Is health IT reaching a plateau?

EHR adoption is rising among doctors and hospitals, but waning interest in meaningful use incentives indicates that some practices may not fully implement the technology.

By — Posted July 22, 2013

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There's been no lack of evidence backing up assertions by the Office of the National Coordinator for Health Information Technology that the meaningful use incentive program to date is having the intended impact on health IT adoption. But some health professionals are questioning whether the current path will get the nation to full adoption of electronic health records.

Three reports on health IT adoption published online July 9 in Health Affairs show that the adoption of EHRs among office-based physicians jumped from 51% in 2010 to 72% in 2012. The biggest gains were seen among doctors in small and rural practices and community health centers — settings which have historically had low adoption rates.

Researchers also found that 44% of hospitals had at least a basic EHR system in 2012, nearly triple the rate in 2010. A study in the series found a steady growth in participation in health information exchanges, with 30% of hospitals and 10% of ambulatory practices participating in one of the 119 operational HIEs across the country.

The progress has been good, the authors of the studies said. But a deeper look at the data reveals the health IT gold rush may be coming to an end.

Experts say without new strategies, a completely connected health care system may be more difficult than many imagined.

More than half of all hospitals, for instance, do not have at least a basic EHR system. And even though 72% of practices say they have adopted some type of EHR, only 40% of those had systems with enough functions to be considered basic. An EHR must have seven core functions to meet basic requirements and 15 functions to qualify for stage 1 of the meaningful use incentive program.

Although there's been growing interest in HIEs, the future of those organizations is at risk because the majority do not have a sustainable business model and 74% are unsure how they will continue when federal funding stops.

A recent analysis of meaningful use attestation data by the American Academy of Family Physicians added to concerns about the future of health IT. The academy revealed a significant dropout rate of about 20% of physician practices that attested to meaningful use in 2011 but did not return to the program in 2012.

Jason Mitchell, MD, director of the AAFP's Center for Health IT, said the dropout rate is a concern, considering the required measurements for the program did not change from 2011 to 2012. Only the length of the reporting period changed.

Although those practices could return in 2013, they will not only have to meet stage 1 requirements for the 2013 calendar year, they also must prepare for stage 2, which starts in 2014 for early adopters.

“Moving to stage 2 will be a heavy lift,” Dr. Mitchell said. “We're talking about major upgrades to systems and adding major functionalities to systems.” He said some of the functionalities that will be required, such as patient portals, are new to the market. Because they haven't been proven, physicians are apprehensive about adopting them.

Reasons for the drop-off

20% of family physician practices that attested to meaningful use in 2011 dropped out of the program in 2012.

As the meaningful use program moves ahead, financial incentives for adopting new processes in the practice will not be nearly as high as they were in the beginning. The annual Medicare incentive, which started at $18,000 for the first year, drops to $4,000 by the fourth year.

The AAFP's analysis looked at only practices participating in the Medicare program. The dropout rate from the Medicaid program, especially from stage 1 to stage 2, could be even higher because stage 1 requires only attesting that an EHR can perform certain functions, not that it's in use.

“I think what we're going to have is general progress over the next year or two,” said Ashish K. Jha, MD, MPH, who was involved with all three Health Affairs studies on health IT. Then, “we're probably going to start hitting a wall.”

Implementation projects in the works will continue, but there also will be more doctors who leave the program, said Dr. Jha, professor of health policy and management at Harvard School of Public Health in Boston. Some may come back, others may not. Some will make no progress at all, he said.

“We're probably going to get to 60%, 70% or maybe 80% [in EHR adoption], at which point we're going to kind of top off and we're going to have a group of providers, both on the outpatient side as well as the hospitals, that are really going to struggle,” Dr. Jha said.

He said even 80% adoption would be a problem, because that would leave many patients who go to a hospital with no care coordination between the hospitals and their primary care doctors.

Dr. Jha said he has been talking with the ONC and leaders in Congress about the need to develop a strategy to address further decline.

Before developing a strategy, the Centers for Medicare & Medicaid Services attempted to define the source of the problem by surveying the practices that did not come back for a second year of the meaningful use program.

In a presentation to CMS' HIT Policy Committee on July 9, Robert Anthony, deputy director of the HIT Initiatives Group at CMS' Office of E-Health Standards and Services, presented findings of the survey from among the roughly 10,000 eligible health professionals who didn't return to the program.

Half of the respondents cited only one reason for dropping out of the program, such as switching to a practice without an EHR.

The other half gave multiple reasons, including not having the time, missing the deadline and waiting for stage 2 information. Thirty-two percent of those respondents said the program was too complicated, and 25% could not meet one or more objectives.

Steps to get back on course

Dr. Mitchell said it's possible the 12-month reporting period for the second year of meaningful use was too much for some practices. The reporting period was only 90 days in 2011. Physicians didn't have to do anything differently, such as adopt new EHR functions, in the second year, but they lost the opportunity to adjust the start date if measurements couldn't be met.

To ensure they have met requirements for a full 12-month period, practices should constantly monitor and run reports, he said.

Practices had to undergo significant workflow changes, implementation headaches and process changes to qualify for the first year of stage 1. It's possible, after the 90-day reporting period, that some practices may have fallen back into old habits.

“The way that meaningful use is set up, you don't have to slide back very far for you to have lost the whole opportunity,” Dr. Mitchell said.

It will become even more difficult in stage 2 as all of the menu objectives that physicians choose from for stage 1 become required for everyone, he said. The AAFP has advocated for CMS to change the program from an all-or-nothing setup and possibly create mechanisms for partial payments for practices that cannot meet 100% of the objectives.

The American Medical Association also has called for more leniency in the meaningful use program.

“We firmly believe that unless more flexibility is infused into stage 2 requirements of [meaningful use] that many physicians — including physicians who have already received incentives under stage 1 — will be unable to meet them and, as a result, we will fail to meet our shared goal of widespread adoption and use of electronic health records,” wrote AMA Executive Vice President and CEO James L. Madara, MD, in a June 14 letter to Kathleen Sebelius, secretary of the Dept. of Health and Human Services.

Even if physicians aren't motivated by the meaningful use program, Dr. Mitchell believes some practices will continue to embrace technology as they prepare for a shift to value-based care.

“I don't think that meaningful use is the only incentive, or the only way, to get physicians to use improved information management tools and to focus on care coordination and improved communication across the health care system,” Dr. Mitchell said.

Dr. Jha said the shift to value-based care will stoke physician interest in HIEs.

Policymakers are doing what they can to help health information exchanges, he said, by creating interoperability standards and making them part of the meaningful use criteria. “But ultimately, people will exchange clinical data when there is a compelling business need to do so and that is not something ONC can make happen. That's something that payers are going to have to do,” Dr. Jha said.

At a July 9 briefing to release the Health Affairs studies, Farzad Mostashari, MD, national coordinator for health IT, acknowledged there was a lot of work to be done. “This is not a sprint,” he said. “This is a marathon.”

Along the way, it's important to take note of the milestones that will inform future strategies, he said.

“It's OK to level all sorts of constructive criticisms and concerns and issues about our implementation of the [meaningful use] program,” he said. “But one thing I'll take issue with is that meaningful use is easy, that it was a 'gimme.' … This has been extremely hard work.”

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Reasons for not returning to the meaningful use program

The Centers for Medicare & Medicaid Services surveyed eligible health professionals who participated in the meaningful use incentive program in 2011 but did not return in 2012.

Half of the respondents cited only one reason for dropping out of the program.
Factor for nonreturn % who were impacted
Did not meet deadline 28%
Switched to practice without EHR 17%
Retired 5%
The other half gave multiple reasons.
Factor for nonreturn % who were impacted
Changed to different EHR system 6%
Program does not fit medical specialty 9%
Too expensive to invest and maintain 10%
Problem/dissatisfaction with EHR vendor 15%
Could not meet one or more objectives 25%
Too complicated 32%
Waiting for stage 2 information 35%
Too time-consuming 36%
Intended to attest, missed deadline 37%

Note: Percentages do not add up to 100% because respondents could pick all the factors that applied to them.

Source: Medicare & Medicaid EHR Incentive Programs, HIT Policy Committee presentation, Centers for Medicare & Medicaid Services, July 9 (link)

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More office-based physicians embrace meaningful use

Adoption of electronic health record systems among office-based physicians has significantly increased since 2010, thanks to the meaningful use incentive program, but officials say there's still a lot of work to be done. Although 72% of office-based physicians said they had some sort of EHR system, only about 40% had systems with enough functionality to at least meet the definition of a “basic EHR system.”

Group with at least a basic EHR 2010 adoption rates 2012 adoption rates
All office-based physicians 25.8% 38.2%
Primary care 29.8% 42.5%
Other 22.0% 34.0%
Solo practices 11.3% 25.6%
Practices with 2-5 physicians 26.0% 36.6%
Practices with 6-10 physicians 29.7% 44.0%
Practices with 11 or more physicians 45.0% 57.7%

Source: “Office-Based Physicians Are Responding To Incentives and Assistance by Adopting and Using Electronic Health Records,” Health Affairs, published online July 9 (link)

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External links

Medicare & Medicaid EHR Incentive Programs, HIT Policy Committee presentation, Centers for Medicare & Medicaid Services, July 9 (link)

“Operational Health Information Exchanges Show Substantial Growth, But Long-Term Funding Remains A Concern,” Health Affairs, published online July 9 (link)

“Adoption Of Electronic Health Records Grows Rapidly, But Fewer Than Half Of US Hospitals Had At Least A Basic System In 2012,” Health Affairs, published online July 9 (link)

“Office-Based Physicians Are Responding To Incentives And Assistance By Adopting And Using Electronic Health Records,” Health Affairs, published online July 9 (link)

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