This document summarizes a study examining the adoption of electronic health records (EHRs) in U.S. hospitals. The study found that less than 20% of U.S. hospitals had a basic EHR system, and only 4% had a comprehensive EHR system. Larger, teaching, and private hospitals were more likely to adopt EHRs. The biggest barriers to adoption were financial issues and physician resistance. The study provides baseline data on EHR adoption that can help policymakers design incentives to promote more widespread adoption.

1. Use of Electronic Health
Records in U.S. Hospitals
R d i US H it l
A Review of Jha et al. (2009)
Nawanan Theera-Ampornpunt, M.D., M.S.
UMN Health Informatics Journal Club
September 24, 2009

2. Outline
Overview of Health IT Adoption
U.S. EHR Adoption Landscape
Jha t l (2009)’ Study
Jh et al. (2009)’s St d
• Background
• Methods
• Results & Discussions
• Summary
2

3. Overview
of Health IT Adoption
f H lth Ad ti
3

4. Underlying Assumption
y g p
Adoption Use Outcomes
4

5. Underlying Assumption
y g p
• Better clinical outcomes
• Improved patient satisfaction
Individual • More provider productivity/satisfaction
Adoption & use
• Improved operational efficiency
• More patients
p
Organizational • Reduced costs/increased revenues
Adoption & Use
• Better individual health/quality of life
• Better population health
Societal • Long-term cost savings
Adoption & Use
5

6. Areas of IT Adoption Research
p
Adoption Use Outcomes
• Describe the state of • Describe the state of • Determine if/when IT
adoption in a specific health IT use in a adoption & use will lead
setting specific setting to better outcomes
(+ what outcomes?)
• Compare adoption in 2 • Compare adoption in 2
settings settings • Compare impacts of
same health IT in
• Identify facilitators and • Identify facilitators and different settings
diff i
barriers of IT adoption barriers of IT use
• Reveal
• Determine if/when mechanisms/pathways
adoption will lead to use that translate adoption &
use to outcomes
6

7. U.S. EHR Adoption
Landscape
L d
7

8. Past Studies
U.S. Ambulatory Setting U.S. Hospital Setting
As f
A of 2005 As of 2005
• 24% of physicians used EHRs • No high quality estimate of
Systematic review by Jha et al. (2006)
y y ( )
hospital EHR adoption Jha et al. (2006)
al
• HIMSS 2005: 17% of hospitals had a
2006 fully integrated EHR (but low quality)
• 28% of primary care physicians • M Lascholber (2005): 59% used an
M.
used EMRs Schoen et al. (2006) EHR (high quality methods but
• 29.2% of office-based physicians problematic EHR definition)
used full or partial EMRs Hing et al. (2007))
p g (
2006
2007-2008
• 11% of hospitals had fully and 57%
• 17% of physicians used basic or had partially implemented an EHR
fully functional EHRs DesRoches et al. (2008) (but study used e-mail & fax
surveys) AHA (2007)
8

9. Jha et al. (2009) Study
( ) y
9

10. Background
g
Rising costs and inconsistent quality of U S
U.S.
health care system
AND
Potential of health IT to improve efficiency
and effectiveness
d ff ti
LEAD TO
Promotion of a national, interoperable health
information system in ARRA*, with bipartisan
y , p
support
* American Recovery and Reinvestment Act of 2009 10

11. Background
g
Providers have been slow to adopt EHRs despite
broad consensus on their benefits
Prior data: Hospital EHR adoption between 5 59%
5-59%
• Different definitions
• Use of convenience samples
• Low response rates
Reliable estimates of EHR adoption prevalence in
U.S. hospitals are lacking
p g
11

12. Background
g
Purposes
p
To provide more precise estimates of EHR adoption
among U.S. hospitals
With a clear definition of key clinical functions
constituting a hospital EHR system (“basic EHRs”)
Also a definition of “comprehensive EHRs”
To evaluate hypotheses that larger, teaching, and
private hospitals are more lik l t adopt EHR
i t h it l likely to d t EHRs
To identify barriers to adoption to guide policymakers
Study commissioned by ONC*
* Office of the National Coordinator for Health Information Technology 12

13. Scope of Study
p y
Adoption Use Outcomes
• Describe the state of • Describe the state of • Determine if/when IT
adoption in a specific health IT use in a adoption & use will lead
setting specific setting to better outcomes
(+ what outcomes?)
• Compare adoption in 2 • Compare adoption in 2
settings settings • Compare impacts of
same health IT in
• Identify facilitators and • Identify facilitators and different settings
diff i
barriers of IT adoption barriers of IT use
• Reveal
• Determine if/when mechanisms/pathways
adoption will lead to use that translate adoption &
use to outcomes
13

14. Methods
Design
g
Cross-sectional mail survey
Sample
p
All acute care general medical and surgical hospitals
that are member of the American Hospital Association
(N = 4814)
Survey Administration (Mar - Sep 2008)
Presented as an IT supplement to AHA’s annual
survey of members, sent to hospital’s CEO
CIOs
CIO are t i ll assigned t complete survey
typically i d to l t
Multiple phone calls and reminder letters 14

15. Methods
Survey Development
y p
Developed an initial survey draft based on prior
surveys and working with experts
Feedback sought from CIOs, hospital leaders, and
survey experts
Input also obtained from a consensus panel of
experts in health IT, health services research, survey
research,
research and health policy
policy.
Survey modifications approved by expert panel
15

16. Methods
Survey Content
Presence/absence of 32 clinical functionalities of an
EHR system
Whether their hospital h d f ll i l
Wh th th i h it l had fully implemented th
t d these
functions
in all major clinical units
in one or more (but not all) major clinical units
in none of the units
Whether certain factors were major or minor barriers
or were not barriers to EHR adoption and whether
p
specific policy changes would have a positive or
negative effect on their decision to adopt 16

17. Results
63.1%
63 1% (3049 h
hospitals) responded
it l ) d d
Federal hospitals and those located outside
the 50 states and D.C. were excluded,
leaving 2952 hospitals in the sample
17

18. Respondents vs. Nonrespondents
p p
Modest differences of responding & nonresponding hospital
characteristics
h t i ti
All comparisons p < 0.05 Jha et al. (2009) 18

19. Adoption of Functionalities
p
• Large variations in implementation of key clinical
functionalities
Jha et al. (2009) 19

20. Adoption of Functionalities
(Cont.)
(C t )
Jha et al. (2009) 20

21. Definitions of Basic &
Comprehensive EHRs
Jha et al. (2009) 21

22. Definitions of Basic &
Comprehensive EHRs (Cont )
(Cont.)
Jha et al. (2009) 22

23. Adoption of EHRs
p
Jha et al. (2009) 23

24. Organizational Factors Associated
with EHR Adoption
Jha et al. (2009) 24

25. Organizational Factors Associated
with EHR Adoption (Cont.)
(Cont )
Jha et al. (2009) 25

26. Barriers to EHR Adoption
p
Jha et al. (2009) 26

27. Facilitators of EHR Adoption
p
Jha et al. (2009) 27

28. Discussion
More th 90% of U S h
M than f U.S. hospitals d not use
it l do t
health IT that meets the requirement for a
basic
b i EHR system t
Though EHR adoption is low, many
functionalities are widely implemented (e.g.
lab & radiologic reports, imaging, medication
lists)
28

29. Discussion
High levels of d i i support without
Hi h l l f decision t ith t
comparable adoption of computerized order
entry, suggesting presence of decision-
t ti fd i i
support functions in only certain systems
(e.g. pharmacy)
( h )
Higher adoption among larger, urban, and
teaching hospitals, reflecting greater
availability of financial resources needed to
acquire EHRs
29

30. Discussion
EHR adoption rate i l
d ti t is lower th prior studies
than i t di
(but this study has better response rates,
clearer & more restrictive d fi iti
l t i ti definitions)
)
Much of health IT benefits come from
decision support, which is not part of the
“basic EHR” requirements
Risks of uneven adoption within the hospital
unclear
30

31. Discussion
Financial i
Fi i l issues id tifi d as predominant
identified d i t
barriers to adoption
Importance of physician resistance as barrier
should be noted and addressed
31

32. Policy Implications
y p
Rewarding h
R di hospitals f using h lth IT may
it l for i health
play a central role in widespread adoption
Other potentially helpful approaches
Incentives to increase IT workforce
Harmonizing standards
Creating disincentives for not using
technology may be helpful
32

33. Limitations
Nonresponse bi could l d t
N bias ld lead to
overestimation of EHR adoption
Focused on adoption, not actual use or
effectiveness of EHR systems
No information on adopted systems’
certification
Low adoption leads to limited power to
identify predictors of EHR adoption
User satisfaction out of scope
33

34. Summary
y
Very few U.S. hospitals h
V f US h it l have a
comprehensive EHR system
A small minority have a basic EHR system
Critical strategies to p
g promote adoption
p
include financial support, interoperability, and
training of IT support staff
g pp
34

35. References
Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields
A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S.
hospitals. N Engl J Med. 2009 Apr 16;360(16):1628-38.
Jha AK, Ferris TG, Donelan K, DesRoches C, Shields A, Rosenbaum S,
Blumenthal D How common are electronic health records in the United
D.
States? A summary of the evidence. Health Aff (Millwood). 2006 Nov-
Dec;25(6):w496-507.
Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines
y y g p
of care: primary care doctors’ office systems, experiences, and views in
seven countries. Health Aff (Millwood). 2006 Nov-Dec;25(6):w555-71.
DesRoches CM, Rosenbaum S. Scanning the health information technology-
related policy environment. I Blumenthal D D R h C F bi t V
l t d li i t In: Bl th l D, DesRoches C, Foubister V,
editors. Health information technology in the United States: where we
stand, 2008 [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2008
[
[cited 2009 Sep 20]. p. 8-24. Available from:
p ] p
http://www.rwjf.org/files/research/3297.31831.hitreport.pdf
35

36. References
Continued progress: hospital use of information technology [Internet].
Chicago (IL): American Hospital Association; 2007 Feb [cited 2009 Sep 20]. 20
p. Available from: http://www.aha.org/aha/content/2007/pdf/070227-
continuedprogress.pdf
36

37. Q
Questions?
37