After languishing in the single digits for many years, hospital EHR adoption rates are dramatically increasing. A major driver is the Medicare and Medicaid EHR Incentive Programs, or the “Meaningful Use” program. A recent Health Affairs study suggested hospital participation in the program was lagging. In this post, we report the latest data, which paint a different picture — as of July 2013, two-thirds of hospitals have achieved Stage 1 Meaningful Use, and nearly all are engaged with the program in some way.
The incentive programs were designed to support greater adoption and use of EHRs, with the ultimate goal of improving patient care and health system outcomes. Eligible hospitals have received $9 billion in incentive payments since the programs began in 2011. Starting in 2015, eligible hospitals that do not demonstrate Meaningful Use will be subject to Medicare payment penalties. Beyond the Meaningful Use incentives, the extent to which hospitals are able to adopt and use health IT will have implications for their ability to successfully participate in new payment and delivery models and to improve care and outcomes.
Given the stakes and the rapidly changing landscape, regularly tracking progress towards widespread EHR adoption and use is important. New hospitals join the ranks of those who have achieved Meaningful Use each month, and important program milestones are near. To receive the maximum possible Medicare incentive amount, hospitals must achieve Meaningful Use Stage 1 by the end of 2013. Providers that achieved Stage 1 by the end of 2012 will move to Meaningful Use Stage 2 in 2014.
Here, we present the most recent trends in hospital engagement with the EHR incentive programs, assessing participation overall and whether all types of hospitals are moving forward at the same pace. We include data from both the Medicare and Medicaid EHR Incentive Programs and the Office of the National Coordinator for Health IT (ONC) Regional Extension Center program, which is providing technical assistance to Critical Access Hospitals and small rural hospitals that are working toward Meaningful Use.
Overall, what are the latest trends in hospital progress towards Meaningful Use?
As of July 2013, two-thirds of hospitals had successfully achieved Stage 1 Meaningful Use, and an additional 16 percent had received Medicaid incentive payments for adopting certified EHR technology (Figure 1). When viewed as a share of acute care hospital beds or discharges, Meaningful Use attainment was even more widespread.
Of the remaining 17 percent of hospitals that had not yet qualified for an incentive payment, more than half had either registered for the Medicare or Medicaid EHR Incentive Programs or enrolled with a Regional Extension Center, demonstrating awareness of the incentive programs and signaling they are working towards Meaningful Use.
Figure 1. Progress towards Meaningful Use among eligible hospitals as of July 2013
This represents remarkable growth in the share of hospitals that have achieved Meaningful Use, from 17 percent at the end of 2011 to 53 percent at the end of 2012 to 67 percent midway through 2013 (Figure 2). In 2011 and 2012, there were surges in the number of new hospitals achieving Meaningful Use near the November reporting deadline; it is likely there will be another surge at the end of 2013.
Figure 2. Trend in percent of hospitals achieving Meaningful Use and percent of hospitals not yet participating in EHR Incentive Programs or REC Program
These figures reflect the number of hospitals that have successfully attested to meeting Meaningful Use requirements and have therefore qualified for an incentive payment. There is a lag between successful attestation and receipt of the associated incentive payment. Therefore, publicly available data on hospitals that have received payment at a given point in time (reported in the recent Health Affairs paper) do not accurately capture the number of hospitals that have successfully attested at that same point in time, which we report here and in another recent paper. (As required by HITECH, the Center for Medicare and Medicaid Services publishes a list of hospitals that have received Medicare incentive payments for attesting to Meaningful Use on a quarterly basis.)
Are all types of hospitals achieving Meaningful Use at the same pace?
Differences by size and location?
Prior to HITECH, data suggested that small hospitals and rural hospitals faced resource constraints and other barriers that led to low rates of EHR adoption. Policies and programs were put into place to address these challenges; for example, ONC Regional Extension Centers received funding dedicated to assisting Critical Access Hospitals and other small rural hospitals with achieving Meaningful Use. Since HITECH, we have continued to track progress by hospital size and location to assess whether these hospitals have been able to catch up and keep pace going forward.
To date, the highest rates of Meaningful Use achievement have been among small rural hospitals (76 percent) and medium (72 percent) and large (77 percent) hospitals (Figure 3). Relative to these leaders, rates were slightly lower among Critical Access Hospitals (61 percent) and small urban hospitals (56 percent). The Meaningful Use attainment gap between Critical Access Hospitals and the leading hospitals (medium, large, and small rural) narrowed substantially at the end of the 2012 reporting period, but has slightly widened over the first half of 2013. Nearly all Critical Access Hospitals (97 percent) are either registered with the Medicare or Medicaid EHR Incentive Programs or engaged with a Regional Extension Center (Table 1), suggesting they are working toward Meaningful Use and may make another surge in Meaningful Use attainment at the end of 2013.
Figure 3. Trend in hospitals attesting to Meaningful Use by hospital size, type, and rural/urban location
Source: ONC analysis of data from the Medicare and Medicaid EHR Incentive Programs and the Regional Extension Center program matched to data from the 2011 AHA Annual Survey. Note: Small is less than 100 beds; Medium is 100-399 beds; Large is 400 or more beds. Rural is non-metropolitan; urban is metropolitan.
Differences by safety net status?
Prior to HITECH, data also suggested that hospitals serving a large proportion of low income patients lagged in adoption of EHRs. However, as of July 2013, there were no differences in Meaningful Use achievement by hospital safety net status (as measured by Disproportionate Share Hospital (DSH) Index) (Table 1). Moreover, over 90 percent of hospitals in the highest DSH Index quartile had qualified for an EHR incentive payment, either by achieving Meaningful Use or adopting certified EHR technology.
Differences by other characteristics?
There were few differences in rates of Meaningful Use achievement based on other key hospital characteristics including ownership, system membership, or teaching status (Table 1). The one notable difference was lower Meaningful Use achievement among hospitals in the West compared to other regions.
Table 1. Progress towards Meaningful Use by hospital characteristics as of July 2013
Source: ONC analysis of data from the Medicare and Medicaid EHR Incentive Programs and the Regional Extension Center program matched to data from the 2011 AHA Annual Survey and Medicare Cost Reports. Note: Categories are hierarchical and mutually exclusive. MU is Meaningful Use; AIU indicates hospitals that have received Medicaid incentive payment for adopt/implement/upgrade to certified EHR; REC is Regional Extension Center; DSH is disproportionate share hospital. Small is less than 100 beds; Medium is 100-399 beds; Large is 400 or more beds. Rural is non-metropolitan; urban is metropolitan.
Midway through 2013, nearly two-thirds of hospitals have achieved Stage 1 Meaningful Use, including over half of hospitals across all the key subgroups we examined here. Small numbers of non-participants suggest that the remaining one-third of hospitals are working to achieve Meaningful Use. However, these remaining hospitals are likely facing a more challenging road to EHR adoption and Meaningful Use.
Key to the programs’ success is that hospitals continue to expand how they use EHRs to improve patient care and demonstrate this by achieving future stages of Meaningful Use. Just over half (53 percent) of hospitals were able to achieve Stage 1 Meaningful Use by 2012; these hospitals will lead the transition to subsequent stages of Meaningful Use as well, moving to Stage 2 in 2014 and Stage 3 in 2016. This group contains roughly six in ten large (61 percent), medium (57 percent), and small rural (59 percent) hospitals; about half of Critical Access Hospitals (51 percent); and a minority of small urban hospitals (43 percent). All remaining hospitals that achieve Stage 1 in 2013 or after will move to subsequent stages of Meaningful Use at later points in time (i.e., Stage 2 in 2015 or after and Stage 3 in 2017 or after).
It is critical to continue monitoring whether hospitals make it across the finish line and to make certain those who stumble near the end have the necessary support to keep moving forward. By making sure all hospitals are able to achieve Meaningful Use — Stage 1 and beyond — the nation will move closer to ensuring all patients are receiving the high quality health care that is enabled by EHRs.