation Begun or Resources Identified*

No Implementation,

with No Specific Plans

percent of hospitals

Clinical documentation

Medication lists 45 17 18 20

Nursing assessments 36 21 18 24

Physicians’ notes 12 15 29 44

Problem lists 27 17 23 34

Test and imaging results

Diagnostic-test images (e.g., electrocar- diographic tracing)

37 11 19 32

Diagnostic-test results (e.g., echocardio- graphic report)

52 10 15 23

Laboratory reports 77 7 7 9

Radiologic images 69 10 10 10

Radiologic reports 78 7 7 8

Computerized provider-order entry

Laboratory tests 20 12 25 42

Medications 17 11 27 45

Decision support

Clinical guidelines (e.g., beta-blockers af- ter myocardial infarction)

17 10 25 47

Clinical reminders (e.g., pneumococcal vaccine)

23 11 24 42

Drug-allergy alerts 46 15 16 22

Drug–drug interaction alerts 45 16 17 22

Drug–laboratory interaction alerts (e.g., digoxin and low level of serum potas- sium)

34 14 21 31

Drug-dose support (e.g., renal dose gui- dance)

31 15 21 33

* These hospitals reported that they were either beginning to implement the specified functionality in at least one unit or had identified the resources required for implementation in the next year.

Use of Elec tronic He a lth R ecor ds in U.S. Hospita l s

n engl j med 360;16 nejm.org april 16, 2009 1633

for adoption (75%). Other facilitators of adoption included the availability of technical support for the implementation of information technology (47%) and objective third-party evaluations of elec-

tronic health record products (35%). Hospitals with and those without electronic-records systems were equally likely to cite these factors (P>0.10 for each comparison) (Fig. 2).

Table 3. Electronic Requirements for Classification of Hospitals as Having a Comprehensive or Basic Electronic- Records System.*

Requirement Comprehensive

EHR System

Basic EHR System with

Clinician Notes

Basic EHR System without Clinician Notes

Clinical documentation

Demographic characteristics of patients √ √ √ Physicians’ notes √ √ Nursing assessments √ √

Problem lists √ √ √ Medication lists √ √ √ Discharge summaries √ √ √ Advanced directives √ Test and imaging results

Laboratory reports √ √ √ Radiologic reports √ √ √ Radiologic images √ Diagnostic-test results √ √ √ Diagnostic-test images √ Consultant reports √ Computerized provider-order entry

Laboratory tests √ Radiologic tests √ Medications √ √ √ Consultation requests √ Nursing orders √ Decision support

Clinical guidelines √ Clinical reminders √ Drug-allergy alerts √ Drug–drug interaction alerts √ Drug–laboratory interaction alerts (e.g., digox-

in and low level of serum potassium) √

Drug-dose support (e.g., renal dose guidance) √ Adoption level — % of hospitals (95% CI) 1.5 (1.1–2.0) 7.6 (6.8–8.1) 10.9 (9.7–12.0)

* A comprehensive electronic-health-records (EHR) system was defined as a system with electronic functionalities in all clinical units. A basic electronic-records system was defined as a system with electronic functionalities in at least one clinical unit.

T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 360;16 nejm.org april 16, 20091634

D i s c u s s i o n

We found that less than 2% of acute care hospi- tals have a comprehensive electronic-records sys- tem, and that, depending on the definition used, between 8 and 12% of hospitals have a basic elec- tronic-records system. With the use of the defini- tion that requires the presence of functionalities for physicians’ notes and nursing assessments, in- formation systems in more than 90% of U.S. hos- pitals do not even meet the requirement for a basic electronic-records system.

Although levels of adoption of electronic health records were low, many functionalities that un- derlie electronic-records systems have been widely implemented. A sizable proportion of hospitals reported that laboratory and radiologic reports, radiologic images, medication lists, and some de- cision-support functions are available in electronic format. Others reported that they planned to up- grade their information systems to an electronic- records system by adding functionalities, such as computerized provider-order entry, physicians’ notes, and nursing assessments. However, these

Table 4. Adoption of Comprehensive and Basic Electronic-Records Systems According to Hospital Characteristics.*

Characteristic Comprehensive

EHR System Basic EHR System†

No EHR System

Overall P Value

percent of hospitals

Size <0.001

Small (6–99 beds) 1.2±0.3 4.9±0.6 93.9±0.6

Medium (100–399 beds) 1.7±0.4 8.1±0.8 90.2±0.8

Large (≥400 beds) 2.6±0.9 15.9±2.2 81.5±2.3

Region 0.77

Northeast 1.1±0.5 8.9±1.4 90.1±1.5

Midwest 1.7±0.4 6.6±0.8 91.7±0.9

South 1.4±0.4 7.3±0.8 91.3±0.8

West 1.9±0.6 7.0±1.2 91.1±1.3

Profitability status 0.08

For-profit hospital 1.3±0.5 5.2±1.1 93.5±1.2

Private nonprofit hospital 1.5±0.3 8.4±0.6 90.1±0.7

Public hospital 1.7±0.5 5.8±0.9 92.4±1.0

Teaching status <0.001

Major teaching hospital 2.6±1.1 18.5±2.6 78.9±2.7

Minor teaching hospital 2.4±0.7 10.6±1.4 87.0±1.6

Nonteaching hospital 1.3±0.2 5.6±0.5 93.1±0.5

Member of hospital system 0.006

Yes 2.1±0.4 8.4±0.9 89.5±0.9

No 1.1±0.2 6.3±0.6 92.6±0.6

Location <0.001

Urban 1.9±0.3 8.4±0.6 89.7±0.6

Nonurban 0.6±0.3 4.0±0.7 95.3±0.8

Dedicated coronary care unit‡ 0.002

Yes 1.9±0.4 9.7±0.9 88.4±1.0

No 1.3±0.3 6.3±0.6 92.4±0.6

* Plus–minus values are means ±SE. EHR denotes electronic health record. † The definition of a basic system that included functionalities for physicians’ notes and nursing assessments was used

for this analysis. ‡ The presence of a coronary care unit is a marker of technological capability.

Use of Elec tronic He a lth R ecor ds in U.S. Hospita l s

n engl j med 360;16 nejm.org april 16, 2009 1635

functionalities are typically more difficult to im- plement than the others that we examined, and it remains unclear whether hospitals will be able to do so successfully.

We found high levels of decision support in the absence of a comparable prevalence of com- puterized provider-order entry. It is possible that respondents reporting that their hospitals have implemented electronic decision support were in- cluding in that category decision-support capabili- ties that are available only for electronic pharmacy systems, thereby overstating the preparedness of hospitals to provide physicians with electronic de- cision support for patient care.

We found somewhat higher levels of adoption among larger, urban, teaching hospitals, proba- bly reflecting greater availability of the financial resources necessary to acquire an electronic-records system. We expected to find lower levels of adop- tion among public hospitals, which might be fi- nancially stressed and therefore less able to pur- chase these systems. Although our results do not support this hypothesis, we did not directly ex- amine detailed indicators of the financial health of the hospitals, such as their operating margins.

In 2006, we performed a comprehensive review of the literature on hospital adoption of electronic- records systems in the United States and found

that the most rigorous assessment made was for computerized provider-order entry and that its prevalence was between 5 and 10%.6,9,14 An ear- lier AHA survey showed a higher prevalence of computerized provider-order entry,13 but the re- sponse rate was only 19%. A Mathematica survey showed that 21% of U.S. hospitals had comput- erized provider-order entry and 59% had elec- tronic clinical documentation.10 However, this survey’s definition of clinical documentation al- lowed for the inclusion of systems that were only capable of recording demographic characteristics of patients, a definition that is likely to have in- flated adoption levels, given that Medicare requires electronic reporting of demographic data. A re- cent analysis, based on a proprietary database with an unclear sampling frame and an unknown re- sponse rate, showed that 13% of the hospitals had implemented computerized provider-order entry, a prevalence similar to that in our study.11

Most reports of a beneficial effect of electronic- records systems involved systems capable of com- puterized provider-order entry with clinical-deci- sion support.4 Our experts took a lenient approach by not requiring the presence of clinical-decision support as part of a basic electronic-records sys- tem and by requiring adoption of computerized provider-order entry in only one clinical unit.

33p9

Hospitals with EHR Hospitals without EHR

AUTHOR:

FIGURE:

JOB:

4-C H/T

RETAKE

SIZE

ICM

CASE

EMail Line H/T Combo

Revised

AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset.

Please check carefully.

REG F

Enon

1st 2nd

3rd

Jha

1 of 2

04-16-09

ARTIST: ts

36016 ISSUE:

Inadequate capital for purchase

Unclear ROI Maintenance cost

Physicians’ resistance

Inadequate IT staff

Barriers

P ro

p o

rt io

n o

f H

o sp

it al

s (%

)

Figure 1. Major Perceived Barriers to Adoption of Electronic Health Records (EHRs) among Hospitals with Electronic- Records Systems as Compared with Hospitals without Systems.

Hospitals with electronic-records systems include hospitals with a comprehensive electronic-records system and those with a basic electronic-records system that includes functionalities for physicians’ notes and nursing assess- ments. P<0.01 for all comparisons except physicians’ resistance (P = 0.20). IT denotes information technology, and ROI return on investment.

T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 360;16 nejm.org april 16, 20091636

Whether a hospital that has successfully imple- mented computerized provider-order entry in one unit can easily implement in other units and add clinical-decision support is unclear. Furthermore, a nonuniform information system within the hos- pital (paper-based in some units and electronic in others) may increase clinical hazards as patients move from one unit to another. Whether the ben- efits of adoption of an electronic-records system in some clinical units outweigh the theoretical hazards posed by uneven adoption within the hos- pital requires examination.

Respondents identified financial issues as the predominant barriers to adoption, dwarfing is- sues such as resistance on the part of physicians. Other studies have shown that physicians’ resis- tance, partly driven by concerns about negative effects of the use of electronic health records on clinical productivity,17 can be detrimental to adop- tion efforts.18 Whether our respondents, most of whom have not adopted electronic health records, underestimated the challenges of overcoming this barrier or whether physicians are becoming more receptive to adoption is unclear. Either way, ob- taining the support of physicians — often by get- ting the backing of clinical leaders — can be help- ful in ensuring successful adoption.19

Another potential barrier to adoption is con-

cern about interoperability: few electronic-records systems allow for easy exchange of clinical data between hospitals or from hospitals to physicians’ offices. Low levels of health information exchange in the marketplace20,21 reduce the potential value of these systems and may have a dampening ef- fect on adoption.

From a policy perspective, our data suggest that rewarding hospitals — especially financially vul- nerable ones — for using health information tech- nology may play a central role in a comprehensive approach to stimulating the spread of hospital electronic-records systems. Creating incentives for increasing information-technology staff and har- monizing information-technology standards and creating disincentives for not using such technol- ogy may also be helpful approaches.

Some providers, such as the VHA, have success- fully implemented electronic-records systems. VHA hospitals have used electronic health records for more than a decade with dramatic associated im- provements in clinical quality.22,23 Their medical records are nearly wholly electronic, and includ- ing them in our analyses led to a doubling of our count of U.S. hospitals with a comprehensive sys- tem. Some developed countries, such as the United Kingdom and the Netherlands, have also success- fully spurred adoption of health information tech-

33p9

100

P ro

p o

rt io

n o

f H

o sp

it al

s (%

) 80

Hospitals with EHR Hospitals without EHR

Additional reimbursement

for HIT use

Financial incentives for

implementation

Technical support for

implementation

Facilitators

Objective EHR evaluation

List of certified EHRs

AUTHOR:

FIGURE:

JOB:

4-C H/T

RETAKE

SIZE

ICM

CASE

EMail Line H/T Combo

Revised

AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset.

Please check carefully.

REG F

Enon

1st 2nd

3rd

Jha

2 of 2

04-16-09

ARTIST: ts

36016 ISSUE:

Figure 2. Perceived Facilitators of Adoption of Electronic-Records Systems among Hospitals with Systems as Compared with Hospitals without Systems.

Hospitals with electronic-records systems include hospitals with a comprehensive system and those with a basic system that includes functionalities for physicians’ notes and nursing assessments. P>0.10 for all comparisons. EHR denotes electronic health record, and HIT health information technology.

Use of Elec tronic He a lth R ecor ds in U.S. Hospita l s

n engl j med 360;16 nejm.org april 16, 2009 1637

nology, although most of their progress has been in ambulatory care. Few countries have yet to make substantial progress in the inpatient setting.24

There are limitations to our study. First, al- though we achieved a 63% response rate, the hos- pitals that did not respond to our survey were somewhat different from those that did respond. We attempted to compensate for these differences by adjusting for potential nonresponse bias, but such adjustments are imperfect. Given that non- responding hospitals were more likely to have characteristics associated with lower levels of adoption of electronic health records, residual bias may have led us to overestimate adoption levels. Second, we focused on adoption and could not ac- curately gauge the actual use or effectiveness of electronic-records systems. Third, we did not as- certain whether the systems that were adopted had been independently certified (by parties such as the Certification Commission for Health Informa- tion Technology). Fourth, given low adoption lev- els, we had limited power to identify predictors of the adoption of comprehensive electronic-records systems as compared with basic systems. Finally, we did not ascertain whether users of electronic health records were satisfied with them.

In summary, we examined levels of electronic

health record adoption in U.S. hospitals and found that very few have a comprehensive electronic sys- tem for recording clinical information and that only a small minority have even a basic system. However, many institutions have parts of an elec- tronic-records system in place, suggesting that policy interventions could increase the prevalence of electronic health records in U.S. hospitals faster than our low adoption levels might suggest. Criti- cal strategies for policymakers hoping to promote the adoption of electronic health records by U.S. hospitals should focus on financial support, in- teroperability, and training of information tech- nology support staff.

Supported by grants from the Office of the National Coordinator for Health Information Technology in the Department of Health and Human Services and the Robert Wood Johnson Foundation.

Dr. Jha reports receiving consulting fees from UpToDate; Drs. Donelan and Rao, receiving grant support from GE Corporate Healthcare; and Dr. Blumenthal, receiving grant support from GE Corporate Healthcare, the Macy Foundation, and the Office of the National Coordinator for Health Information Technology in the Department of Health and Human Services and speaking fees from the FOJP Service Corporation and serving as an adviser to the presidential campaign of Barack Obama. He has been named Na- tional Coordinator for Health Information Technology. No other potential conflict of interest relevant to this article was reported.

We thank our expert consensus panel for their assistance in conducting this research and Paola Miralles of the Institute for Health Policy for assistance in the preparation of an earlier ver- sion of the manuscript.

References

Smith C, Cowan C, Heffler S, Catlin A. 1. National health spending in 2004: recent slowdown led by prescription drug spend- ing. Health Aff (Millwood) 2006;25:186- 96.

McGlynn EA, Asch SM, Adams J, et al. 2. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-45.

Jha AK, Li Z, Orav EJ, Epstein AM. 3. Care in U.S. hospitals — the Hospital Quality Alliance program. N Engl J Med 2005;353:265-74.

Chaudhry B, Wang J, Wu S, et al. Sys-4. tematic review: impact of health informa- tion technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006;144:742-52.

Blumenthal D, Glaser JP. Information 5. technology comes to medicine. N Engl J Med 2007;356:2527-34.

Jha A, Ferris T, Donelan K, et al. How 6. common are electronic health records in the United States? A summary of the evi- dence. Health Aff (Millwood) 2006;25: w496-w507.

Schoen C, Osborn R, Huynh PT, Doty 7. M, Peugh J, Zapert K. On the front lines of

care: primary care doctors’ office sys- tems, experiences, and views in seven countries. Health Aff (Millwood) 2006; 25:w555-w571.

DesRoches CM, Campbell EG, Rao 8. SR, et al. Electronic health records in am- bulatory care — a national survey of phy- sicians. N Engl J Med 2008;359:50-60.

Cutler DM, Feldman NE, Horwitz JR. 9. U.S. adoption of computerized physician order entry systems. Health Aff (Millwood) 2005;24:1654-63.

Laschober M, Maxfield M, Lee M, Ko-10. vac M, Potter F, Felt-Lisk S. Hospital re- sponses to public reporting of quality data to CMS: 2005 survey of hospitals. Wash- ington, DC: Mathematica, October 12, 2005.

Furukawa MF, Raghu TS, Spaulding 11. TJ, Vinze A. Adoption of health informa- tion technology for medication safety in U.S. hospitals, 2006. Health Aff (Millwood) 2008;27:865-75.

Healthcare Information and Manage-12. ment Systems Society (HIMSS). 2002 Hot topic survey. Chicago: HIMSS Analytics, 2002.

Forward momentum: hospital use of 13.

information technology. Chicago: Ameri- can Hospital Association, 2005.

Ash JS, Gorman PN, Seshadri V, Hersh 14. WR. Computerized physician order entry in U.S. hospitals: results of a 2002 survey. J Am Med Inform Assoc 2004;11:95-9.

Key capabilities of an electronic health 15. record system. Washington, DC: Institute of Medicine, 2003.

Blumenthal D, DesRoches C, Donelan 16. K, et al. Health information technology in the United States: the information base for progress. Princeton, NJ: Robert Wood Johnson Foundation, 2006.

Scott JT, Rundall TG, Vogt TM, Hsu J. 17. Kaiser Permanente’s experience of imple- menting an electronic medical record: a qualitative study. BMJ 2005;331:1313-6.

Simon SR, Kaushal R, Cleary PD, et al. 18. Correlates of electronic health record adoption in office practices: a statewide survey. J Am Med Inform Assoc 2007; 14:110-7.

Sequist TD, Cullen T, Hays H, Taualii 19. MM, Simon SR, Bates DW. Implementa- tion and use of an electronic health rec- ord within the Indian Health Service. J Am Med Inform Assoc 2007;14:191-7.

n engl j med 360;16 nejm.org april 16, 20091638

Use of Elec tronic He a lth R ecor ds in U.S. Hospita l s

Adler-Milstein J, McAfee AP, Bates 20. DW, Jha AK. The state of regional health information organizations: current activi- ties and financing. Health Aff (Millwood) 2008;27:w60-w69.

Adler-Milstein J, Bates DW, Jha AK. 21. Update on regional health information organizations: progress but critical work

remains. Health Aff (Millwood) 2009;28: 483-92.

Jha AK, Perlin JB, Kizer KW, Dudley 22. RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003; 348:2218-27.

Perlin JB. Transformation of the US 23.

Veterans Health Administration. Health Econ Policy Law 2006;1(Pt 2):99-105.