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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

A Strong Start for Electronic Health Records in the United States

Three years ago, the US government began implementing the Health Information Technology for Economic and Clinical Health (HITECH) Act, a federal initiative with an ambitious goal: to convince all physicians and hospitals to adopt electronic health record systems (EHRs) and then use them in ways that improve the quality and efficiency of care. The motivation for the policy was the abysmally low use of EHRs by physicians and hospitals, which meant that an IT-enabled health care system was likely decades away.

The act authorized financial incentives to “eligible providers,” physicians, nurse practitioners, and others, as well as hospitals that meaningfully use EHRs. Meaningful use comes in stages, beginning with basic EHR functions and progressing to sophisticated use that evidence suggests should improve health care delivery.

As the act was crafted and implementation began, 3 important concerns were raised:

  • It was unclear whether the incentives would be sufficient to convince physicians and hospitals to incur the substantial costs associated with EHR adoption.

  • There was concern that an existing digital divide would worsen, and physicians and hospitals with financial means would increasingly adopt EHRs while safety-net providers would fall further behind.

  • Some skeptics raised concerns about whether the HITECH Act would lead to better care at lower costs.

These concerns can serve as our guide to take stock of what we have accomplished after 3 years and where we still have work to do.   

Did Incentives Motivate Adoption?

The early data on whether incentives were sufficient to motivate adoption are encouraging. Over the past 3 years, there has been a notable uptick in EHR adoption rates. Just 9% of hospitals had even a basic EHR system in 2008, a number that increased to only 15% by 2010. Starting in 2011, as the incentives began, the proportion of hospitals with a basic EHR system climbed quickly, nearly tripling to 44% by 2012.

It is remarkable that nearly 1 in 3 acute care US hospitals became an EHR user during 2011 and 2012. Among ambulatory physicians, the numbers are similarly impressive, essentially doubling over the past 2 years.

These gains are reflected in payments made through the meaningful use incentive program. Through May 2013, 79% of eligible hospitals and 56% of eligible ambulatory providers had received an incentive payment. Furthermore, it appears that hospitals and ambulatory care physicians are using EHRs as part of routine care. For example, while federal policy makers initially required that hospitals use computerized provider order entry (CPOE) of medications for 30% of their patients, hospitals on average report using CPOE for 84% of their patients.

Little Evidence of an Increasing Digital Divide

Early data on the second concern are reassuring: there is little evidence of a growing digital divide. Adoption of EHRs among rural ambulatory clinicians is keeping pace with that of their urban counterparts. And although rural hospitals and safety-net hospitals are somewhat behind on adoption, they are receiving incentives at rates similar to those of urban and better-capitalized institutions.

This success is attributable in part to specific HITECH programs that structured incentives in a more flexible way for physicians and hospitals that care for a large proportion of Medicaid patients. On the ambulatory side, the incentives are larger and the timeline for achieving meaningful use is extended. On the hospital side, the “adopt, implement, or upgrade” (AIU) option allows hospitals that serve a large number of Medicaid patients to receive financial support prior to demonstrating that they are meaningfully using EHRs. As of December 2012, 24% of all hospitals had received funding under this mechanism.

Will HITECH Foster Better Care and Lower Costs?

On the third concern of whether HITECH will lead to better care and reduce costs, the data are not yet in. Early studies, mostly conducted before HITECH was enacted, found inconsistent relationships between EHR use and better care or lower costs.

By demonstrating that simply adopting EHRs is not enough to improve health care delivery, these studies motivated federal policy makers to define meaningful use in ways that maximize the chances that EHRs will improve care delivery. It is too early to tell whether this approach will succeed. 

Challenges Moving Forward

Given the notable progress in EHR adoption and use, it is tempting to conclude that these trends will continue with little additional policy effort. However, important challenges require attention as the nation moves forward.

For example, although many physicians and hospitals were able to meet the first stage of meaningful use, the second stage asks substantially more. Whether those who have met stage 1 will be able to make the jump to stage 2 is unclear. A recent national survey found that only 5% of hospitals are able to meet all stage 2 criteria. Hospitals appear to have a particularly difficult time being able to share their data with other organizations and with patients. Policy makers have important work ahead to ensure that physicians and hospitals have options for electronic data exchange and use those options to share data when clinically appropriate.

A second challenge is that a digital divide could emerge over the next few years. Although safety-net hospitals have received incentives at rates similar to those of other hospitals, they predominantly received AIU funding, which was meant as an “advance payment.” The AIU option does not require that safety-net providers be meaningful users of EHRs. Whether these institutions will successfully use these funds to pave the path to meaningful use is unclear.

Because AIU funding is only available in the first year of program participation, we will soon know whether providing safety-net institutions with this alternative funding mechanism was a wise investment. If these hospitals are unable to transition to becoming meaningful users of EHR by 2015, they will be subject to financial penalties by the Medicare program. Such penalties will make future progress toward EHR adoption even more difficult.

The ultimate challenge is whether doctors and hospitals will be able to use EHRs in ways that improve care and reduce costs. The HITECH incentives are front-loaded, requiring physicians and hospitals to start early and move quickly to receive the full amount. Although there is ample evidence from other industries that IT adoption leads to gains in quality and efficiency when organizations substantially redesign the way they work to take advantage of new capabilities, there is little to indicate that new IT adoption is leading to substantial changes in the way care is delivered.

Without these changes, the promise of EHRs—better care at lower costs—will not be achieved. Policy makers have an important role to play in promoting research into how care can be optimally redesigned to take advantage of new EHR functionalities.

Final Thoughts

As we near the end of the third year of HITECH, policy makers, clinicians, and hospitals should take pride in all that they have accomplished. Adoption rates for EHRs have increased 3- to 5-fold over the past few years. A majority of Americans now receive their health care through an EHR, a stretch goal that few thought achievable just a few years ago.

However, delivering on HITECH requires tackling a range of additional issues, most important of which is learning how to use technology to deliver care in fundamentally different ways. Until we are able to do these things well, any evaluation of this important national initiative will have to offer a grade of “incomplete.”

About the authors:
Julia Adler-Milstein, PhD, is an Assistant Professor in the School of Information at the University of Michigan, with a joint appointment in the School of Public Health (Health Management and Policy). She received her PhD in Health Policy from Harvard University. Dr Adler-Milstein’s research focuses on policy and management issues related to the use of IT in health care delivery. She is a national expert on health information exchange and she has conducted 4 national surveys of health information organizations. Her work also examines the adoption and productivity effect of electronic health records.
Ashish K. Jha, MD, MPH,is Professor of Health Policy at the Harvard School of Public Health and a practicing Internist at the Boston VA. He received his MD from Harvard Medical School and trained in Internal Medicine at the University of California, San Francisco. He received his MPH from Harvard School of Public Health. Dr Jha’s major research interests lie in improving the quality and costs of health care. His work has focused on 4 primary areas—public reporting, pay-for-performance, health information technology, and leadership—and the roles they play in fixing the US health care system.