Vol. 00 No. 0 xxx 2014
1
Enabling Quality: Electronic Health Record Adoption and Meaningful Use Readiness in Federally Funded Health Centers Michael Wittie, Quyen Ngo-Metzger, Lydie Lebrun-Harris, Leiyu Shi, and Suma Nair
Purpose Despite long-term Federal investments in health center health information technology (HIT), little is known about federally funded health centers’ current use of HIT, either in terms of adoption rates or their use of specific technologies for quality improvement (Moiduddin, Gaylin, & Ford, 2007; Singh, Lichter, Danzo, Taylor, & Rosenthal, 2011). We examined electronic health record (EHR) use in all federally funded health centers to provide the first comprehensive assessment of their progress toward Meaningful Use of EHRs, and to evaluate the possibility of a digital divide (i.e., a difference in the use of or benefit from technology between racial, ethnic, and/or socioeconomic groups [McConnaughey, Everette, Reynolds, & Lader, 1999]) in HIT adoption.
Background and Significance HIT has been widely promoted for its potential to improve the quality, safety, efficiency, and cost-effectiveness of healthcare (Health Information Technology for Economic and Clinical Health (HITECH) Act, 2009). HIT can enable enhancements in areas such as care coordination, standardization, and clinical decision support based on best practice guidelines; recent evidence indicates that these benefits are being realized among some safety-net providers (those who serve underserved and vulnerable populations, such as poor, uninsured, and minority patients; Buntin, Burke, Hoaglin, & Blumenthal, 2011; Cebul, Love, Jain, & Hebert, 2011; Friedberg et al., 2009). However, numerous authors have warned of a potential digital divide in HIT adoption among vulnerable populations (Bahensky, Jaana, & Ward, 2008; Glaser, 2007; Ngo-Metzger, Hayes, Yunan, Cygan, & Garfield, 2010). In 2006, safety-net providers were adopting EHRs at much lower rates than other ambulatory care providers (Moiduddin et al., 2007). Federally funded health centers are one of the largest safety-net providers in the United
Abstract: The Health Resources and Services Administration has supported the adoption of electronic health records (EHRs) by federally funded health centers for over a decade; however, little is known about health centers’ current EHR adoption rates, progress toward Meaningful Use, and factors related to adoption. We analyzed cross-sectional data from all 1,128 health centers in 2011, which served over 20 million patients during that year. As of 2011, 80% of health centers reported using an EHR, and high proportions reported using many advanced EHR functionalities. There were no indications of disparities in EHR adoption by census region, urban/rural location, patient sociodemographic composition, physician staffing, or health center funding; however, there were small variations in adoption by total patient cost and percent of revenue from grants. Findings revealed no evidence of a digital divide among health centers, indicating that health centers are implementing EHRs, in keeping with their mission to reduce health disparities.
States. The U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) funds health centers to provide comprehensive primary care and supportive services to underserved and vulnerable populations. In 2011, HRSA provided funding to 1,128 health centers operating over 8,500 delivery sites in all 50 states and the U.S. territories. Among over 20 million patients served, 93% were under 200% of the federal poverty level (FPL), 62% were racial/ethnic minorities, 40% were Medicaid-insured, and 36% were uninsured (Bureau of Primary Health Care, 2011a). EHR adoption has great potential to enhance health centers’ ability to provide high quality of care (Health Information Technology for Economic and Clinical Health (HITECH) Act, 2009). Besides being socioeconomically disadvantaged, health center patients suffer higher rates of chronic disease than other populations, including diabetes and hypertension (Politzer et al., 2001). EHR use can greatly improve the coordination and quality of care for such patients. Given HIT’s potential to help eliminate ´ disparities (Custodio & Graham, 2009; Lopez, Tan-McGrory, King, & Betancourt, 2011), it is important to examine health centers’ use
Keywords community health centers electronic health record health disparities health information technology primary care
Journal for Healthcare Quality Vol. 00, No. 0, pp. 1–9 C 2014 National Association for Healthcare Quality
2
Journal for Healthcare Quality
of HIT to evaluate whether there is a digital divide. The federal government is committed to assuring that underserved and at-risk individuals enjoy the benefits of HIT to the same extent as the general population (Office of the National Coordinator for Health Information Technology [ONC]), and HIT adoption by health centers has been a HRSA priority for over a decade. Since 2007, HRSA has awarded over $121 million to support HIT-related projects in health centers and Health Center Controlled Networks (HCCNs—groups of health centers pursuing shared/integrated services to enhance members’ operations; Murchinson, Ray, & Sison, 2008). HRSA is actively seeking attainment of Meaningful Use of EHR by all health centers with the goals of improving quality of care, increasing efficiency in care delivery, and reducing health disparities, as well as allowing health centers to benefit from incentive payments and pay-for-performance reforms. In 2006, only 26% of health centers had any EHR capacity (Shields et al., 2007); by 2010, a survey of health centers indicated that their adoption rate had reached 69%, but these results were based on a survey with a relatively low response rate (63.5%) (Cunningham, Lara, & Shin, 2011). Another study (Li & West-Strum, 2010) found no difference in EHR adoption between health centers and other care settings, but only included 12 health centers in the study. Studies of ambulatory care providers in general have found disparities in EHR adoption associated with multiple factors, including urban/rural location, practice size, and patient population factors such as payer mix and race/ethnicity (Hing & Hsiao, 2010; L´opez et al., 2011; Menachemi, Matthews, Ford, & Brooks, 2007). HRSA annually collects information on all federally funded health centers through its Uniform Data System (UDS). We used the UDS to examine these health centers’ EHR adoption status and the center characteristics associated with adoption. We examined whether factors associated with EHR use in other ambulatory practice settings were associated with adoption in federally funded health centers. Our findings begin to fill the gaps in the current literature about the rate of health centers’ EHR adoption. In addition, these results can help inform policies and programs advancing the Federal Health IT Strategic Plan goals of in-
creasing EHR adoption and HIT-enabled quality improvement (ONC).
Study Design and Methods HRSA requires all federally funded health centers to submit a variety of organization-level data to the UDS each year, including patient sociodemographic and diagnostic information, services provided, staffing, clinical indicators and health outcomes, utilization, costs, and revenues (Bureau of Primary Health Care, 2011a). UDS data are reviewed to ensure grantee compliance with program requirements, improve health center performance, and report overall program accomplishments (Bureau of Primary Health Care, 2011a). The 2010 UDS was the first comprehensive effort to query health centers about their EHR capacity. In those UDS reports, about 65% of all health centers reported having an EHR in use at some or all of their care delivery sites. For this study, we used the most recent year of data available (2011 UDS), as well as HRSA grant records. This study defines “health centers” specifically as those that receive funding under Section 330 of the Public Health Service Act.
Measures We examined reported EHR use, as well as use of quality-related EHR functions. We compared health centers that reported using EHRs at some/all sites with those who reported no EHR use at all, which corresponds to the definition of EHR Adoption, Implementation, or Upgrade (AIU) in the Meaningful Use regulations (Code of Federal Regulations, 2010). We asked health centers that had EHRs if they had any of 28 functionalities (Table 2) installed and in use in their EHRs. These functionalities were selected because they aligned with the National Ambulatory Medical Care Survey EHR supplement (CDC National Center for Health Statistics, 2009), are considered necessary to support system use for quality improvement, and were similar to those functionalities required for Stage 1 Meaningful Use (Centers for Medicare and Medicaid Services). We examined institutional, provider, and patient characteristics associated with EHR adoption among other ambulatory providers in the literature to determine whether associations with EHR use also existed in health centers. Institutional characteristics examined included health center geography (census region and
Vol. 00 No. 0 xxx 2014
Table 1. Characteristics of Health Centers, Comparison of EHR Users versus Non-EHR Users EHR Grantees (N = 898) N (%) 167 (83.5) 170 (80.2) 319 (82.2) 236 (78.7)
Non-EHR Grantees (N = 230) N (%) 33 (16.5) 42 (19.8) 69 (17.8) 64 (21.3)
579 (51.4) 548 (48.6)
471 (81.4) 427 (77.9)
108 (18.7) 121 (22.1)
1,042 (92.5) 85 (7.5)
840 (80.6) 58 (68.2)
202 (19.4) 27 (31.8)
Duration of HRSA funding ࣙ3 years 1,065 (94.4)
1
Enabling Quality: Electronic Health Record Adoption and Meaningful Use Readiness in Federally Funded Health Centers Michael Wittie, Quyen Ngo-Metzger, Lydie Lebrun-Harris, Leiyu Shi, and Suma Nair
Purpose Despite long-term Federal investments in health center health information technology (HIT), little is known about federally funded health centers’ current use of HIT, either in terms of adoption rates or their use of specific technologies for quality improvement (Moiduddin, Gaylin, & Ford, 2007; Singh, Lichter, Danzo, Taylor, & Rosenthal, 2011). We examined electronic health record (EHR) use in all federally funded health centers to provide the first comprehensive assessment of their progress toward Meaningful Use of EHRs, and to evaluate the possibility of a digital divide (i.e., a difference in the use of or benefit from technology between racial, ethnic, and/or socioeconomic groups [McConnaughey, Everette, Reynolds, & Lader, 1999]) in HIT adoption.
Background and Significance HIT has been widely promoted for its potential to improve the quality, safety, efficiency, and cost-effectiveness of healthcare (Health Information Technology for Economic and Clinical Health (HITECH) Act, 2009). HIT can enable enhancements in areas such as care coordination, standardization, and clinical decision support based on best practice guidelines; recent evidence indicates that these benefits are being realized among some safety-net providers (those who serve underserved and vulnerable populations, such as poor, uninsured, and minority patients; Buntin, Burke, Hoaglin, & Blumenthal, 2011; Cebul, Love, Jain, & Hebert, 2011; Friedberg et al., 2009). However, numerous authors have warned of a potential digital divide in HIT adoption among vulnerable populations (Bahensky, Jaana, & Ward, 2008; Glaser, 2007; Ngo-Metzger, Hayes, Yunan, Cygan, & Garfield, 2010). In 2006, safety-net providers were adopting EHRs at much lower rates than other ambulatory care providers (Moiduddin et al., 2007). Federally funded health centers are one of the largest safety-net providers in the United
Abstract: The Health Resources and Services Administration has supported the adoption of electronic health records (EHRs) by federally funded health centers for over a decade; however, little is known about health centers’ current EHR adoption rates, progress toward Meaningful Use, and factors related to adoption. We analyzed cross-sectional data from all 1,128 health centers in 2011, which served over 20 million patients during that year. As of 2011, 80% of health centers reported using an EHR, and high proportions reported using many advanced EHR functionalities. There were no indications of disparities in EHR adoption by census region, urban/rural location, patient sociodemographic composition, physician staffing, or health center funding; however, there were small variations in adoption by total patient cost and percent of revenue from grants. Findings revealed no evidence of a digital divide among health centers, indicating that health centers are implementing EHRs, in keeping with their mission to reduce health disparities.
States. The U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) funds health centers to provide comprehensive primary care and supportive services to underserved and vulnerable populations. In 2011, HRSA provided funding to 1,128 health centers operating over 8,500 delivery sites in all 50 states and the U.S. territories. Among over 20 million patients served, 93% were under 200% of the federal poverty level (FPL), 62% were racial/ethnic minorities, 40% were Medicaid-insured, and 36% were uninsured (Bureau of Primary Health Care, 2011a). EHR adoption has great potential to enhance health centers’ ability to provide high quality of care (Health Information Technology for Economic and Clinical Health (HITECH) Act, 2009). Besides being socioeconomically disadvantaged, health center patients suffer higher rates of chronic disease than other populations, including diabetes and hypertension (Politzer et al., 2001). EHR use can greatly improve the coordination and quality of care for such patients. Given HIT’s potential to help eliminate ´ disparities (Custodio & Graham, 2009; Lopez, Tan-McGrory, King, & Betancourt, 2011), it is important to examine health centers’ use
Keywords community health centers electronic health record health disparities health information technology primary care
Journal for Healthcare Quality Vol. 00, No. 0, pp. 1–9 C 2014 National Association for Healthcare Quality
2
Journal for Healthcare Quality
of HIT to evaluate whether there is a digital divide. The federal government is committed to assuring that underserved and at-risk individuals enjoy the benefits of HIT to the same extent as the general population (Office of the National Coordinator for Health Information Technology [ONC]), and HIT adoption by health centers has been a HRSA priority for over a decade. Since 2007, HRSA has awarded over $121 million to support HIT-related projects in health centers and Health Center Controlled Networks (HCCNs—groups of health centers pursuing shared/integrated services to enhance members’ operations; Murchinson, Ray, & Sison, 2008). HRSA is actively seeking attainment of Meaningful Use of EHR by all health centers with the goals of improving quality of care, increasing efficiency in care delivery, and reducing health disparities, as well as allowing health centers to benefit from incentive payments and pay-for-performance reforms. In 2006, only 26% of health centers had any EHR capacity (Shields et al., 2007); by 2010, a survey of health centers indicated that their adoption rate had reached 69%, but these results were based on a survey with a relatively low response rate (63.5%) (Cunningham, Lara, & Shin, 2011). Another study (Li & West-Strum, 2010) found no difference in EHR adoption between health centers and other care settings, but only included 12 health centers in the study. Studies of ambulatory care providers in general have found disparities in EHR adoption associated with multiple factors, including urban/rural location, practice size, and patient population factors such as payer mix and race/ethnicity (Hing & Hsiao, 2010; L´opez et al., 2011; Menachemi, Matthews, Ford, & Brooks, 2007). HRSA annually collects information on all federally funded health centers through its Uniform Data System (UDS). We used the UDS to examine these health centers’ EHR adoption status and the center characteristics associated with adoption. We examined whether factors associated with EHR use in other ambulatory practice settings were associated with adoption in federally funded health centers. Our findings begin to fill the gaps in the current literature about the rate of health centers’ EHR adoption. In addition, these results can help inform policies and programs advancing the Federal Health IT Strategic Plan goals of in-
creasing EHR adoption and HIT-enabled quality improvement (ONC).
Study Design and Methods HRSA requires all federally funded health centers to submit a variety of organization-level data to the UDS each year, including patient sociodemographic and diagnostic information, services provided, staffing, clinical indicators and health outcomes, utilization, costs, and revenues (Bureau of Primary Health Care, 2011a). UDS data are reviewed to ensure grantee compliance with program requirements, improve health center performance, and report overall program accomplishments (Bureau of Primary Health Care, 2011a). The 2010 UDS was the first comprehensive effort to query health centers about their EHR capacity. In those UDS reports, about 65% of all health centers reported having an EHR in use at some or all of their care delivery sites. For this study, we used the most recent year of data available (2011 UDS), as well as HRSA grant records. This study defines “health centers” specifically as those that receive funding under Section 330 of the Public Health Service Act.
Measures We examined reported EHR use, as well as use of quality-related EHR functions. We compared health centers that reported using EHRs at some/all sites with those who reported no EHR use at all, which corresponds to the definition of EHR Adoption, Implementation, or Upgrade (AIU) in the Meaningful Use regulations (Code of Federal Regulations, 2010). We asked health centers that had EHRs if they had any of 28 functionalities (Table 2) installed and in use in their EHRs. These functionalities were selected because they aligned with the National Ambulatory Medical Care Survey EHR supplement (CDC National Center for Health Statistics, 2009), are considered necessary to support system use for quality improvement, and were similar to those functionalities required for Stage 1 Meaningful Use (Centers for Medicare and Medicaid Services). We examined institutional, provider, and patient characteristics associated with EHR adoption among other ambulatory providers in the literature to determine whether associations with EHR use also existed in health centers. Institutional characteristics examined included health center geography (census region and
Vol. 00 No. 0 xxx 2014
Table 1. Characteristics of Health Centers, Comparison of EHR Users versus Non-EHR Users EHR Grantees (N = 898) N (%) 167 (83.5) 170 (80.2) 319 (82.2) 236 (78.7)
Non-EHR Grantees (N = 230) N (%) 33 (16.5) 42 (19.8) 69 (17.8) 64 (21.3)
579 (51.4) 548 (48.6)
471 (81.4) 427 (77.9)
108 (18.7) 121 (22.1)
1,042 (92.5) 85 (7.5)
840 (80.6) 58 (68.2)
202 (19.4) 27 (31.8)
Duration of HRSA funding ࣙ3 years 1,065 (94.4)
