1. Trends In The Adoption Of Health Information Technology Susan Dentzer Editor-In-Chief

2. Health Affairs thanks for its ongoing support of the journal as well as today’s briefing

3. David Muntz, MBA Principal Deputy National Coordinator Office of the National Coordinator for Health IT, US Department of Health And Human Services

4. 4 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

5. 5 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

6. 6 “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

7. 7 Health Information Technology Improving patients’ experience of care within the Institute of Medicine’s 6 domains of quality: Safety, Effectiveness, Patient- Centeredness, Timeliness, Efficiency, and Equity. Better healthcare 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. Better health Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries. Reduced costs $ Health IT: Helping to Drive the 3-Part Aim 7

8. 8 Stage 2 MU ACOs Stage 3 MU PCMHs 3-Part Aim Registries to manage patient populations Team based care, case management Enhanced access and continuity Privacy & security protections Care coordination Privacy & security protections Patient centered care coordination Improved population health Registries for disease management Evidenced based medicine Patient self management Privacy & security protections Care coordination Structured data utilized Data utilized to improve delivery and outcomes Patient informed Patient engaged, community resources Stage 1 MU Privacy & security protections Basic EHR functionality, structured data Utilize technology to gather information Improve access to information Use information to transform Meaningful Use as a Building Block

9. 9 “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%.

10. 10 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

11. 11 Providers Registered for Medicare and Medicaid EHR Incentive Programs 8/22/2015 Office of the National Coordinator for Health Information Technology Source: CMS EHR Incentive Program Data as of 3/31/2012 222,282 eligible professionals 3,483 eligible hospitals Over 225 thousand providers are registered to achieve Meaningful Use through the Medicare or Medicaid EHR Incentive Programs

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

13. 13 Number of EHR Incentive Payments Made to Eligible Hospitals as of March 31, 2012 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. Source: CMS EHR Incentive Program

14. 14 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 8/22/2015 Office of the National Coordinator for Health Information Technology

15. 15 Online Job Postings Have Grown Substantially Supporting activities – Community College Consortia – University Based Training – Curriculum development – Competency Exam SOURCE: ONC analysis of data from O’Reilly Job Data Mart

16. 16 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

17. 17 Why is HIT important? Patients are not averages. They are part of a community. 59 year-old woman in Dallas, TX who was diagnosed with glaucoma in 1982 and has been taking Timoptic eye drops daily. During the admission, she received personalized risk assessment forms, was placed on standardized order sets. Medication reconciliation was done. She was sent to the Cath Lab for an angiogram. Prior to and after her procedures, telemetry results were entered automatically into the EHR. Using an EHR with imaging, her physician was able to review her angiogram with her on the TV screen in her room and discuss the potential risks of an additional beta blocker to ensure the best possible outcome. Personalized discharge instructions were given to her spouse. The outcome and prognosis are good. Last Sunday, April 15, 10 minutes after entering the water for the first leg of a mini- triathlon she suffered what was eventually diagnosed as a non- STEMI cardiac event. She was admitted to the Heart Hospital at Baylor Plano.

18. 18 Thank you! For additional comments or questions please contact David.Muntz@HHS.gov

19. 19 Stay Connected. Communicate. Collaborate. Centers for Medicare & Medicaid Services

20. 20 CMS References for Stage 2 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

21. 21 Stay Connected. Communicate and Collaborate. Browse the ONC website at: HealthIT.govHealthIT.gov click the Facebook “Like” button to add us to your network Contact us at: onc.request@hhs.gov 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

22. Michael W. Painter, JD, MD Senior Program Officer Robert Wood Johnson Foundation

23. 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

24.  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. Introduction 24

25.  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? Research Questions 25

26.  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. Methodology 26

27.  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. Overall Findings 27

28. 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.orgwww.healthaffairs.org

29. Smaller, Non-Teaching Hospitals Fell Further Behind Hospital Size Teaching Status Percent of hospitals 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.orgwww.healthaffairs.org

30. Rural Hospitals Had The Lowest Rate Of Adoption 30 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.orgwww.healthaffairs.org

31. Fewer Than 1 In 5 Hospitals Met The Proxy For Meaningful Use Electronic functionality% of hospitals Patient demographics 81.9 Patient medication allergy list 79.2 Vital signs 75.5 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 18.4% of hospitals had all 12 measures implemented in at least one unit of the hospital.

32. 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.orgwww.healthaffairs.org

33. 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

34. American Hospital Association Chantal Worzala Peter Kralovec Maulik Joshi Harvard School of Public Health Ashish K. Jha Study team 34

35. 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.

36. 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)

42. 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.

43. 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.

44. 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

45. 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

46. 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

47. 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

48. HITECH @3: How Far Have We Come? How Far Do We Have To Go? Ashish K. Jha, MD, MPH Harvard School of Public Health

49. 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

50. 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

51. Health Information Exchange

52. The vision: Broad-based exchange of structured clinical data Appears deceptively simple – Likely the hardest part of HITECH

53. 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

54. 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

55. Challenges Beyond HIE

56. 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

57. Summary: Looking Back, Moving Forward

58. 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?

59. Acknowledgements RWJF NCHS, AHA ONC Health Affairs

60. Health Affairs thanks for its ongoing support of the journal as well as today’s briefing