Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2015

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adoptionThe adoption and meaningful use of electronic health records (EHRs) are key objectives of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the Federal Health IT Strategic Plan (1). This brief uses data from the American Hospital Association to describe trends in adoption of EHR technology among non-federal acute care hospitals from 2008 to 2015. It tracks the adoption of Basic EHR systems and the possession of certified EHR technology. Unless otherwise stated, this brief refers to Basic EHR adoption with clinical notes, a measure which represents a minimum use of 10 core functionalities determined to be essential to an EHR system (see Table A1)(2).

Basic EHR adoption increased while certified EHR adoption remained high

Figure 1: Percent of non-Federal acute care hospitals with adoption of at least a Basic EHR with notes system and possession of a certified EHR: 2008-2015

This figure contains two line charts. The first line from the bottom describes adoption of Basic EHR systems from 2008 to 2015 (2008, 9.4; 2009, 12.2; 2010, 15.6; 2011, 27.6; 2012, 44.4; 2013, 59.4; 2014 75.5 ; 2015 83.8). The measures for 2009, 2010, 2011, 2012, 2013, and 2014 are marked as significantly different from the previous year. The second line from the bottom describes adoption of certified EHR systems from 2011 to 2015 (2011, 71.9; 2012, 85.2; 2013, 94.0; 2014, 96.9; 2015, 96.0). The measures for 2012, 2013, and 2014 are marked as significantly different from the previous year.

NOTE: Basic EHR adoption requires the EHR system to have a set of EHR functions defined in Table A1. A certified EHR is EHR technology that meets the technological capability, functionality, and security requirements adopted by the Department of Health and Human Services. Possession means that the hospital has a legal agreement with the EHR vendor, but is not equivalent to adoption. *Significantly different from previous year (p<0.05).

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

  • Nearly all reported hospitals (96%) possessed a certified EHR technology in 2015.
  • In 2015, 84% of hospitals adopted at least a Basic EHR system; this represents a 9-fold increase since 2008.
  • In 2015, Basic EHR adoption rates increased by 11% from 2014.
At least 8 out of 10 small, rural, and Critical Access hospitals adopted a Basic EHR

Figure 2: Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system by hospital type

The figure 2 contains a bar chart that presents hospital EHR adoption among small, rural, critical access, and all hospitals for years 2011-2015. In 2011, small, rural, and critical access hospitals had EHR adoption of 22%, 22%, and 20% respectively, which were significantly lower than all hospitals with EHR adoption at 28%. In 2012, small, rural, and critical access hospitals had EHR adoption of 39%, 36%, and 35% respectively, which were significantly lower than all hospitals with EHR adoption at 44%. In 2013, small, rural, and critical access hospitals had EHR adoption of 53%, 53%, and 54% respectively, which were significantly lower than all hospitals with EHR adoption at 59%. In 2014, small, rural, and critical access hospitals had EHR adoption of 70%, 70%, and 68% respectively, which were significantly lower than all hospitals with EHR adoption at 76%. In 2015, small, rural, and critical access hospitals had EHR adoption of 81%, 80%, and 80% respectively, which were significantly lower than all hospitals with EHR adoption at 84%.

NOTE: *Significantly different from all hospitals (p<0.05). Small = <100 beds; rural = non-metropolitan; Critical Access = <25 beds and at least 35 miles away from any other general or Critical Access hospital. Basic EHR adoption requires the EHR system to have a set of EHR functions defined in Table A1.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

  • Small, rural, and Critical Access hospitals continue to have significantly lower Basic EHR adoption rates compared to all hospitals.
  • Since 2014, small and rural hospitals increased their adoption of Basic EHRs by at least 14% and Critical Access hospitals increased their adoption of Basic EHRs by 18%.
Basic EHR adoption among children’s and psychiatric hospitals is significantly lower than general medicine hospitals

Figure 3: Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system by hospital specialty

The figure 3 contains a bar chart that presents hospital EHR adoption among childrens, psychiatric, and general medicine hospitals for 2008 and 2015. In 2008, childrens, psychiatric, and general medicine hospitals had EHR adoption rate of 10%, 7%, and 12%, respectively. In 2015, the EHR adoption rate 55%, 15%, and 84% for childrens, psychiatric, and general medicine hospitals, respectively. In 2008, EHR adoption was significantly lower for psychiatric than for general medicine hospitals while in 2015, the rates were significantly lower among childrens and psychiatric than general medicine hospitals.

NOTE: *Significantly different from General Medicone (p<0.05). Children’s hospitals include general medicine and specialty hospitals.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

  • In 2015, while over 8 in 10 general medicine hospitals adopted a Basic EHR, a little over half of children’s hospitals adopted a Basic EHR and only 15% of psychiatric hospitals adopted a Basic EHR.
  • In 2008, there were no significant differences in Basic EHR adoption rates between children’s and general medicine hospitals; whereas, psychiatric hospitals were significantly lower than general medicine hospitals.
  • Between 2008 and 2015, adoption of Basic EHR doubled among psychiatric hospitals, increased five-fold for children’s hospitals, and increased seven-fold for general medicine hospitals.
For all states, at least 6 in 10 hospitals adopted a Basic EHR

Figure 4: Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system at the State-Level for years 2008, 2011, and 2015

This figure contains three heat maps of the United States: one for 2008, 2011, and 2015. Each describes the percentage of Basic EHR adoption rates for each state. The legend ranges include "Not Reliable Estimate," "0-19%", "20-39," "40-59%," "60-79%," and "80-100%." The maps show large increases in Basic EHR adoption by state from 2011 to 2015. 

maps

NOTES: Basic EHR adoption requires the EHR system to have at least a basic set of EHR functions, including clinician notes, as defined in Table A1. Estimates for states shaded gray did not meet the standards for reliability (NR). See the Table A2 for a complete list of 2008, 2011, and 2015 hospital adoption by state.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

  • In 2015, hospital Basic EHR adoption rates were above 65% across all states, whereas in 2008, all states had Basic EHR adoption rates at or below 22%.
  • In 2011, hospital adoption of Basic EHRs across a majority of states (n=28) was between 20 and 39%.
  • State-level hospital adoption of Basic EHR systems was 80% or higher in 35 states in 2015, whereas no states in 2011 had hospital Basic EHR adoption rates at 80% or higher.
Trends in EHR adoption show increasing use of advanced functionality

Figure 5: Percent of non-federal acute care hospitals with adoption of EHR systems by level of functionality: 2008 – 2015

This figure is a stacked bar chart describing the hospital adoption of EHR systems by type of system adopted. In 2008, 1.6% adopted comprehensive EHR systems, 7.8% adopted Basic EHR systems with notes, and 4.0% adopted Basic EHR systems without notes. The total was 13.4%. In 2009, 2.8% adopted comprehensive EHR systems, 9.4% adopted Basic EHR systems with clinician notes, and 3.9% adopted Basic EHR systems without clinical notes. The total was 16.1%. In 2010, 3.6% adopted comprehensive EHR systems, 12.0% adopted Basic EHR systems with clinical notes, and 3.5% adopted Basic EHR systems without clinical notes. The total was 19.1%. In 2011, 8.8% adopted comprehensive EHR systems, 18.8% adopted Basic EHR systems with clinical notes, and 7.2% adopted Basic EHR systems without clinical notes. The total was 34.8%. In 2012, 16.9% adopted comprehensive EHR systems, 27.5% adopted Basic EHR systems with clinical notes, and 11.5% adopted Basic EHR systems without notes. The total was 55.9%. In 2013, 25.7% adopted comprehensive EHR systems, 33.7% adopted Basic EHR systems with clinical notes, and 10.9% adopted Basic EHR systems without clinical notes. The total was 60.3%. In 2014, 34.4% adopted comprehensive EHR systems, 41.1% adopted Basic EHR systems with clinical notes, and 7.7% adopted Basic EHR systems without clinical notes. The total was 83.2%. In 2015, 40.0% adopted comprehensive EHR systems, 43.8% adopted Basic EHR systems with clinical notes, and 4.5% adopted Basic EHR systems without clinical notes. The total was 88.3%.All measures after 2008 except for the Basic EHR system without notes in 2013 were marked as significantly different from the previous year.

NOTES: Definitions of Basic EHR and Comprehensive EHR systems are reported in Table A1. *Significantly different from previous year (p<0.05).

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

  • In 2015, 8 out of 10 hospitals (84%) adopted EHRs with advanced levels of functionality above Basic EHRs without Clinician Notes; this refers to the adoption of Comprehensive EHRs (40%) and Basic EHRs with Clinician Notes (44 %).
  • While there was an 11% increase in the adoption of EHRs with advanced levels of functionality above Basic EHRs between 2014 and 2015, there was a 42% decrease in the use of less advanced EHRs (Basic without Clinician Notes functionality).
Summary

Adoption of EHRs among non-federal acute care hospitals is nearly universal. In 2015, nearly all reported hospitals (96%) possessed certified EHR technology. This rate is similar to 2014, suggesting that adoption of certified EHR systems may be plateauing. In 2015, over 8 in 10 non-federal acute care hospitals adopted all the functionalities associated with a Basic EHR; this represents a nine-fold increase since 2008, prior to the HITECH Act of 2009. Basic EHRs, a historical measure of EHR adoption, includes functionalities, such as viewing imaging results, which are not included in certified EHRs. Hospital adoption of EHRs with more advanced functionality is also increasing while adoption of EHRs with less advanced functionality is declining. Although EHR adoption rates differ depending upon the specific measure, both key measures of EHR adoption — certified EHRs and Basic EHRs — consistently show widespread adoption of EHRs.

Similar to national trends, EHR adoption is also widespread at the state-level. Basic EHR adoption was above 80% for 35 states in 2015; whereas no states in 2011 had basic EHR adoption rates at or above 80%. In 2008, all states had adoption rates of 22% or less. This change represents a substantial increase in EHR adoption at the state-level.

Certain types of hospitals that have traditionally lagged behind in EHR adoption, such as small, rural, and Critical Access hospitals are now closing the gap with other non-federal acute care hospitals (3). Although still significantly lower compared to all non-federal acute care hospitals, at least 8 in 10 of small, rural and Critical Access hospitals have adopted Basic EHRs. Between 2014 and 2015, Basic EHR adoption increased by at least 14% across small and rural hospitals and increased by 18% among Critical Access hospitals. However, compared to general medicine hospitals, children’s and psychiatric hospitals have substantially lower rates of Basic EHR adoption. This is not altogether surprising as only 69% of children’s hospitals successfully attested to Stage 1 of the CMS Medicaid EHR Incentive Program and psychiatric hospitals are not eligible for the CMS Medicaid or Medicare EHR Incentive Program (4).

In summary, EHR adoption is widespread across most hospitals and at the state-level. Efforts that have focused on EHR adoption now are shifting to interoperability of health information, and the use of health information technology to support care delivery system reform (1, 5). Realizing the full value of widespread EHR adoption will require focusing on these new challenges and it will be important to shift our focus from hospital adoption of EHRs to monitoring progress in these new areas. This would not only include hospitals’ interoperability but also examining health IT adoption and interoperability across additional settings including long-term care providers and behavioral health care providers, and beyond the care continuum, such as social services and public health (5).

Definitions

Non-federal acute care hospital: Includes acute care general medical and surgical, general children’s, and cancer hospitals owned by private/not-for-profit, investor-owned/for-profit, or state/local government and located within the 50 states and District of Columbia. The inclusion of children’s general and cancer hospitals makes this definition different from previous peer-reviewed research. However, it is more consistent with the population of hospitals eligible for federal health IT adoption incentives.

Adoption of Basic EHR: Table A1 defines the electronic functions required for hospital adoption of a Basic or Comprehensive EHR system, which a consensus expert panel established (2). Basic EHR adoption requires that each function be implemented in at least one unit in the hospital. However, Comprehensive EHR adoption requires that each function be implemented in all units. Because the panel disagreed on the need to include physician notes and nursing assessments to classify a Basic system, so they developed two definitions of Basic EHR adoption (Basic EHR without Notes and Basic EHR with Notes) (2). Since the first stage of the CMS EHR Incentive Program did not require clinician notes, an earlier brief reported Basic EHR without Clinician Notes. However, clinician notes are now a requirement for the second stage, the definition of Basic EHR in this brief includes clinician notes as a requirement for at least a Basic EHR system.

Possession of Certified EHR: A certified EHR is EHR technology that meets the technological capability, functionality, and security requirements adopted by the Department of Health and Human Services. This includes the capability to securely work with other certified EHR systems to share information (interoperability). “Possession” of certified EHR technology is considered to be either the physical possession of the medium on which a certified EHR system resides or a legally enforceable right by a health care provider to access and use, at its discretion, the capabilities of a certified EHR system.

Data Source and Methods

Data are from the American Hospital Association (AHA) Information Technology (IT) Supplement to the AHA Annual Survey. Since 2008, ONC has partnered with the AHA to measure the adoption and use of health IT in U.S. hospitals. ONC funded the 2015 AHA IT Supplement to track hospital adoption and use of EHRs and the exchange of clinical data.

The chief executive officer of each U.S. hospital was invited to participate in the survey regardless of AHA membership status. The person most knowledgeable about the hospital’s health IT (typically the chief information officer) was requested to provide the information via a mail survey or secure online site. Non-respondents received follow-up mailings and phone calls to encourage response. The survey was fielded from October 2015 to the end of February 2016.

This analysis consisted of non-federal, acute care hospitals, including children’s and cancer hospitals. Differences in the estimates in this brief from a prior study reporting Basic EHR adoption with clinician notes are due to the inclusion of children’s and cancer hospitals and small differences in the calculation of hospital-level weights.

The response rate for non-federal acute care hospitals was 56.15%. A logistic regression model was used to predict the propensity of survey response as a function of hospital characteristics, including size, ownership, teaching status, system membership, availability of a cardiac intensive care unit, urban status, and region. Hospital-level weights were derived by the inverse of the predicted propensity.

Estimates considered unreliable had a relative standard error adjusted for finite populations greater than 0.49. Responses with missing values were assigned zero values. Significant differences were tested using p < 0.05 as the threshold.

References

1. ‘Federal Health IT Strategic Plan 2015-2020,’ Office of the National Coordinator for Health Information Technology, 2014, page 2. Available at http://dashboard.healthit.gov/strategic-plan/federal-health-it-strategic-plan-2015-2020.php.

2. Blumenthal D, DesRoches CM, Donelan K, Ferris TG, Jha AK, Kaushal R, et al. Health Information Technology in the United States: The Information Base for Progress. Princeton, NJ: Robert Wood Johnson Foundation; 2006.

3. DesRoches CM, Worzala C, Joshi MS, Kralovec PD, Jha AK. “Small, Nonteaching, and Rural Hospitals Continue to be Slow in Adopting Electronic Health Record Systems.” Health Affairs. 31(5): 1092-1099; 2012.

4. Office of the National Coordinator for Health Information Technology. ‘Hospital Progress to Meaningful Use by Size, Type, and Urban/Rural Location,’ Health IT Quick-Stat #5. http://dashboard.healthit.gov/quickstats/pages/FIG-Hospital-Progress-to-Meaningful-Use-by-size-practice-setting-area-type.php. May 2016.

5. ‘Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap version 1.0,’ Office of the National Coordinator for Health Information Technology. Available at https://www.healthit.gov/policy-researchers-implementers/interoperability.

About the Authors

The authors are with the Office of the National Coordinator for Health Information Technology, Office of Planning, Evaluation, and Analysis.

Suggested Citation

Henry, J., Pylypchuck, Y., Searcy Y. & Patel V. (May 2016). Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2015. ONC Data Brief, no.35. Office of the National Coordinator for Health Information Technology: Washington DC.

Appendix

Appendix Table A1: Electronic Functions Required for Hospital Adoption of Basic or Comprehensiove EHR Systems

EHR Functions Required Basic EHR without Clinician Notes Basic EHR with Clinician Notes Comprehensive EHR
Electronic Clinical Information
Patient demographics ? ? ?
Physician notes ? ?
Nursing Assessments ? ?
Problem lists ? ? ?
Medication lists ? ? ?
Discharge Summaries ? ? ?
Advance directives ?
Computerized Provider Order Entry
Lab reports ?
Radiology tests ?
Medications ? ? ?
Consultation requests ?
Nursing orders ?
Results Management
View lab reports ? ? ?
View radiology reports ? ? ?
View radiology images ?
View diagnostic test results ? ? ?
View diagnostic test images ?
View consultant reports ?
Decision Support
Clinical guidelines ?
Clinical reminders ?
Drug allergy results ?
Drug-drug interactions ?
Drug-lab interactions ?
Drug dosing support ?

Appendix Table A2: Percent of non-federal acute care hospitals with adoption of at least a Basic EHR system by U.S. State, 2008, 2011, and 2015

State 2008 Basic EHR, % n(N) 2011 Basic EHR, % n(N) 2015 Basic EHR, % n(N)
Alabama 9% 34(99) 22% 44(95) 80% 35(87)
Alaska 0% 7(21) NR 13(22) 89% 9(20)
Arizona 14% 31(60) 17% 31(62) 78% 25(60)
Arkansas 9% 53(75) 32% 40(72) 90% 35(69)
California 9% 179(343) 22% 153(333) 85% 198(320)
Colorado 11% 41(70) 30% 42(72) 87% 46(72)
Connecticut 22% 24(31) 22% 22(30) 83% 21(28)
Delaware 0% 4(6) 39% 5(6) 67% 6(6)
District of Columbia NR 5(9) 37% 8(9) 85% 6(8)
Florida 11% 96(186) 51% 93(183) 87% 118(182)
Georgia 5% 78(140) 15% 53(139) 85% 70(129)
Hawaii NR 11(22) NR 9(23) 71% 7(22)
Idaho NR 24(39) 19% 24(39) 80% 18(38)
Illinois 9% 130(185) 35% 131(180) 87% 129(177)
Indiana 11% 70(106) 19% 66(107) 88% 61(105)
Iowa 2% 79(117) 35% 83(117) 82% 95(117)
Kansas 0% 76(122) 19% 102(123) 73% 99(125)
Kentucky 6% 67(97) 24% 58(98) 82% 46(94)
Louisiana 8% 58(108) 14% 48(101) 70% 58(99)
Maine 3% 29(36) 20% 24(36) 87% 22(34)
Maryland 16% 37(46) 28% 39(46) 95% 34(45)
Massachusetts 9% 35(71) 37% 39(67) 93% 32(60)
Michigan 14% 103(133) 31% 87(133) 85% 76(128)
Minnesota 17% 80(128) 44% 127(131) 88% 124(128)
Mississippi 8% 39(90) 17% 37(88) 86% 27(88)
Missouri 9% 69(113) 35% 113(113) 87% 109(110)
Montana 6% 33(54) 15% 31(54) 83% 36(53)
Nebraska 6% 50(83) 19% 52(84) 75% 52(85)
Nevada 0% 11(29) 36% 13(30) 94% 12(29)
New Hampshire 4% 23(26) 29% 14(26) 79% 18(26)
New Jersey 16% 40(66) 11% 41(63) 75% 42(62)
New Mexico 22% 16(31) 23% 16(29) 90% 20(32)
New York 11% 120(190) 26% 118(177) 82% 119(167)
North Carolina 11% 79(109) 24% 76(111) 86% 73(105)
North Dakota NR 20(42) NR 15(42) 89% 20(41)
Ohio 4% 115(157) 20% 96(158) 85% 111(152)
Oklahoma 15% 56(103) 14% 39(102) 87% 42(104)
Oregon 17% 30(57) 42% 25(58) 85% 42(59)
Pennsylvania 8% 111(163) 30% 109(158) 78% 101(153)
Rhode Island NR 6(11) 55% 9(11) 70% 7(10)
South Carolina 7% 39(59) 27% 24(57) 71% 32(60)
South Dakota 11% 47(51) 17% 27(51) 80% 27(49)
Tennessee 6% 61(114) 21% 49(116) 87% 51(109)
Texas 9% 215(346) 20% 175(349) 81% 203(331)
Utah NR 20(41) NR 8(41) 93% 25(44)
Vermont 15% 13(14) 45% 7(14) 65% 6(14)
Virginia 15% 52(80) 53% 40(79) 93% 53(80)
Washington 7% 46(85) 38% 51(85) 94% 50(90)
West Virginia 7% 38(50) 23% 27(50) 74% 30(48)
Wisconsin 10% 85(122) 47% 73(121) 83% 95(123)
Wyoming 10% 20(24) 21% 15(24) 94% 14(23)

NOTE: Basic EHR adoption requires the EHR system to have a set of EHR functions defined in Table A1. n = survey respondents; N = Non-Federal acute care hospitals surveyed. NR = estimate does not meet standards for reliability.

JaWanna Henry, MPH; Yuriy Pylypchuk, PhD; Talisha Searcy, MPA, MA; Vaishali Patel, PhD MPH

SOURCE: ONC/AHA, AHA Annual Survey Information Technology Supplement

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