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					Trends In The Adoption
Of Health Information
Technology


Susan Dentzer
Editor-In-Chief
     Health Affairs thanks




for its ongoing support of the journal
       as well as today’s briefing
David Muntz, MBA
Principal Deputy National Coordinator
Office of the National Coordinator for Health IT,
US Department of Health And Human Services
        Health Affairs Forum
          Meaningful Use
    National Press Club Meeting
           April 25, 2012

David S. Muntz, CHCIO, FCHIME, FHIMSS
     Principal Deputy National Coordinator
Office of the National Coordinator for Health IT
   Department of Health & Human Services




                                                   4
The Time is for Health IT is Now!

• The goals to achieve Meaningful Use are
  ambitious, but achievable
• $22.5B available to healthcare providers in
  form of incentives
• The momentum is building




                                                5
“HIT Is The Means, But Not The End.”


Dr. David Blumenthal, previous National
Coordinator of HIT, emphasizes,
“Getting an EHR up and running in health
care is not the main objective behind the
incentives provided by the federal
government under ARRA. Improving health
is.”

                - At the National HIPAA Summit
                           in Washington, D.C.
                       on September 16, 2009




                                                 6
Health IT: Helping to Drive the 3-Part Aim


 Better healthcare   Improving patients’ experience of care within the Institute of
                     Medicine’s 6 domains of quality: Safety, Effectiveness, Patient-
                     Centeredness, Timeliness, Efficiency, and Equity.

   Better health     Keeping patients well so they can do what they want to do.
                     Increasing the overall health of populations: address behavioral
                     risk factors; focus on preventive care.

  Reduced costs      Lowering the total cost of care while improving quality, resulting
                     in reduced monthly expenditures for Medicare, Medicaid, and
        $            CHIP beneficiaries.




                     Health Information Technology
                                                                                          77
Meaningful Use as a Building Block
                                                                      Use information
                                                                       to transform
                                                                          Improved
                                                                       population health

                          Improve access                               Enhanced access
                           to information                               and continuity
                                                  Data utilized to       Data utilized to
                                                 improve delivery       improve delivery
                                                  and outcomes           and outcomes
                                                   Patient self         Patient engaged,
        Utilize                                    management             community
                                                                           resources
    technology to                                                       Patient centered
        gather              Care coordination    Care coordination
                                                                       care coordination
     information                                 Evidenced based       Team based care,
                             Patient informed
                                                     medicine          case management
         Basic EHR                                 Registries for        Registries to
       functionality,        Structured data
                                                     disease            manage patient
      structured data            utilized
                                                   management            populations
     Privacy & security     Privacy & security   Privacy & security    Privacy & security
        protections            protections          protections           protections

                                                     PCMHs                  ACOs
      Stage 1 MU             Stage 2 MU
                                                   3-Part Aim            Stage 3 MU         8
“How are we doing?”

• Physician adoption of any EHR system has more than
  tripled since 2002, going from 17 percent to 57 percent in
  2011 (NCHS Data Brief).

• The adoption of basic EHRs has doubled since 2008, going
  from 17% to 34% in 2011 (NCHS Data Brief).

• Adoption has grown significantly important subgroups of
  physicians including small practices and rural providers.

• The share of hospitals using EHRs has more than doubled
  from 16% to 35%.


                                                               9
Who is helping?

•   The public – patients and consumers
•   The IT industry
•   The Health Care industry
•   Professional and consumer organizations
•   Other Federal agencies including but not limited to:
     –   AHRQ -- HRSA
     –   CMS
     –   FCC
     –   FDA
     –   NIST
     –   NLM
     –   NTSB
     –   OCR
     –   USDA

                                                           10
Providers Registered for
Medicare and Medicaid EHR
Incentive Programs are registered to achieve Meaningful Use
    Over 225 thousand providers
              through the Medicare or Medicaid EHR Incentive Programs


       222,282 eligible professionals                                     3,483 eligible hospitals




                                                                                          Source: CMS EHR Incentive
                                                                                          Program Data as of 3/31/2012

                                 Office of the National Coordinator for
 3/14/2013
                                    Health Information Technology                                                        11
Number of EHR Incentive Payments Made to
Eligible Professionals as of March 31, 2012




                                                                                Source: CMS EHR Incentive Program
  Note: Medicaid payments are for adopting, implementing, or upgrading EHR technology. Medicare payments are for the
  meaningful use of certified EHR technology.
                                                                                                                       12
Number of EHR Incentive Payments Made
to Eligible Hospitals as of March 31, 2012




                                                                               Source: CMS EHR Incentive Program

  Note: Medicaid payments are for adopting, implementing, or upgrading EHR technology. Medicare payments are for the
  meaningful use of certified EHR technology. 566 hospitals have received payments under both Medicare and Medicaid.   13
Regional Extension Centers (RECs)
Over 132,000 primary care providers are working with a Regional
  Extension Center to achieve Meaningful Use

This includes
• Over 40% of all primary care providers in the nation

• Over half of all primary care providers working in rural
  locations

• Small providers are having successes at getting on EHR
  systems

• Working with 963 Critical Access Hospitals (CAHs) and 85 rural
  hospitals, all of whom have 25 beds or less
                       Office of the National Coordinator for
3/14/2013
                          Health Information Technology            14
Online Job Postings Have Grown Substantially




                                       SOURCE: ONC analysis of data from O’Reilly Job Data Mart

•   Supporting activities
     –   Community College Consortia
     –   University Based Training
     –   Curriculum development
     –   Competency Exam
                                                                                                  15
How does Health IT transform health and
health care? By hardwiring the 3-Part Aim.
 • Improving adherence to evidence-based best practice
     –   Order Sets
     –   Care Plans
     –   Clinical Decision Support (CDS)
     –   Documentation Templates
     –   Collection and Reporting of Clinical Quality Measures (CQM’s)
     –   Data aggregation for new knowledge generation

 • Facilitating access to information during encounters, between encounters
   and across care venues
     –   Collect once, use many times
     –   Anytime, anywhere access to patient information
     –   Easy access to clinical reference data
     –   Health information exchange (HIE)

 • Involving and engaging the patients, their families, and consumers
     – Patient as partner - Empowered
     – Participation in care – Compliance with care

                                                                              16
   Why is HIT important?
   Patients are not averages. They are part of a community.

59 year-old woman in                             During the admission, she
                                                 received personalized risk
Dallas, TX who was                               assessment forms, was placed
diagnosed with                                   on standardized order sets.
glaucoma in 1982 and                             Medication reconciliation was
has been taking                                  done. She was sent to the
                                                 Cath Lab for an angiogram.
Timoptic eye drops                               Prior to and after her
daily.                                           procedures, telemetry results
                                                 were entered automatically
Last Sunday, April 15,                           into the EHR.
10 minutes after
entering the water for                           Using an EHR with imaging,
                                                 her physician was able to
the first leg of a mini-                         review her angiogram with her
triathlon she suffered                           on the TV screen in her room
what was eventually                              and discuss the potential risks
                                                 of an additional beta blocker to
diagnosed as a non-                              ensure the best possible
STEMI cardiac event.                             outcome. Personalized
She was admitted to                              discharge instructions were
the Heart Hospital at                            given to her spouse. The
                                                 outcome and prognosis are
Baylor Plano.                                    good.
                                                                              17
                   Thank you!

For additional comments or questions please contact
               David.Muntz@HHS.gov




                                                      18
Stay Connected. Communicate. Collaborate.
Centers for Medicare & Medicaid Services




                                            19
  CMS References for Stage 2

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html




                                                                                           20
Stay Connected.
Communicate and Collaborate.

• Browse the ONC website at: HealthIT.gov
 click the Facebook “Like” button to add us to your network

• Contact us at: onc.request@hhs.gov

• Subscribe, watch, and share:

              @ONC_HealthIT

              http://www.youtube.com/user/HHSONC

              Health IT and Electronic Health Records

              http://www.scribd.com/HealthIT/

              http://www.flickr.com/photos/healthit           Health IT Buzz Blog

                                                                                    21
Michael W. Painter, JD, MD
Senior Program Officer
Robert Wood Johnson Foundation
Small, Non-Teaching, And
Rural Hospitals Continue To Be
Slow In Adopting Electronic
Health Record Systems

Catherine M. DesRoches, PhD
Maulik Joshi, Chantal Worzala, Peter
Kralovec, & Ashish K. Jha
Introduction
    By February 2012, more than three
     thousand hospitals had registered for
     Medicare or Medicaid electronic
     health record incentive program.
    Overall pace of adoption has been
     slow.
    A recent study suggests that the pace
     of adoption may be quickening but
     nationally representative data has
     been missing.

                                             2
Research Questions
 What proportion of US hospitals had a
    basic or comprehensive electronic health
    record system or could meet our proxy
    standard of meaningful use in 2011?
   Are there specific types of hospitals that
    appear to be making progress more rapidly
    than others?
   Which electronic functions appear to be
    the biggest barriers to hospitals reaching
    the meaningful use mark?

                                                 25
Methodology
 National survey of U.S. hospitals
 Field period: October – December 2011
 Response rate: 58%
 Analytic sample: 2,646 acute care hospitals
 Measures: 1) basic and comprehensive EHR
                 2) proxy measure for meaningful
                    use
   All results are weighted to adjust for potential
    non-response basis.


                                                       26
Overall Findings
    Hospital adoption of EHRs
     accelerated between 2010 and 2011.
    Gaps in adoption based on hospital
     size, teaching status and location
     appear to be widening.
    Meeting Stage 1 meaningful use
     criteria is a challenge for most
     hospitals.


                                          27
Substantial Increase In Adoption Of At Least A
Basic EHR: 2010-2011




DesRoches CM, Joshi M, Worzala C, Kralovec P, Jha AK. (2012) Small, non-teaching, and rural hospitals continue to be slow in adopting electronic
health record systems. Health Aff (Millwood). 2012;31(5). [Epub ahead of print] archived and available at www.healthaffairs.org
                    Smaller, Non-Teaching Hospitals Fell
                    Further Behind
     Percent of hospitals




                                     Hospital Size                                                       Teaching Status
DesRoches CM, Joshi M, Worzala C, Kralovec P, Jha AK. (2012) Small, non-teaching, and rural hospitals continue to be slow in adopting electronic
health record systems. Health Aff (Millwood). 2012;31(5). [Epub ahead of print] archived and available at www.healthaffairs.org
  Rural Hospitals Had The Lowest Rate Of Adoption




DesRoches CM, Joshi M, Worzala C, Kralovec P, Jha AK. (2012) Small, non-teaching, and rural hospitals continue to be slow in adopting electronic
health record systems. Health Aff (Millwood). 2012;31(5). [Epub ahead of print] archived and available at www.healthaffairs.org
                                                                        30
Fewer Than 1 In 5 Hospitals Met The Proxy For
Meaningful Use
Electronic functionality                              % of hospitals   18.4% of
                                                                       hospitals had all
Patient demographics                                      81.9         12 measures
                                                                       implemented in
Patient medication allergy list                           79.2
                                                                       at least one unit
Vital signs                                               75.5         of the hospital.
Smoking status                                            71.3
Clinical decision support                                 74.4
Patient medication list                                   74.2
Electronic copy of discharge instructions                 68.8
Patient problem list                                      55.5
Computerized provider order entry                         50.1
Provide patients with copy of record upon request         49.6
Generate quality measures                                 46.8
Implement drug-drug/drug allergy interaction checks       41.7
 Barriers Remain, Even For Hospitals That Are
 Close To Meaningful Use
 Percent of acute care hospitals with 9 to 11 of the 12 meaningful use functions




DesRoches CM, Joshi M, Worzala C, Kralovec P, Jha AK. (2012) Small, non-teaching, and rural hospitals continue to be slow in adopting electronic
health record systems. Health Aff (Millwood). 2012;31(5). [Epub ahead of print] archived and available at www.healthaffairs.org
Continued Federal Efforts Are Needed In The
Following Areas:
• Hospitals that appear to be moving more slowly – their
  needs may be beyond the capabilities of the Regional
  Extension Centers.
• The shortage of trained HIT professionals
• Vendor supply appears to be strained – smaller hospitals
  may have a hard time competing with large, urban
  facilities.
• Lack of infrastructure for health information exchange
• Setting the bar for Stage 2 of meaningful use
Study team
 American Hospital Association
   Chantal Worzala
   Peter Kralovec
   Maulik Joshi
 Harvard School of Public Health
   Ashish K. Jha



                                   34
Physicians In Nonprimary Care And
Small Practices And Those Age 55 And
Older Lag In Adopting Electronic Health
Record Systems


Sandra L. Decker, Ph.D.
Eric W. Jamoom, Ph.D.
Jane E. Sisk, Ph.D.
The authors thank the Office of the National Coordinator for Health
Information Technology (ONC) for funding the National Ambulatory Care
Electronic Medical Records supplement. The findings and conclusions in this
presentation are those of the authors and do not necessarily represent he
views of the Centers for Disease Control and Prevention, the Institute of
Medicine, or the Office of the National Coordinator.
 Goal and Methods
Background
In 2002, about one-in-five office-based physicians had Electronic Health Records
(EHRs) (Burt & Sisk, Health Affairs, Sept/Oct 2005). By 2011, more than half of
physicians had EHRs (Hsiao et al., NCHS Data Brief 79).

Purpose
To trace the increase in adoption of EHRs among office-based physicians in the past
decade by physician and practice characteristics.

Data
2002-2011 National Ambulatory Medical Care Survey (NAMCS) of office-based
physicians, excluding radiologists, anesthesiologists, and pathologists (N =22,885).

Outcomes
    Any EHR
    Basic EHR system includes computerized capabilities hypothesized to lead to
    improved quality and efficiency of care (i.e. ability to record information on
    patient demographics, problem lists, medications, and clinical notes, and the
    ability to view laboratory and imaging results and use computerized
    prescription ordering)
  Physicians with Electronic Health Records, 2002-2011
                 60
                                           Any EHR                  Basic EHR
                                                                                                        55


                 50




                 40

                                                                                                        36
% (Unadjusted)




                 30




                 20

                       18

                                                                       12
                 10




                 0
                      2002   2003   2004      2005   2006           2007        2008   2009   2010   2011
                                                            Years
Physicians With Any Electronic Health Records
By Practice Size

                      ≥ 10 Physicians with Any EHR          3-9 Physicians with Any EHR      1-2 Physicians with Any EHR

                 90

                                                                                                                 83.1
                 80


                 70


                 60                                                                                              61.3
% (Unadjusted)




                 50


                 40
                                                                                                                 36.7
                       29.2
                 30

                       20.1
                 20


                 10    12.4


                 0
                       2002      2003      2004      2005      2006      2007      2008   2009     2010      2011
                 Physicians With Any Electronic Health Records By Age
                 80


                                       Age 45 years or younger          Ages 46-55          Age over 55 years
                 70

                                                                                                                         68
                 60


                                                                                                                         60
                 50
% (Unadjusted)




                 40
                                                                                                                         45

                 30

                           22
                 20
                      20

                       16
                 10



                  0
                      2001      2002    2003       2004          2005     2006       2007       2008       2009   2010    2011
             Physicians With Any Or Basic Electronic
             Health Records By Specialty


                 70.0


                 60.0                                                   60.1


                 50.0                                                   50.5   Primary-Care Specialists with
                                                                               Any EHR
                                                                               Non-Primary-Care Specialists
% (Unadjusted)




                 40.0                                                   41.3   with Any EHR
                                                                               Primary-Care Specialists with
                                                                        31.5   Basic EHR
                 30.0
                                                                               Non-Primary-Care Specialists
                                                                               with Basic EHR
                        18.7
                 20.0
                                                    15.0
                        16.5
                 10.0                               10.0


                  0.0
                        2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Physicians With Any Or Basic Electronic
Health System By Ownership
                  80.0


                                                                       68.3
                  70.0


                  60.0

                                                                       49.6
                  50.0
                                                                              Practice Owned by Physician or
% (Unadjusted )




                                                                       48.0   Physician Group with Any EHR
                  40.0                                                        Other Ownership Arrangment with
                                                                              Any EHR
                                                  30.7                        Practice Owned by Physician or
                  30.0   26.6                                                 Physician Group with Basic EHR
                                                                       29.0   Other Ownership Arrangment with
                                                                              Basic EHR
                  20.0

                         16.1
                  10.0
                                                   9.4


                   0.0
                         2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
 Conclusions
● Upturn in EHR adoption from 2004 as federal efforts ramped up

● By 2011, more than half of physicians reported some use, but only
about one-third had basic capabilities hypothesized to lead to improved
quality and efficiency of care

● During the 2002-2011 decade, differences in adoption by specialty and
practice size, as well as by physician age and practice ownership,
persisted or widened

● Federal programs have targeted primary-care specialists and those in
small practices. To achieve the stated aim of widespread use, they may
need to also focus on non-primary care specialists.
Most Physicians Were Eligible
For Federal Incentives In 2011,
But Few Had EHR Systems That
Met Meaningful-Use Criteria
Chun-Ju Hsiao, Ph.D., M.H.S.
Sandra L. Decker, Ph.D.
Esther Hing, M.P.H.
Jane E. Sisk, Ph.D.
We would like to thank the Office of the National Coordinator for Health Information Technology
for funding the Electronic Medical Records Supplement to the National Ambulatory Medical Care
Survey. The findings and conclusions in this article are those of the authors and do not necessarily
represent the views of the Centers for Disease Control and Prevention,
the Institute of Medicine, or the Office of the National Coordinator.
Policy Context And Purpose
• Eligible professionals must show meaningful use
  of certified EHRs to receive financial incentives
  from Medicaid or Medicare
• To assess physicians' eligibility and intentions to
  apply for these incentives and the computerized
  capabilities of physicians' EHRs to support
  meaningful use
Data And Methods
• 2011 National Ambulatory Medical Care Survey
  (NAMCS) Electronic Medical Record (EMR)
  Supplement of office-based physicians
• Assessed eligibility for financial incentives based
  on Medicare revenue or approximate Medicaid
  volume
• Assessed intentions to apply for financial
  incentives
• Assessed capabilities/readiness of EHRs to
  support 10 of the 15 required stage 1 objectives
  for meaningful use
Results
• 91% of physicians eligible for Medicare or Medicaid
  financial incentives

• 51% intended to apply

• 11% both intended to apply and had EHRs with capabilities
  to support two-thirds of the stage 1 core objectives
   – More likely: physicians in practices of 11 or more
      physicians, physicians in practices not owned by
      physician/physician group
   – Less likely: non-primary care specialists, physicians
      eligible for Medicaid incentives

• States with higher percentages intending to apply differed
  from states with higher percentages ready with the
  required EH R capabilities
Conclusions
• Great discrepancy exists between physicians’
  intentions to apply for incentives and their EHRs’
  readiness
• Gaps in readiness are widespread across the states
• Low level of EHR readiness illustrates meeting
  federal schedule for financial incentives will be
  challenging
HITECH @3:
How Far Have We Come?
How Far Do We Have To Go?


Ashish K. Jha, MD, MPH
Harvard School of Public Health
Why HITECH?
• U.S. Healthcare “system” is a mess
  – High cost, disappointing quality
• Paper-based records a contributor
  – Lead to lots of errors, waste
• EHR adoption was low, moving slow
• The largest payer intervened
What Happened?
• Well-crafted, strong incentives work
• Through 2010, EHR adoption slow moving
  – 3-5% per year
• 2011 was the game-changer year
  – 1 in 10 physicians, hospitals adopted an EHR
• Broad enthusiasm in the marketplace
  – Majority of docs, hospitals intend to apply for
    MU
Health Information Exchange
Health Information Exchange
• The vision: Broad-based exchange of
  structured clinical data
• Appears deceptively simple
  – Likely the hardest part of HITECH
Health Information Exchange
• Five major challenges ahead:
  – Concerns about privacy, security
  – Exchange of structured data
  – Those left out of HITECH
    • Leaves large gaps in the patient’s care picture
  – Competitiveness
  – Clinical data workflow
    • Dealing with an onslaught of new data
Moving Forward On HIE
• Steps for policymakers
  – Reassurance about privacy/security
  – Bringing excluded providers in
  – Pushing for structured data exchange
  – Focus on new payment models
    • ACOs, etc. are a double-edged sword
• Innovations in the market place
  – Manage the explosion of data
Challenges Beyond HIE
Big Challenges Ahead
• Ensuring safe implementation
• Digital divide emerging
  – Widening gap by size, location
• Getting benefits out of Health IT
  – Recent debate on cost, quality misses point
  – EHR systems have differential effects
  – We don’t know why
Summary: Looking Back,
Moving Forward
 Getting Health IT Right Is Essential
• Infrastructure for payment, delivery reform
• HITECH is having an effect
  – Early in the ballgame
• Metrics to watch in the years ahead:
  –   Will adoption continue to accelerate?
  –   Will we begin to narrow the digital divide?
  –   Will clinical data begin to flow?
  –   Will we learn to get the benefits out of HIT?
Acknowledgements
•   RWJF
•   NCHS, AHA
•   ONC
•   Health Affairs
     Health Affairs thanks




for its ongoing support of the journal
       as well as today’s briefing

				
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