Change in Adoption of Electronic Health Records by
US Children
’
s Hospitals
WHAT’S KNOWN ON THIS SUBJECT: Electronic health record (EHR) uptake by US hospitals has been slow, including among
children’s hospitals. The Health Information Technology for
Economic and Clinical Health program, which began in 2011, offers incentives for adoption and meaningful use of EHRs.
WHAT THIS STUDY ADDS: Using an annual survey, we evaluated
how children’s hospitals have progressed in EHR adoption from
2008 through the start of the Health Information Technology for Economic and Clinical Health program and assessed their ability to meaningfully use EHRs.
abstract
OBJECTIVES:To assess electronic health record (EHR) adoption and meaningful use among US children’s hospitals through 2011 and compare these outcomes with adult hospitals and among subgroups of children’s hospitals. We hypothesized that children’s hospitals would show progress since our initial evaluation of health informa-tion technology (HIT) implementainforma-tion in 2008.
METHODS: We identified children’s hospitals using the membership directory of the Children’s Hospital Association and analyzed their responses from 2008 to 2011 to the American Hospital Association’s annual HIT survey. EHR adoption rates were determined by using previously specified definitions of the essential functionalities com-prising an EHR. Achievement of meaningful use was evaluated based on hospitals’ ability to fulfill 12 core meaningful use criteria. We compared these outcomes in 2011 between children’s and adult hos-pitals and among subgroups of children’s hospitals.
RESULTS: Of 162 children’s hospitals, 126 (78%) responded to the survey in 2011. The proportion of children’s hospitals with an EHR increased from 21% (in 2008) to 59% (in 2011). In 2011, 29% of children’s hospitals met the 12 core criteria in our meaningful use proxy measure. EHR adoption rates and meaningful use were signif-icantly higher for children’s hospitals than for adult hospitals as a whole but similar for children’s and adult major teaching hospitals. Among children’s hospitals, major teaching hospitals were signifi -cantly more likely to have an EHR.
CONCLUSIONS:Children’s hospitals have achieved substantial gains in HIT implementation although minor teaching and nonteaching insti-tutions are not keeping pace.Pediatrics2013;131:e1563–e1575 AUTHORS:Mari M. Nakamura, MD, MPH,a,bMarvin B.
Harper, MD,a,c,dand Ashish K. Jha, MD, MPHe,f,g
aDivision of Infectious Diseases,bDivision of General Pediatrics, andcDivision of Emergency Medicine, Department of Medicine, anddInformation Services Department, Boston Children’s Hospital, Boston, Massachusetts;eDepartment of Health Policy and Management, Harvard School of Public Health, Boston Massachusetts;fDivision of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; andgVeterans Affairs Boston Healthcare System, Boston, Massachusetts
KEY WORDS
electronic health records, pediatric hospitals
ABBREVIATIONS
CHA—Children’s Hospital Association CPOE—computerized provider order entry EHR—electronic health record
EMRAM—Electronic Medical Record Adoption Model HIT—health information technology
HITECH—Health Information Technology for Economic and Clinical Health
Dr Nakamura conceptualized and designed the study, carried out the analyses and interpreted the studyfindings, and wrote the manuscript; Dr Harper interpreted the studyfindings and reviewed and revised the manuscript; Dr Jha conceptualized and designed the study, interpreted the studyfindings, and reviewed and revised the manuscript; and all authors approved thefinal manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-2904
doi:10.1542/peds.2012-2904
Accepted for publication Jan 4, 2013
Address correspondence to Mari M. Nakamura, MD, MPH, Division of Infectious Diseases, 300 Longwood Avenue, Enders 7, Boston, MA, 02115. E-mail: mari.nakamura@childrens.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE:The authors have indicated they have nofinancial relationships relevant to this article to disclose.
Improving pediatric health care quality is a national policy priority. Under the 2009 Children’s Health Insurance Pro-gram Reauthorization Act, a Pediatric Quality Measures Program was estab-lished and charged with defining evidence-based quality measures for use by Medicaid and the Children’s Health Insurance Program, which to-gether cover nearly 40 million chil-dren.1–3 The success of efforts to
measure and improve quality will de-pend on the presence of a robust in-formation infrastructure. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act tries to make this infrastructure a reality by creating financial incen-tives for physicians and hospitals to adopt and meaningfully use electronic health records (EHRs).4
EHRs facilitate delivery of high-quality care.5They allow collection of data
re-quired to evaluate care processes and outcomes and provide feedback on performance.6 EHRs aid providers
in organizing and integrating infor-mation, safely managing medications and other interventions, and making decisions guided by evidence and pa-tient preferences.7–9 Such support is
vital for the care of pediatric patients, whose health conditions and needs vary widely by age and developmental stage.10,11 Recognizing that providers
at children’s hospitals, which serve an increasingly complex, chronically ill population, wouldfind EHRs especially useful,12 policymakers ensured that
pediatric providers and hospitals were eligible for incentives under HITECH through state Medicaid programs.13
We previously found that in 2008, the year before the passage of HITECH, few children’s hospitals possessed EHRs: only 3% of hospitals had a comprehen-sive EHR system, while an additional 18% had a basic system.14We are
un-aware of any data on how adoption rates among children’s hospitals have
changed since HITECH was passed. Given the importance of EHRs as a tool to advance the broader quality agenda within pediatrics, understanding how these hospitals have fared under HITECH is critical. We therefore sought to answer 4 questions: (1) How have EHR adoption rates changed among children’s hospitals between 2008 and 2011? (2) How are children’s hospitals performing on metrics of meaningful use? (3) How do children’s hospitals compare with adult hospitals in EHR adoption and meaningful use? (4) Are subgroups of children’s hospitals fall-ing behind in EHR adoption?
METHODS
Survey Development and Administration
Development of the survey, which is administered by the American Hospital Association, was described previously.15
Since 2008, the survey has been sent annually, both online and by mail, to the chief executive officers of all US hospi-tals, who typically assign it to their most knowledgeable staff members (usually the chief information officer or equiva-lent). Nonresponding hospitals are en-couraged to participate via multiple mailings and telephone calls. The survey analysis was considered exempt from human subjects review by the in-stitutional review boards of Boston Children’s Hospital and the Harvard School of Public Health.
Identification of Children’s Hospitals
We identified children’s hospitals among the survey respondents using the Children’s Hospital Association (CHA) member directory. Among the 162 general acute care hospitals in our primary study population, there were 42 freestanding children’s hospitals; 76 nonfreestanding hospitals, referred to as “children’s hospitals within hos-pitals”; and 44 associate hospitals,
a membership category requiring a minimum daily pediatric census of 45, pediatric graduate education program, and recognition as a pediatric referral center.16We also performed a
second-ary analysis of EHR adoption that in-cluded CHA specialty hospitals (ie, those that care for specific conditions such as burns, orthopedic conditions, or neu-rologic conditions) and rehabilitation hospitals. Each institution received a single annual survey.
Survey Content
Questions assessed adoption of 24 in-dividual clinical EHR functionalities (Appendix Table 1), with implementa-tion measured as (1) not planned, (2) being considered or planned within the next year, (3) begun in at least 1 unit, (4) complete in at least 1 unit, or (5) complete across all units. Starting in 2010, the survey also included ques-tions addressing the criteria hospitals must meet to achieve“meaningful use” under the EHR incentive program (Ap-pendix Table 2).
EHR Definitions
We used the same definitions of basic and comprehensive EHR systems used in previous studies, thereby allowing for assessment of adoption trends over time and comparisons between child-ren’s and adult hospitals. These defi -nitions incorporate functionalities that are considered universally important to clinical care, including within pedi-atrics.11,17 A basic EHR must include
Achievement of Meaningful Use
To achieve meaningful EHR use under stage 1 of the EHR incentive program, hospitals must fulfill 14 core criteria, as well as at least 5 of 10 additional measures called menu criteria.13
Be-cause many functionalities required for meaningful use differ from those required for a basic or comprehensive EHR, we evaluated meaningful use separately from EHR adoption, focusing on 12 meaningful use criteria that were well addressed by survey questions. The full list is provided in the accom-panying Appendix (Appendix Table 2). These 12 criteria have been used pre-viously to create a“proxy”measure for a hospital’s ability to meet the mean-ingful use standards.18
Analysis
We compared characteristics of child-ren’s hospitals that responded and did not respond to the survey. Although we found no significant differences, we used a logistic regression model with hospital characteristics as covariates to predict each hospital’s likelihood of responding to the survey. Sub-sequently, as is convention, we used the inverse of these propensity values as weights to correct for potential nonresponse bias in all analyses.
To measure EHR adoption progress from 2008 to 2011, we calculated adoption rates for basic and compre-hensive EHRs during each year. Ques-tions used to assess EHR adoption remained consistent across all 4 years of the survey. To analyze meaningful use achievement, we calculated the pro-portion of hospitals that could meet each of the 12 core meaningful use criteria assessed by the survey and the proportions satisfying fewer criteria. We focused on full implementation across all hospital units for the mean-ingful use analysis because children’s hospitals within hospitals and associate hospitals did not complete a separate
survey from their parent institutions, preventing us from being certain that instances of partial adoption (ie, in at least 1 but not all units) included pedi-atric units. Because questions about many of the meaningful use function-alities were not asked until the 2010 survey, we assessed progress in meaningful use by determining the change from 2010 to 2011 in the pro-portion of hospitals fulfilling all 12 core measures.
We also assessed implementation in 2011 of 6 EHR functionalities considered to be likely to have an impact on quality of care,194 of which are included in the
meaningful use criteria and 2 are not. We again focused on comprehensive adoption (ie, implementation across all units) of these functionalities for the reason stated previously.
Next, we gauged rates of EHR adoption and meaningful use by children’s hos-pitals against those of adult hoshos-pitals. Adult hospitals were identified among survey respondents as those that de-scribed their primary service as“ gen-eral medical and surgical” and were not CHA members. We compared children’s and adult hospitals overall, but because children’s hospitals are predominantly teaching institutions and teaching status is known to predict EHR adoption,18,20 we also specifically
compared children’s and adult major teaching hospitals. “Major teaching hospital”is defined for all hospitals by membership in the Council of Teaching Hospitals and Health Systems.
Last, to determine whether subgroups of children’s hospitals lag behind oth-ers in HIT adoption, we used multivar-iate logistic regression to evaluate how 5 hospital characteristics (type of children’s hospital, size, region, own-ership, and teaching status) relate to EHR adoption or achievement of meaningful use.
We used the t test and logistic re-gression for bivariate analyses and
logistic regression for multivariate analyses. A 2-sidedP,.05 was used as the criterion for statistical signifi -cance.
RESULTS
Survey Respondents
Of 162 general acute care CHA hospitals surveyed in 2011, 126 (78%) responded. Respondents and nonrespondents did not differ significantly in teaching sta-tus, size, geographic region, ownership, or children’s hospital type (Appendix Table 3). Consistent with the overall composition of general acute care children’s hospitals, all but 2 respon-dents were teaching institutions, with three-quarters categorized as major teaching hospitals. Three-quarters were large. One-quarter of hospitals were freestanding, and half were children’s hospitals within hospitals.
EHR Adoption
The proportion of children’s hospitals with either a basic or comprehensive EHR increased from 21% in 2008 to 59% in 2011 (Fig 1A). Inclusion of specialty and rehabilitation hospitals did not substantively change the results (2011 adoption rate for any EHR: 57%). Gains in overall EHR adoption rates were steady, with increases of ∼16% from 2008 to 2009 and 11% in each sub-sequent year. Over the 3-year period, the comprehensive EHR adoption rate increased from 3% to 19%, whereas the basic EHR adoption rate increased from 18% to 40%.
Meaningful Use
(87%), a clinical decision support rule (86%), medication lists (85%), and key demographics (85%) (Appendix Table 4).
Among hospitals achieving 9 to 11 cri-teria in 2011, the functionalities most often lacking were quality measure
reporting, drug-drug and drug-allergy interaction checks, and problem lists (Appendix Table 4).
Adoption of Individual EHR Functionalities
When we examined adoption of 6 clin-ically important EHR functionalities, we observed that comprehensive imple-mentation rates varied among func-tionalities (Fig 3). The adoption rate for physician notes (40%), a functionality not included in the meaningful use criteria, was significantly lower than for CPOE for medications (68%) and 3 types of clinical decision support (56% to 66%), all of which are meaningful use functionalities (P #.001). Like-wise, the adoption rate for bar coding for drug administration (48%), an-other functionality not included in the meaningful use criteria, was signifi -cantly lower than for CPOE for medi-cations and 2 of the types of clinical decision support (P#.02).
HIT Adoption by Children’s Versus Adult Hospitals
In 2011, a significantly greater pro-portion of children’s hospitals than adult hospitals had adopted at least a basic EHR (59% vs 27%,P,.0001) or comprehensively implemented the 12 core meaningful use function-alities we evaluated (29% vs 11%,P, .0001).18When we limited our analysis
to children’s and adult major teach-ing hospitals, we found similar rates of adoption of at least a basic EHR (60% vs 53% in 2011,P= .36) (Fig 1B) and of comprehensive implementa-tion of all 12 meaningful use func-tionalities (32% vs 28% in 2011, P= .15) (Table 1).
HIT Adoption by Subgroups of Children’s Hospitals
On multivariate analysis of 2011 EHR adoption rates, only teaching status was related to EHR adoption (P= .03), with
FIGURE 1
A, All children’s hospitals. B, Children’s and adult major teaching hospitals. EHR adoption. For children’s
hospitals: 2008,n= 108; 2009,n= 130; 2010 and 2011,n= 126. Proportions are weighted to adjust for
nonresponse bias but are not adjusted for hospital characteristics. Please see Appendix Table 1 for
definitions of basic and comprehensive EHRs. The difference in EHR adoption rate in 2011 between
children’s and adult major teaching hospitals is not statistically significant (P= .36).
FIGURE 2
Number of core meaningful use criteria fulfilled by children’s hospitals in 2011. Proportions are
minor teaching hospitals significantly less likely to have an EHR than major teaching hospitals (P= .009) (Table 2). Neither teaching status nor other hospital
characteristics were significantly re-lated to achievement of all 12 vs,12 core meaningful use criteria (Appendix Table 5).
DISCUSSION
Using the official federal definition of an EHR, we found that the rate of EHR adoption among US children’s hospitals has nearly tripled since 2008, reaching
∼60% in 2011. The proportion of hos-pitals with a comprehensive EHR rose most dramatically, increasing more than sixfold, such that by 2011, nearly 1 in 5 children’s hospitals had achieved this high level of HIT capability. Child-ren’s hospitals have demonstrated corresponding gains in their mean-ingful use of EHRs: in 2011, nearly 30% met the 12 core meaningful use criteria assessed by our survey, a proportion up twofold from just the year prior. Among children’s hospitals, gains in adoption have been widespread, encompassing all types and sizes of children’s hospitals, although major teaching hospitals continue to outstrip other children’s hospitals. Thesefi nd-ings are encouraging, particularly be-cause essential EHR functionalities, such as CPOE, data extraction for quality measurement, and clinical decision support, when implemented well by children’s hospitals, provide crucial benefits, including improvements in evidence-based practice, increased medication safety, and even associated reductions in mortality.21–23
In our previous analysis of EHR imple-mentation, using 2008 survey data, we found that children’s hospitals were further ahead than adult hospitals (adoption rate for any EHR: 21% vs 9%).14 We posited that children’s
hos-pitals’relative HIT sophistication might be attributed to their being mostly large, urban, and teaching institutions, all characteristics associated with EHR adoption.18,20,24,25Our current analysis
provides further support for the im-portance of teaching status in EHR adoption. The adoption rate for child-ren’s hospitals continues to far exceed that of adult hospitals overall, but children’s and adult major teaching
FIGURE 3
Comprehensive implementation of selected functionalities by children’s hospitals in 2011.
Compre-hensive implementation means adoption across all hospital units. Proportions are weighted to adjust
for nonresponse bias.aThe implementation rate for physician notes is significantly lower than for
clinical guidelines, clinical reminders, drug dosing support, and CPOE for medications (eachP#.001).b
The implementation rate for bar coding for drug administration is significantly lower than for clinical
reminders, drug dosing support, and CPOE for medications (eachP#.02).
TABLE 1 Adjusted Rates of Meaningful Use Among Children’s and Adult Major Teaching Hospitals in 2011
Children’s Major Teaching Hospitals,
n= 93
Adult Major Teaching Hospitals
n= 165
Percentage of Hospitals
Meaningful use core criteria
Use CPOE for medication orders 71 61
Implement drug-drug and drug-allergy checks 54 50
Maintain up-to-date problem list 62 61
Maintain active medication list 85 83
Maintain active medication allergy list 86 83
Record key demographics 84 90
Record and chart changes in key vital signs 75 80 Record smoking for patients 13 y and older 71 76 Report hospital quality measures to CMS or the state 54 50 Implement clinical decision support rule for high-priority
condition and track compliance
88 79
Provide patients with electronic copy of their health information upon request
73 70
Provide patients with electronic copy of discharge instructions upon request
74 71
All core criteriaa 32 28
Data shown are for comprehensive implementation (full replacement of paper record by the electronic functionality across all hospital units). Proportions are weighted to adjust for nonresponse bias and adjusted for hospital size, region, owner-ship, and urban or rural location. CMS, Centers for Medicare and Medicaid Services.
aUsing a multivariate logistic regression model, the difference in fulfillment of all 12 core criteria between children’s and
hospitals have similar adoption rates. The gap between children’s and adult hospitals appears attributable to the vast majority of children’s hospitals’ being teaching institutions. In addition, organizations such as CHA and the American Academy of Pediatrics have played a vital role in advancing EHR adoption among children’s hospitals by providing technical expertise and fa-cilitating collaboration among child-ren’s hospitals for advocacy and HIT development.26
We found that children’s hospitals may be prioritizing functionalities needed for meaningful use over other func-tionalities. For 6 functionalities be-lieved to be important for quality of care, adoption rates for the 2 that are not part of meaningful use (physician notes and bar coding for medication administration) were, on average, 19% lower than for the 4 that are part of meaningful use (CPOE for medications and 3 types of clinical decision sup-port). These findings offer indirect evidence that the meaningful use
program is likely influencing decisions by children’s hospitals regarding which functionalities to adopt. While this may not be surprising, it warrants close attention to ensure that hospitals do not forgo key functionalities just be-cause they are not included in the meaningful use regulations.
Although children’s hospitals have made progress in EHR adoption,∼40% of children’s hospitals still lacked even a basic EHR in 2011, and 70% did not meet our proxy for meaningful use. Several features of the Medicaid EHR incentive program may limit its effec-tiveness in driving HIT implementation by these hospitals. The incentive pay-ments are administered individually by each state Medicaid program, and state participation is optional.27
Hos-pitals can therefore receive incentives only if and when their states start an incentive program. More than half of states did not have their incentive program running by September 2011.28
In addition, unlike the Medicare pro-gram, the Medicaid program requires
only purchase, implementation, or up-grading of a certified system in thefirst year of participation and does not re-quire demonstration of meaningful use until the second year and beyond.13
Furthermore, the Medicaid program does not penalize hospitals that do not become meaningful users.13
Although our study is thefirst of which we are aware to examine changes in EHR adoption by children’s hospitals over time, data from the Healthcare Information Management and Sys-tems Society Electronic Medical Re-cord Adoption Model (EMRAM), which scores hospitals based on 1 of 8 stages of increasingly advanced HIT capa-bilities, revealfindings consistent with ours. As of 2010, 54% of children’s hospitals had reached EMRAM stage 4 (similar to our definition of a basic EHR) or higher, as compared with only 19% of adult hospitals.29 Also
consistent with our findings, 2012 Health Information and Management Systems Society data show that teaching/academic hospitals have higher EMRAM scores than non-academic hospitals (mean score, 4.5 vs 3.4, respectively).25
Our study had multiple limitations. Because children’s hospitals within hospitals and associate hospitals did not complete a separate survey from their parent institutions, we could not tell whether EHR functionalities had been adopted in pediatric units unless hospitals reported comprehensive (across all units) implementation. As a result, we used a threshold of com-prehensive implementation to judge whether hospitals met meaningful use criteria, a standard more stringent than the actual requirements for most of the meaningful use measures.13 In
addition, of the 14 core capabilities required for meaningful use, the sur-vey did not address 2 capabilities (demonstration of electronic infor-mation exchange and health inforinfor-mation TABLE 2 Adjusted EHR Adoption Rates in 2011 by Children’s Hospital Characteristics
Hospital Characteristic Any EHR,n= 75 No EHR,n= 51 PValue
Percentage of Children’s Hospitals
Teaching statusa
Major teaching 67 33 .03
Minor teaching 34 66
Nonteaching 23 77
Size
Small (6–99 beds) 58 42 .98
Medium (100–399 beds) 62 38
Large (400+ beds) 58 42
Region
Northeast 49 51 .35
Midwest 58 42
South 58 42
West 78 22
Ownership
Private nonprofit 63 37 .11
Public 42 58
Children’s hospital type
Freestanding 59 41 .16
Children’s hospital within hospital 72 28
Associate 49 51
Proportions are calculated across rows; weighted to adjust for nonresponse bias; and adjusted for teaching status, hospital size, region, ownership, and children’s hospital type.
aIn a multivariate logistic regression model incorporating all 5 hospital characteristics, minor teaching hospitals were
security), so we cannot be certain what proportion of hospitals would actually qualify for incentives. The survey also did not ask directly how the EHR incentive program has influenced adoption prior-ities or what challenges, if any, hospitals have encountered in attempting to join Medicaid incentive programs. An un-avoidable limitation was limited power to detect differences between sub-groups of children’s hospitals because of the small number of children’s hos-pitals overall.
Finally, although our study addressed adoption of important EHR function-alities, we did not evaluate their effec-tiveness. The survey did not ask about unintended consequences that may result from poorly designed or badly implemented EHRs, such as degra-dation of documentation quality,30
introduction of medication errors,31
and delay of critical care processes.32It
also did not assess whether EHRs were suited for pediatric care. Most EHR systems were initially designed for adult patients and require custom-ization for child health, as detailed in a key report by the American Academy of Pediatrics’ Council on Clinical In-formation Technology.33 Without
fea-tures such as pediatric normal values for vital signs and laboratory results, growth charts for all age groups, drug-dosing support and dose-range checking based on age and weight, and problem lists and clinical decision support that incorporate pediatric di-agnoses, EHRs may fail to support, or may possibly hamper, effective care.33
Children’s hospitals are doing rela-tively well with HIT adoption, but they
remain an important sector to monitor in coming years: 40% of children’s hospitals still do not have even a basic EHR, and benefits from Medicaid incentives may be limited by state Medicaid programs’ability to adminis-ter them. Even for hospitals making progress in implementing EHRs, chal-lenges remain in adapting systems for pediatrics and using them to drive improvements in care. Whether the EHR incentive program encourages these tasks will depend on how well later stages of meaningful use in-corporate pediatric capabilities. Al-though our findings represent good news in EHR adoption among children’s hospitals, we need to monitor whether the HITECH program drives adoption of systems that facilitate the care of children and adolescents.
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APPENDIX
APPENDIX TABLE 1 Definitions of Basic and Comprehensive EHRs
Basic EHR Comprehensive EHR
Electronic clinical documentation
Patient demographics X X
Physician notes X X
Nursing assessments X X
Problem lists X X
Medication lists X X
Discharge summaries X X
Advance directives X
Test and imaging results
Laboratory reports X X
Radiology reports X X
Radiology images X
Diagnostic test results X X
Diagnostic test images X
Consultant reports X
Computerized provider order entry
Laboratory tests X
Radiology tests X
Medications X X
Consultation requests X
Nursing orders X
Decision support
Clinical guidelines X
Clinical reminders X
Drug allergy alerts X
Drug-drug interaction alerts X
Drug-laboratory interaction alerts X
Drug dosing support X
APPENDIX TABLE 2 Core Meaningful Use Criteria and Corresponding Survey Questions
Core Meaningful Use Criterion Measure Details 2011 Survey Question: Does Your Hospital Have a Computerized System That Allows for:
1. Use CPOE for medication orders .30% of patients whose record is maintained in EHR and who are on at least 1 medication have at least 1 medication order entered via CPOE.
Use of CPOE for medication orders, with orders entered directly by providers?
2. Implement drug-drug and drug-allergy checks
Have functionality enabled during entire reporting period. Use of the following type of decision support, integrated in the clinical EHR system and offered directly to the provider? (1) Drug-drug interaction checks; (2) Drug-allergy interaction checks
3. Maintain up-to-date problem list .80% of patients admitted to hospital or ED have at least 1 entry (or documented as having no known problems).
Recording and charting a problem list of current diagnoses as structured data?
4. Maintain active medication list .80% of patients admitted to hospital or ED have at least 1 entry (or documented as having no current medications).
Recording and charting a list of active medications as structured data?
5. Maintain active medication allergy list .80% of patients admitted to hospital or ED have at least 1 entry (or documented as having no known medication allergies).
Recording and charting a list of drug allergies as structured data?
6. Record key demographics .50% of patients admitted to hospital or ED have recorded as structured data: preferred language, gender, race, ethnicity, DOB, date and preliminary cause of death in event of death in hospital.
Recording and charting the following as structured data? (1) Gender; (2) DOB; (3) Race and ethnicity; (4) Preferred language for communication with hospital care providers; (5) Date and preliminary cause of death in the event of death in the hospital
7. Record and chart changes in key vital signs
.50% of patients aged 2 y and older whose record is maintained in EHR have recorded as structured data: height, weight, blood pressure.
Recording and charting the following as structured data? (1) Blood pressure; (2) Height and weight
8. Record smoking for patients 13 y and older .50% of patients aged 13 y and older whose record is maintained in EHR have smoking status recorded as structured data.
Recording and charting smoking status for patient 1 3 y of age or older as structured data?
9. Report hospital quality measures to CMS or the state
For patients whose record is maintained in EHR, report to CMS (or for Medicaid-eligible hospitals) clinical quality measures in manner specified by CMS.
(1) Capturing hospital quality measures electronically? (2) Submitting electronically captured clinical quality measures to CMS or your state?
10. Implement CDS rule for high-priority condition and track compliance
Implement 1 clinical decision support rule. Using a clinical decision support rule related to a high-priority hospital condition?
11. Provide patients with electronic copy of their health information upon request
.50% of patients admitted to hospital or ED and who request electronic copy of health information receive it within 3 business days of request.
Providing patients with an electronic copy of the following health information on request? Diagnostic test results, problem list, medication list, drug allergies, procedures, and discharge summary 12. Provide patients with electronic copy of
discharge instructions upon request
.50% of patients discharged from hospital or ED who request electronic copy of discharge instructions are provided it.
Discharge summaries
13. Demonstrate capability to exchange key information
Perform at least 1 test of capacity to electronically exchange key information (examples given for“key information”: problem list, medication list, medication allergies, diagnostic test results).
No analogous survey question
14. Protect health information through appropriate technical capabilities
Conduct or review security risk analysis; implement security updates as necessary and correct deficiencies.
Analogous survey question left unanswered by approximately 80% of respondents
APPENDIX TABLE 3 Characteristics of Hospitals Responding to 2011 Survey
Hospitals Responding to Survey,n(%)
Hospitals Not Responding to Survey,n(%)
Teaching status
Major teaching 93 (74) 22 (61)
Minor teaching 31 (25) 13 (36)
Non-teaching 2 (2) 1 (3)
Size
Small (6–99 beds) 2 (2) 1 (3)
Medium (100–399 beds) 31 (25) 14 (39)
Large (400+ beds) 93 (74) 21 (58)
Region
Northeast 30 (24) 5 (14)
Midwest 33 (26) 7 (19)
South 45 (36) 13 (36)
West 18 (14) 11 (31)
Ownership
For profit 0 (0) 1 (3)
Private nonprofit 103 (82) 32 (89)
Public 23 (18) 3 (8)
Children’s hospital type
Freestanding 30 (24) 12 (33)
Hospital within a hospital 62 (49) 14 (39)
Associate 34 (27) 10 (28)
Total 126 (78% of CHA acute-care hospitals)
36 (22% of CHA acute-care hospitals)
APPENDIX TABLE 5 Adjusted Rates of Meaningful Use Achievement in 2011 by Children’s Hospital Characteristics
Hospital Characteristic 12 Core Criteria Fulfilled #11 Core Criteria Fulfilled PValue Percentage of Children’s Hospitals
Teaching status
Major teaching 39 61 .14
Minor teaching 17 83
Nonteaching 62 38
Size
Small (6-99 beds) 40 60 .20
Medium (100-399 beds) 18 82
Large (400+ beds) 40 60
Region
Northeast 36 64 .43
Midwest 37 63
South 26 74
West 46 54
Ownership
Private nonprofit 38 62 .54
Public 21 79
Children’s hospital type
Freestanding 35 65 .85
Children’s hospital within hospital 39 61
Associate 33 67
Total 29 71
DOI: 10.1542/peds.2012-2904 originally published online April 15, 2013;
2013;131;e1563
Pediatrics
Mari M. Nakamura, Marvin B. Harper and Ashish K. Jha
Change in Adoption of Electronic Health Records by US Children's Hospitals
Services
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