EHR Adoption Report Is Both Positive and Murky

January 21, 2014

A new study from the Centers for Disease Control and Prevention (CDC) shows more and more physicians adopting electronic health record (EHR) systems, but provides a fuzzy forecast of how many will qualify in 2014 for a Medicare or Medicaid bonus for "meaningful use" of this technology.

"How many" is a burning question, because for many veteran participants in the meaningful-use program, the requirements have ramped up this year from Stage 1 to Stage 2, making it harder to earn a bonus. Among other things, physicians must now give patients the opportunity to communicate with them online through secure messaging. EHR systems themselves must be certified as meeting more rigorous Stage 2 specs, and there's anxiety in healthcare circles that software vendors aren't moving fast enough to upgrade their products.

The study released online last week by the CDC's National Center for Health Statistics (NCHS) otherwise reassures believers in EHRs and their potential to improve patient care and lower costs. In 2013, 78.4% of office-based physicians used some sort of EHR system, whether or not it satisfied the government's meaningful-use criteria, according to an NCHS survey conducted from February through June of last year. That level of adoption compares with just 18.2% in 2001.

The NCHS also looked at adoption of a subset of EHRs that it calls "basic." Meeting some but not all meaningful-use requirements, such systems automate the patient's history and demographics, problem list, clinical notes, and a list of medications and allergies. They also allow physicians to generate prescriptions and view lab and imaging results electronically. Here again, the trend line for digital medicine is encouraging — the percentage of physicians with basic EHRs increased from 10.5% in 2006 to 48.1% in 2013.

All these numbers represent good news, said Peter Basch, MD, who chairs the medical informatics committee of the American College of Physicians (ACP).

"The survey confirms that the use of EHRs has moved way past the tipping point," Dr. Basch told Medscape Medical News. "And we're also seeing improvement in functional capabilities. While it's not perfect, it's moving in the right direction, and moving pretty quickly."

State Laggards and Leaders

Although the percentage of physicians with basic EHR systems has grown dramatically since 2006, some states lagged significantly behind the national average for adoption in 2013.

Table. States With Lowest Physician Adoption Rate of Basic EHRs

State Percentage of Office-Based Physicians With a "Basic" EHR System1
New Jersey 21.2%
Connecticut 30.1%
Washington, DC 31.0%
Nevada 33.0%
West Virginia 36.9%
Oklahoma 36.9%
Vermont 37.0%
Wyoming 37.1%
Maryland 37.1%

1 Systems defined as basic meet some but not all of the requirements for a program to be certified for Stage 1 or Stage 2 meaningful use.

Source: National Center for Health Statistics, CDC.


Other states were way out in front in terms of converting to electronic charts.

Table. States With Highest Physician Adoption Rate of Basic EHRs

State Percentage of Office-Based Physicians With a "Basic" EHR System
North Dakota 82.9%
Minnesota 75.5%
Massachusetts 70.0%
Wisconsin 67.9%
Iowa 65.5%
Utah 65.5%
Oregon 64.9%
Washington 60.6%
South Dakota 58.1%

Source: National Center for Health Statistics, CDC.

No Stage 2-Certified EHRs On Scene When Survey Taken

When the NCHS surveyed physicians about EHR usage in the first half of 2013, it also attempted to assess their readiness to satisfy Stage 2 requirement in the government's meaningful-use program. It's not an academic question for physicians. At stake is a maximum bonus of $44,000 over 5 years through Medicare or almost $64,000 over 6 years through Medicaid. And in 2015, physicians will suffer a 1% cut in Medicare pay if they failed to achieve meaningful use in either 2013 or 2014, depending on their past participation in the program. The penalty grows to 2% in 2016, and 3% in 2017 and beyond.

The meaningful-use program began in 2011 with physicians initially subject to Stage 1 criteria. Those who qualified for a bonus for at least 2 years under Stage 1 must graduate to the more rigorous Stage 2 requirements this year. Failure to satisfy them — the reporting period is only a single quarter — means a penalty in 2016. Physicians who achieved Stage 1 meaningful use for the first time in 2013 will stay on this level in 2014, and won't come under Stage 2 until 2015.

Stage 3 requirements debut in 2017 for physicians who have aced Stage 2 for at least 2 years.

To earn a bonus for Stage 2 meaningful use, a physician must achieve 17 "core objectives," some of which carried over from Stage 1. These objectives include generating and transmitting prescriptions electronically, providing clinical summaries to patients for each office visit, and having the capability of sending patient data to immunization registries and information systems. There are 6 additional "menu set" objectives; physicians must knock off any 3 of these.

The NCHS asked physicians in the first half of 2013 whether they intended to participate in the meaningful-use program. Sixty-nine percent of office-based physicians answered "yes." That group included those who had already applied to the program as well as those who planned to apply.

The NCHS didn't ask if a physician had an EHR system that was certified for Stage 2 meaningful-use because they couldn't — Stage 2 systems weren't even on the market then. Instead, the NCHS asked physicians whether their software had any of 14 capabilities that closely corresponded to 14 of the 17 core objectives of Stage 2.

Thirteen percent of physicians told the NCHS that yes, they were going to try to earn a meaningful-use bonus, and yes, their software did all 14 things the survey asked about. Conversely, 56% said they were going to participate in the program but that they lacked systems that could help them achieve 14 of the 17 core objectives.

Meaningless Meaningful-Use Data?

To Jason Mitchell, MD, the EHR guru of the American Academy of Family Physicians (AAFP), the inquiry into Stage 2 readiness in early 2013 amounts to a "weird question," given the unavailability of EHR systems certified for that level back then.

"I don't think this [survey] is representative of how well people are prepared to enter Stage 2," said Dr. Mitchell, director of the AAFP's Center for Health IT, in an interview with Medscape Medical News. "It's not a good extrapolation."

The numbers received a rosier interpretation, though, from the point person for digital medicine in the US Department of Health & Human Services (HHS). Karen DeSalvo, MD, MPH, the new National Coordinator for Health Information Technology at the HHS, described the 13% of meaningful-use seekers whose systems were mostly Stage 2-compliant, as "early adopters who recognize the benefits of EHRs."

"Overall, we are encouraged that physician adoption of EHRs meeting Meaningful Use Stage 2 is increasing significantly," she blogged last week.

Also encouraging, said Dr. DeSalvo, is rising adoption of any sort of EHR system, and those systems defined as basic. Healthcare information technology consultant Ronald Sterling, however, responds to these trends with the question "What's the point?"

"The key issue is whether you're using a certified system or not," said Sterling, president of Sterling Solutions in Silver Spring, Maryland, in an interview with Medscape Medical News. "Anyone that is not using a certified system is not in a good position."

As of January 20, the Office of the National Coordinator for Health Information Technology listed 326 products — 93 complete EHR systems and 233 modular components — that are certified for Stage 2. In contrast, a combination of 3714 systems and modules are certified for Stage 1.

Physicians under the gun to achieve Stage 2 meaningful use in 2014 can do so during any quarter of the year, which means they can wait until October 1 to get started. Healthcare information technology experts such as Dr. Mitchell and the ACP's Dr. Basch said they hope that more vendors can roll out Stage 2-certified EHR systems and modules in time for clinicians to pass the test in the year's final quarter, if not sooner.


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