Change in Adoption of Electronic Health Records by US ... - Pediatrics

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Change in Adoption of Electronic Health Records by US Children’s Hospitals AUTHORS: Mari M. Nakamura, MD, MPH,a,b Marvin B. Harper, MD,a,c,d and Ashish K. Jha, MD, MPHe,f,g aDivision of Infectious Diseases, bDivision of General Pediatrics, and cDivision of Emergency Medicine, Department of Medicine, and dInformation 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; and gVeterans 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 study findings, and wrote the manuscript; Dr Harper interpreted the study findings and reviewed and revised the manuscript; Dr Jha conceptualized and designed the study, interpreted the study findings, and reviewed and revised the manuscript; and all authors approved the final 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: [email protected] 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 no financial relationships relevant to this article to disclose. FUNDING: Supported by the Robert Wood Johnson Foundation, grant number 68754.

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 information technology (HIT) implementation 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 comprising 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 hospitals 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 significantly 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 significantly more likely to have an EHR. CONCLUSIONS: Children’s hospitals have achieved substantial gains in HIT implementation although minor teaching and nonteaching institutions are not keeping pace. Pediatrics 2013;131:e1563–e1575

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Improving pediatric health care quality is a national policy priority. Under the 2009 Children’s Health Insurance Program Reauthorization Act, a Pediatric Quality Measures Program was established and charged with defining evidence-based quality measures for use by Medicaid and the Children’s Health Insurance Program, which together cover nearly 40 million children.1–3 The success of efforts to measure and improve quality will depend on the presence of a robust information infrastructure. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act tries to make this infrastructure a reality by creating financial incentives for physicians and hospitals to adopt and meaningfully use electronic health records (EHRs).4 EHRs facilitate delivery of high-quality care.5 They allow collection of data required to evaluate care processes and outcomes and provide feedback on performance.6 EHRs aid providers in organizing and integrating information, safely managing medications and other interventions, and making decisions guided by evidence and patient 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, would find 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 comprehensive EHR system, while an additional 18% had a basic system.14 We are unaware of any data on how adoption rates among children’s hospitals have e1564

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 falling 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 hospitals, who typically assign it to their most knowledgeable staff members (usually the chief information officer or equivalent). Nonresponding hospitals are encouraged to participate via multiple mailings and telephone calls. The survey analysis was considered exempt from human subjects review by the institutional 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 hospitals”; 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.16 We also performed a secondary analysis of EHR adoption that included CHA specialty hospitals (ie, those that care for specific conditions such as burns, orthopedic conditions, or neurologic conditions) and rehabilitation hospitals. Each institution received a single annual survey. Survey Content Questions assessed adoption of 24 individual clinical EHR functionalities (Appendix Table 1), with implementation 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 questions addressing the criteria hospitals must meet to achieve “meaningful use” under the EHR incentive program (Appendix 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 children’s and adult hospitals. These definitions incorporate functionalities that are considered universally important to clinical care, including within pediatrics.11,17 A basic EHR must include 10 core functionalities, including physician notes, nursing assessments, problem and medication lists, laboratory and radiology reports, and computerized provider order entry (CPOE) for medications, fully implemented in at least 1 clinical unit (Appendix Table 1). A comprehensive EHR must include those plus a broader set of 14 additional functionalities, implemented across all units.

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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 Because 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 accompanying Appendix (Appendix Table 2). These 12 criteria have been used previously to create a “proxy” measure for a hospital’s ability to meet the meaningful use standards.18 Analysis We compared characteristics of children’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. Subsequently, 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 comprehensive EHRs during each year. Questions used to assess EHR adoption remained consistent across all 4 years of the survey. To analyze meaningful use achievement, we calculated the proportion 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 meaningful 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 pediatric units. Because questions about many of the meaningful use functionalities were not asked until the 2010 survey, we assessed progress in meaningful use by determining the change from 2010 to 2011 in the proportion 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,19 4 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 hospitals against those of adult hospitals. Adult hospitals were identified among survey respondents as those that described their primary service as “general 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 others in HIT adoption, we used multivariate logistic regression to evaluate how 5 hospital characteristics (type of children’s hospital, size, region, ownership, and teaching status) relate to EHR adoption or achievement of meaningful use. We used the t test and logistic regression for bivariate analyses and

logistic regression for multivariate analyses. A 2-sided P , .05 was used as the criterion for statistical significance.

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 status, 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 respondents 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 subsequent 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 In 2011, 29% of hospitals fulfilled 12 core meaningful use criteria (Fig 2), a proportion that had doubled from 14% in 2010. Another 30% of hospitals met 9 to 11 criteria in 2011, whereas 12% of hospitals met 4 or fewer (Fig 2). In 2011, the meaningful use functionalities in place for the greatest proportions of hospitals were medication allergy lists



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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 clinically important EHR functionalities, we observed that comprehensive implementation rates varied among functionalities (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). Likewise, the adoption rate for bar coding for drug administration (48%), another functionality not included in the meaningful use criteria, was significantly lower than for CPOE for medications and 2 of the types of clinical decision support (P # .02).

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).

(87%), a clinical decision support rule (86%), medication lists (85%), and key demographics (85%) (Appendix Table 4).

Among hospitals achieving 9 to 11 criteria in 2011, the functionalities most often lacking were quality measure

HIT Adoption by Children’s Versus Adult Hospitals In 2011, a significantly greater proportion 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 functionalities we evaluated (29% vs 11%, P , .0001).18 When we limited our analysis to children’s and adult major teaching 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 implementation of all 12 meaningful use functionalities (32% vs 28% in 2011, P = .15) (Table 1). HIT Adoption by Subgroups of Children’s Hospitals

FIGURE 2 Number of core meaningful use criteria fulfilled by children’s hospitals in 2011. Proportions are weighted to adjust for nonresponse bias.

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On multivariate analysis of 2011 EHR adoption rates, only teaching status was related to EHR adoption (P = .03), with

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DISCUSSION

FIGURE 3 Comprehensive implementation of selected functionalities by children’s hospitals in 2011. Comprehensive 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 (each P #.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 (each P # .02).

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 related to achievement of all 12 vs ,12 core meaningful use criteria (Appendix Table 5).

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 Implement drug-drug and drug-allergy checks Maintain up-to-date problem list Maintain active medication list Maintain active medication allergy list Record key demographics Record and chart changes in key vital signs Record smoking for patients 13 y and older Report hospital quality measures to CMS or the state Implement clinical decision support rule for high-priority condition and track compliance Provide patients with electronic copy of their health information upon request Provide patients with electronic copy of discharge instructions upon request All core criteriaa

71 54 62 85 86 84 75 71 54 88

61 50 61 83 83 90 80 76 50 79

73

70

74

71

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, ownership, and urban or rural location. CMS, Centers for Medicare and Medicaid Services. a Using a multivariate logistic regression model, the difference in fulfillment of all 12 core criteria between children’s and adult major teaching hospitals is not statistically significant, adjusting for hospital size, region, and ownership (P = .15).

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 hospitals 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. Children’s hospitals have demonstrated corresponding gains in their meaningful 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. These findings are encouraging, particularly because 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 implementation, 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 hospitals’ relative HIT sophistication might be attributed to their being mostly large, urban, and teaching institutions, all characteristics associated with EHR adoption.18,20,24,25 Our current analysis provides further support for the importance of teaching status in EHR adoption. The adoption rate for children’s hospitals continues to far exceed that of adult hospitals overall, but children’s and adult major teaching



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TABLE 2 Adjusted EHR Adoption Rates in 2011 by Children’s Hospital Characteristics Hospital Characteristic

Any EHR, n = 75

No EHR, n = 51

P Value

Percentage of Children’s Hospitals Teaching statusa Major teaching Minor teaching Nonteaching Size Small (6–99 beds) Medium (100–399 beds) Large (400+ beds) Region Northeast Midwest South West Ownership Private nonprofit Public Children’s hospital type Freestanding Children’s hospital within hospital Associate

67 34 23

33 66 77

.03

58 62 58

42 38 42

.98

49 58 58 78

51 42 42 22

.35

63 42

37 58

.11

59 72 49

41 28 51

.16

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. a In a multivariate logistic regression model incorporating all 5 hospital characteristics, minor teaching hospitals were significantly less likely to have an EHR as compared with major teaching hospitals (P = .009).

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 facilitating collaboration among children’s hospitals for advocacy and HIT development.26 We found that children’s hospitals may be prioritizing functionalities needed for meaningful use over other functionalities. For 6 functionalities believed 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 support). These findings offer indirect evidence that the meaningful use e1568

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 because 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 effectiveness in driving HIT implementation by these hospitals. The incentive payments are administered individually by each state Medicaid program, and state participation is optional.27 Hospitals 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 program, the Medicaid program requires

only purchase, implementation, or upgrading of a certified system in the first year of participation and does not require 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 the first of which we are aware to examine changes in EHR adoption by children’s hospitals over time, data from the Healthcare Information Management and Systems Society Electronic Medical Record Adoption Model (EMRAM), which scores hospitals based on 1 of 8 stages of increasingly advanced HIT capabilities, reveal findings 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 nonacademic 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 comprehensive 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 survey did not address 2 capabilities (demonstration of electronic information exchange and health information

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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 priorities or what challenges, if any, hospitals have encountered in attempting to join Medicaid incentive programs. An unavoidable limitation was limited power to detect differences between subgroups of children’s hospitals because of the small number of children’s hospitals overall. Finally, although our study addressed adoption of important EHR functionalities, we did not evaluate their effectiveness. The survey did not ask about unintended consequences that may result from poorly designed or badly implemented EHRs, such as degradation of documentation quality,30

introduction of medication errors,31 and delay of critical care processes.32 It also did not assess whether EHRs were suited for pediatric care. Most EHR systems were initially designed for adult patients and require customization for child health, as detailed in a key report by the American Academy of Pediatrics’ Council on Clinical Information Technology.33 Without features 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 diagnoses, EHRs may fail to support, or may possibly hamper, effective care.33 Children’s hospitals are doing relatively 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 administer them. Even for hospitals making progress in implementing EHRs, challenges 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 incorporate pediatric capabilities. Although 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.

7. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA. 1998;280(15):1339–1346 8. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144 (10):742–752 9. Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108–114 10. Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med. 2001;155(9):1002–1007 11. Kim GR, Lehmann CU; Council on Clinical Information Technology. Pediatric aspects of inpatient health information technology systems [published correction appears in Pediatrics. 2009;123(2):604]. Pediatrics. 2008; 122(6). Available at: www.pediatrics.org/cgi/ content/full/122/6/e1287 12. Shiffman RN, Spooner SA, Kwiatkowski K, Brennan PF. Information technology for children’s health and health care: report on

the Information Technology in Children’s Health Care Expert Meeting, September 2122, 2000. J Am Med Inform Assoc. 2001;8(6): 546–551 Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare and Medicaid programs; electronic health record incentive program. Final rule. Fed Regist. 2010;75(144):44313– 44588 Nakamura MM, Ferris TG, DesRoches CM, Jha AK. Electronic health record adoption by children’s hospitals in the United States. Arch Pediatr Adolesc Med. 2010;164(12): 1145–1151 Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628–1638 National Association of Children’s Hospitals and Related Institutions. NACHRI and NACH membership. Available at: www. childrenshospitals.net/AM/Template.cfm? Section=Membership1&Template=/CM/ ContentDisplay.cfm&ContentID=46197. Accessed November 14, 2011 American Academy of Pediatrics. American Academy of Pediatrics: Task Force on Medical Informatics. Special requirements for electronic medical record systems in pediatrics. Pediatrics. 2001;108(2):513–515

REFERENCES 1. Agency for Healthcare Research and Quality. Pediatric Quality Measures Program (PQMP) Centers of Excellence Grant Awards. Available at: www.ahrq.gov/chipra/ pqmpfact.pdf. Accessed July 15, 2012 2. US Congress. Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111-3). Available at: www.gpo. gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW111publ3.pdf. Accessed October 26, 2011 3. Dougherty D, Schiff J, Mangione-Smith R. The Children’s Health Insurance Program Reauthorization Act quality measures initiatives: moving forward to improve measurement, care, and child and adolescent outcomes. Acad Pediatr. 2011;11(suppl 3): S1–S10 4. US Congress. American Recovery and Reinvestment Act of 2009 (Public Law 111-5). Available at: www.gpo.gov/fdsys/pkg/PLAW111publ5/content-detail.html. Accessed August 30, 2010 5. Bates DW. The quality case for information technology in healthcare. BMC Med Inform Decis Mak. 2002;2:7 6. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood). 2010;29(6):1214– 1219

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18. 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 Aff (Millwood). 2012;31(5):1092–1099 19. Blumenthal D, DesRoches C, Donelan K, et al. Health information technology in the United States: where we stand, 2008. Available at: www.rwjf.org/pr/product.jsp? id=31831. Accessed February 2, 2011 20. Amarasingham R, Diener-West M, Plantinga L, Cunningham AC, Gaskin DJ, Powe NR. Hospital characteristics associated with highly automated and usable clinical information systems in Texas, United States. BMC Med Inform Decis Mak. 2008;8:39 21. Chisolm DJ, McAlearney AS, Veneris S, Fisher D, Holtzlander M, McCoy KS. The role of computerized order sets in pediatric inpatient asthma treatment. Pediatr Allergy Immunol. 2006;17(3):199–206 22. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;112(3 pt 1):506–509

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23. Kim GR, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med. 2006;160(5):495–498 24. Kazley AS, Ozcan YA. Organizational and environmental determinants of hospital EMR adoption: a national study. J Med Syst. 2007;31(5):375–384 25. HIMSS Analytics. Current EMRAM scores. Available at: www.himssanalytics.org/emram/ scoreTrends.aspx. Accessed July 15, 2012 26. Fairbrother G, Simpson LA. It is time! Accelerating the use of child health information systems to improve child health. Pediatrics. 2009;123(suppl 2):S61–S63 27. Burke T, Stewart A, Cartwright-Smith L. Meaningful use & Medicaid—challenges for states and providers. LegalNotes. 2010. Available at: www.rwjf.org/files/research/ 71847.pdf. Accessed July 15, 2012 28. Centers for Medicare and Medicaid Services. State EHR incentive program launch times and HIT Web sites. 2012. Available at: www.cms. gov/apps/files/statecontacts.pdf. Accessed July 13, 2012

29. National Association of Children’s Hospitals. Office of the National Coordinator for Health Information Technology Strategic Plan (NACH comment letter). Available at: www.childrenshospitals.net/AM/Template. cfm?Section=Health_IT1&TEMPLATE=/CM/ ContentDisplay.cfm&CONTENTID=56808. Accessed July 16, 2012 30. Siegler EL, Adelman R. Copy and paste: a remediable hazard of electronic health records. Am J Med. 2009;122(6):495–496 31. Caldwell NA, Power B. The pros and cons of electronic prescribing for children. Arch Dis Child. 2012;97(2):124–128 32. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506–1512 33. Spooner SA; Council on Clinical Information Technology, American Academy of Pediatrics. Special requirements of electronic health record systems in pediatrics. Pediatrics. 2007;119(3):631– 637

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APPENDIX

APPENDIX TABLE 1 Definitions of Basic and Comprehensive EHRs Electronic clinical documentation Patient demographics Physician notes Nursing assessments Problem lists Medication lists Discharge summaries Advance directives Test and imaging results Laboratory reports Radiology reports Radiology images Diagnostic test results Diagnostic test images Consultant reports Computerized provider order entry Laboratory tests Radiology tests Medications Consultation requests Nursing orders Decision support Clinical guidelines Clinical reminders Drug allergy alerts Drug-drug interaction alerts Drug-laboratory interaction alerts Drug dosing support

Basic EHR

Comprehensive EHR

X X X X X X

X X X X X X X

X X

X X X X X X

X

X

X X X X X X X X X X X

A comprehensive EHR requires full implementation of the electronic functionalities (ie, complete replacement of paper record) across all hospital units. A basic EHR requires full implementation in at least 1 clinical unit.



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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:

.30% of patients whose record is maintained in EHR and Use of CPOE for medication orders, with orders who are on at least 1 medication have at least 1 entered directly by providers? medication order entered via CPOE. 2. Implement drug-drug and drug-allergy Have functionality enabled during entire reporting period. Use of the following type of decision support, integrated checks 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 Recording and charting a problem list of current diagnoses as structured data? least 1 entry (or documented as having no known problems). 4. Maintain active medication list .80% of patients admitted to hospital or ED have at Recording and charting a list of active least 1 entry (or documented as having no medications as structured data? current medications). 5. Maintain active medication allergy list .80% of patients admitted to hospital or ED have at Recording and charting a list of drug allergies least 1 entry (or documented as having no as structured data? known medication allergies). 6. Record key demographics .50% of patients admitted to hospital or ED have Recording and charting the following as structured data? (1) Gender; (2) DOB; (3) Race and ethnicity; (4) Preferred recorded as structured data: preferred language, gender, race, ethnicity, DOB, date and preliminary language for communication with hospital care providers; (5) Date and preliminary cause of death in the cause of death in event of death in hospital. event of death in the hospital 7. Record and chart changes in key vital .50% of patients aged 2 y and older whose record Recording and charting the following as structured data? (1) Blood pressure; (2) Height and weight signs is maintained in EHR have recorded as structured data: height, weight, blood pressure. 8. Record smoking for patients 13 y and older .50% of patients aged 13 y and older whose Recording and charting smoking status for patient 1 record is maintained in EHR have smoking 3 y of age or older as structured data? status recorded as structured data. 9. Report hospital quality measures to CMS or For patients whose record is maintained in EHR, report (1) Capturing hospital quality measures electronically? (2) the state to CMS (or for Medicaid-eligible hospitals) clinical Submitting electronically captured clinical quality quality measures in manner specified by CMS. measures to CMS or your state? 10. Implement CDS rule for high-priority Implement 1 clinical decision support rule. Using a clinical decision support rule related to condition and track compliance a high-priority hospital condition? 11. Provide patients with electronic copy .50% of patients admitted to hospital or ED and Providing patients with an electronic copy of the following of their health information upon request who request electronic copy of health information health information on request? Diagnostic test results, receive it within 3 business days of request. problem list, medication list, drug allergies, procedures, and discharge summary 12. Provide patients with electronic copy of .50% of patients discharged from hospital or ED Discharge summaries discharge instructions upon request who request electronic copy of discharge instructions are provided it. No analogous survey question 13. Demonstrate capability to exchange key Perform at least 1 test of capacity to electronically information exchange key information (examples given for “key information”: problem list, medication list, medication allergies, diagnostic test results). 14. Protect health information through Conduct or review security risk analysis; implement Analogous survey question left unanswered by appropriate technical capabilities security updates as necessary and correct deficiencies. approximately 80% of respondents 1. Use CPOE for medication orders

Criteria 1 through 12 were included in the proxy measure of meaningful use evaluated in this study. Criteria 13 and 14 were not included due to their lack of coverage by the survey. CDS, clinical decision support; CMS, Centers for Medicare and Medicaid Services; DOB, date of birth; ED, emergency department.

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APPENDIX TABLE 3 Characteristics of Hospitals Responding to 2011 Survey

Teaching status Major teaching Minor teaching Non-teaching Size Small (6–99 beds) Medium (100–399 beds) Large (400+ beds) Region Northeast Midwest South West Ownership For profit Private nonprofit Public Children’s hospital type Freestanding Hospital within a hospital Associate Total

Hospitals Responding to Survey, n (%)

Hospitals Not Responding to Survey, n (%)

93 (74) 31 (25) 2 (2)

22 (61) 13 (36) 1 (3)

2 (2) 31 (25) 93 (74)

1 (3) 14 (39) 21 (58)

30 (24) 33 (26) 45 (36) 18 (14)

5 (14) 7 (19) 13 (36) 11 (31)

0 (0) 103 (82) 23 (18)

1 (3) 32 (89) 3 (8)

30 (24) 62 (49) 34 (27) 126 (78% of CHA acute-care hospitals)

12 (33) 14 (39) 10 (28) 36 (22% of CHA acute-care hospitals)

Proportions are calculated down columns and may not total to 100 due to rounding. Differences between respondents and nonrespondents are not statistically significant.



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Downloaded from http://pediatrics.aappublications.org/ by guest on September 28, 2017 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (18%) 5 (49%) 4 (57%) 10 (76%) 10 (67%) 12 (85%) 10 (100%) 36 (100%)

0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (31%) 2 (33%) 4 (32%) 6 (81%) 11 (86%) 13 (87%) 13 (92%) 10 (100%) 36 (100%)

Proportions are weighted to adjust for nonresponse bias.

88 (69%)

96 (75%)

All Hospitals 107 (85%) 75 (59%) 108 (85%) No. of Meaningful Use Number (%) of Requirements Achieved Hospitals 0 2 (2%) 0 (0%) 0 (0%) 0 (0%) 1 3 (2%) 0 (0%) 0 (0%) 0 (0%) 2 2 (2%) 0 (0%) 0 (0%) 0 (0%) 3 4 (3%) 2 (46%) 1 (23%) 1 (23%) 4 3 (2%) 1 (31%) 0 (0%) 2 (69%) 5 6 (4%) 6 (100%) 1 (16%) 3 (47%) 6 11 (9%) 10 (93%) 4 (32%) 10 (88%) 7 7 (6%) 5 (76%) 1 (19%) 7 (100%) 8 13 (11%) 11 (87%) 4 (31%) 12 (93%) 9 15 (12%) 12 (81%) 9 (58%) 14 (94%) 10 14 (10%) 14 (100%) 11 (79%) 13 (93%) 11 10 (8%) 10 (100%) 8 (82%) 10 (100%) 12 36 (29%) 36 (100%) 36 (100%) 36 (100%)

Smoking Status

Vital Signs

Patient Problem Lists

Patient Medication Lists

Patient Gender, Race, Ethnicity, and DOB

0 (0%) 0 (0%) 0 (0%) 2 (54%) 2 (69%) 3 (49%) 9 (80%) 7 (100%) 12 (93%) 15 (100%) 14 (100%) 10 (100%) 36 (100%)

110 (87%)

Patient Medication Allergy lists

0 (0%) 1 (34%) 0 (0%) 1 (31%) 0 (0%) 2 (30%) 3 (23%) 3 (37%) 5 (39%) 13 (86%) 12 (89%) 10 (100%) 36 (100%)

86 (67%)

CPOE

0 (0%) 2 (66%) 0 (0%) 3 (76%) 0 (0%) 6 (100%) 7 (67%) 6 (81%) 12 (92%) 14 (93%) 14 (100%) 10 (100%) 36 (100%)

110 (86%)

Clinical Decision Support

APPENDIX TABLE 4 Fulfillment of Specific Meaningful Use Criteria in 2011, Broken Down by Total Number of Criteria Achieved

0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (20%) 0 (0%) 2 (32%) 5 (39%) 6 (39%) 7 (58%) 9 (91%) 36 (100%)

66 (53%)

0 (0%) 0 (0%) 2 (100%) 0 (0%) 0 (0%) 2 (35%) 2 (22%) 2 (30%) 7 (51%) 5 (33%) 7 (44%) 5 (45%) 36 (100%)

68 (53%)

0 (0%) 0 (0%) 2 (100%) 1 (23%) 3 (100%) 1 (20%) 6 (55%) 3 (49%) 7 (51%) 11 (73%) 11 (75%) 10 (100%) 36 (100%)

91 (72%)

0 (0%) 0 (0%) 0 (0%) 1 (23%) 3 (100%) 2 (31%) 6 (59%) 3 (39%) 8 (62%) 13 (87%) 12 (86%) 8 (81%) 36 (100%)

92 (72%)

0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 36 (100%)

36 (29%)

Electronic All 12 Core Implement Drug- General Provide Drug and DrugQuality Patient Copy Copy of Allergy Measures of Record On Discharge Request Instructions Interaction Checks

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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

P Value

Percentage of Children’s Hospitals Teaching status Major teaching Minor teaching Nonteaching Size Small (6-99 beds) Medium (100-399 beds) Large (400+ beds) Region Northeast Midwest South West Ownership Private nonprofit Public Children’s hospital type Freestanding Children’s hospital within hospital Associate Total

39 17 62

61 83 38

.14

40 18 40

60 82 60

.20

36 37 26 46

64 63 74 54

.43

38 21

62 79

.54

35 39 33 29

65 61 67 71

.85

Total number of children’s hospitals = 126. 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.



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Change in Adoption of Electronic Health Records by US Children's Hospitals Mari M. Nakamura, Marvin B. Harper and Ashish K. Jha Pediatrics 2013;131;e1563 DOI: 10.1542/peds.2012-2904 originally published online April 15, 2013;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since . Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .


Change in Adoption of Electronic Health Records by US Children's Hospitals Mari M. Nakamura, Marvin B. Harper and Ashish K. Jha Pediatrics 2013;131;e1563 DOI: 10.1542/peds.2012-2904 originally published online April 15, 2013;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/131/5/e1563

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since . Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .
