EHR Adoption: Encouraging Progress, Sobering Obstacles

U.S. hospitals continued their double-digit growth in EHR adoption, according to a new study published in Health Affairs, achieving a 75.2% adoption rate by the end of 2014. Yet the authors identified some troubling obstacles—widespread acquisition and operational cost concerns (just as penalties were poised to begin), lack of physician cooperation, and rule complexity.

At times, it is helpful to remember that pursuit of perfection can be the enemy of the good, but in the case of the electronic health record (EHR), the authors point out that perfection must be the goal. “While achieving EHR adoption among the majority of hospitals is an important milestone, it is critically important to reach close to nationwide adoption of these systems to gain the network benefit of EHR adoption,” write Milstein et al.

The authors used the data from the American Hospital Association Annual Survey and its IT Supplement to understand IT adoption between 2008 and 2014 and the characteristics of the adopting hospitals. Respondents represent 60% of the 4,387 nonfederal, general acute care hospitals in the U.S. The authors acknowledged that they examined only whether a hospital had core meaningful-use functions, not whether they had demonstrated use of those functions.

Good news, bad news

Overall, the spike in adoption of at least a basic EHR between 2013 and 2014 was significant, from 58.9% in 2013 to 75.2% in 2014.  Of the hospitals with EHRs, 41.1% adopted basic technology and 34.1% adopted comprehensive technology.

The authors conjectured that the progress likely was due to the availability of incentives and the oncoming threat of penalties.

Hospitals with a basic system reported implementation of 10 computerized functions in at least one clinical unit of the hospital: patient demographics, physician notes, nursing assessments, patient problem lists, patient medication lists, discharge summaries, laboratory reports, diagnostic test results, and order entry for medications. Hospitals with comprehensive systems reported that the 10 basic functions plus 14 additional ones were implemented in all major clinical units.

The authors also saw a big surge in the number of hospitals that reported the ability to meet stage 2 meaningful use objectives in 2014: 40.5% versus 5.8% in 2013. Nonetheless, with the program entering the second year of stage 2 attestation, nearly 60% are not prepared.

“Hospitals undoubtedly invested a lot of time and energy in the criteria that require health information exchange: the summary care record for each transition objective (provider-to-provider exchange) as well as the patient’s ability to view, download and transmit objective (provider-to-patient exchange),” the authors write. “However, this is counterbalanced by our finding that the majority of hospitals might not be ready to meet the stage 2 core objectives when required to do so.”

Clouds on the horizon

Of some concern is the fact that those hospitals that could not report stage-2 readiness were more likely to report challenges in implementing their EHR. Foremost among them were up-front capital costs (56.7% versus 45.9% of hospitals that reported readiness) and ongoing costs (65.2% versus 56.3%). With penalties of 1.2% of Medicare reimbursement set to begin this year, those challenges will only grow.

The authors found clear IT adoption trends by size, type, and ownership of hospitals under review. Not surprisingly, large hospitals, major teaching hospitals, and urban hospitals were more likely to have comprehensive EHRs, and medium-sized hospitals and minor teaching hospitals were more likely to have basic EHR functionality.

Not-for-profit hospitals were more likely than for-profit, public, and rural hospitals to have comprehensive technology. Critical access hospitals—which have 25 beds or less and provide the majority of care in rural or remote areas, particularly those with high poverty rates—were less likely than non-critical access hospitals (32% versus 21.9%) to have achieved basic EHR functionality.

Nonetheless, 75% of the hospitals that reported not having basic EHR functionality (24.8% of the total respondents) had at least eight of the necessary 10 functions. The function most often missing was physician notes, lacking in 61% of hospitals without basic EHR functionality.

“The EHR adoption gap is persistent,” write the authors. “Since 2008, there has been more than a 10-percentage-point gap between small and large hospitals in adoption of at least a basic EHR system.” The authors call for a renewed focus on this category of hospitals by policy makers.

After financial challenges, the most common challenge reported by all adopters was physician cooperation.  More stage-2 ready hospitals (65.3%) reported difficulty obtaining physician cooperation than hospitals that reported not being prepared to attest to stage 2 (56.3%), demonstrating that technology adoption exacerbates rather than solves the  physician buy-in issue.

Time for a reprieve?

A majority of adopters of both advanced systems (58.1%) and basic systems (57.1%) reported that the complexity of meeting meaningful use within the specified time frame was challenging. The authors note that even the recent proposal to simplify stage 2 requirements has not been enough to appease hospitals, which have called for further simplification, modifications in the “all or nothing” approach to penalties and incentives, and the relaxation of measures that hold providers accountable for the actions of others—likely an allusion to both the requirements that patients view and dowload their data and that physicians adopt the electronic notes capability in hospital EHRs. Providers and policy makers both have called for a delay in establishing stage 3 rules until more providers have begun to attest to stage 2.

With the majority of hospitals still not prepared to attest to stage 2 and competing priorities for change on the table, the authors recommend relaxing the program’s timeframe. “Responding to these calls and continuing to work toward streamlined regulations could free up resources to work on complementary priorities, such as making the transition from volume- to value-based payment,” the authors suggest.

The authors urge policy makers to consider additional resources for resource-constrained small and critical-access hospitals. For instance, the lack of adequate IT support was cited by 43.4% of hospitals unprepared to meet stage 2 objectives, so providing outside support could encourage adoption. Group purchasing arrangements for these hospitals also could help, as could relaxing requirements to meet specific meaningful use criteria among this subset of hospitals.

While concluding that significant progress has been made in EHR adoption, the authors call out specific domains in which hospitals continue to struggle—implementing physician notes, physician stonewalling, and controlling up-front and ongoing costs—for special attention.

“Policy strategies that target these issues will disproportionately benefit small and rural hospitals, which continue to lag behind,” they write. “With such strategies in place, nationwide hospital EHR adoption could be achieved in the near future, enabling the U.S. healthcare system to use EHRs to improve performance.”