Health Information Technology in the United States

For more than a decade, it has been known that HIT in the United States—specifically EHRs—can reduce costs and improve patient care quality and safety (Chaudhry et al, 2006; Walker et al, 2005). The United States is currently challenged to universally implement EHRs across all settings from hospitals to ambulatory care settings to home health agencies and nursing homes. For EHR systems to have the greatest impact on cost and quality, they must also be interoperable with the ability to exchange information across systems and settings in a standardized manner that protects the reliability, confidentiality, privacy, and security of the information.

Within the United States, there are two major influences on the adoption of EHRs, the federal government and America’s health insurance plans (Association of Health Insurance Plans [AHIP], 2005). According to President George W. Bush, “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care” (State of the Union Address, January 20, 2004). To this end, President Bush established a goal to have universal EHR adoption in the United States by 2014. President Barack Obama supported this initiative and allocated $25.9 billion of the American Recovery and Reinvestment Act funds to EHR adoption (U.S. Department of Health & Human Services [DHHS], 2012a, para. 2). As a result, a modest growth in adoption of EHRs has occurred. In 2009, 11.9% of acute care hospitals reported using EHRs compared with 8.9% in 2008 (Jha et al, 2010).

Measuring adoption rates of EHRs in the United States has been a challenge because it was dependent on self-reporting. However, this will soon change. The Centers for Medicare & Medicaid Services (CMS) now offers incentive programs for providers—hospitals and physician practices—that qualify and adopt certified EHRs that meet meaningful use criteria. Therefore, the CMS now has a process to register providers using EHRs because they may qualify for incentive payments.

Key Functions of the EHR

The Institute of Medicine (IOM) (2003) recommends that EHR systems offer the following eight functionalities: 1) health information and data capture; 2) results/data management; 3) provider order entry management; 4) clinical decision support; 5) electronic communication and connectivity between providers, the health care team, and patients; 6) patient support; 7) administrative process support; and 8) reporting and population health management. Table 14-1 provides more detailed information about these core functionalities.

Two specific functionalities recommended by the IOM—clinical decision support and computerized provider order entry (CPOE)—are frequently mentioned in the literature as essential to improve the quality and safety of health care (IOM, 2003; Smith, 2004). Clinical decision support contributes to safety and quality by providing automatic reminders about preventive practices, such as immunizations, drug alerts for dosing and interactions, and electronic resources for data interpretation and clinical decision making.

CPOE is defined as the “process by which the physician or another health care provider, such as a nurse practitioner, physician’s assistant, or physical or occupational therapist, directly enters orders for client care into a hospital information system” (Hebda and Czar, 2009, p. 23). CPOE contributes to safety and quality by eliminating lost orders and illegible handwriting; generating related orders automatically (e.g., a laboratory test needed to monitor a specific medication); monitoring for duplicate or contradictory orders; and reducing time to fill orders (Hebda and Czar, 2009; IOM, 2003). CPOE functions also contribute to medical error prevention through the following (Bates and Gawande, 2003):

In addition to providing the core functions as noted earlier, the EHR must be efficient and offer additional support that is dependent on each institution or facility and the type of services that are provided (i.e., ambulatory or inpatient services). For example, an inpatient facility EHR needs to integrate with nursing services, pharmacy, operating room management systems, and laboratory information systems, to name a few. The most commonly accessed functions of an EHR are the laboratory, diagnostics, and radiology reports (Robert Wood Johnson Foundation, 2010). To view sample screens from an EHR, see Figures 14-1 and 14-2.

EHR Data Management

A fully functional EHR is a complex system. Consider a single data element (datum), such as a person’s weight. The system must be able to capture, or record, the weight, then store it, process it, communicate it to others, and present it in a different format, such as a bar graph or chart. All of this must be done in a secure environment that protects the patient’s confidentiality and privacy. The complexity of these issues and the development of the necessary systems help explain why few fully functional EHR systems are in place today. In fact, according to a Robert Wood Johnson Foundation report, only 6.3% of physician offices had fully functioning EHRs in 2009 (DesRoches and Painter, 2010).

EHRs and “Meaningful Use”

The American Recovery and Reinvestment Act of 2009 directed the “meaningful use” of EHR systems for hospital and physician practice settings and provided for financial incentives from the CMS to providers who adopt and use EHRs that meet the meaningful use standards. “Meaningful use” refers to a complex set of capabilities and standards to be met by EHR use in a series of three stages over several years. The first stage, year 2011-2012, forms the foundation for electronic data capture and information sharing and includes 5 priorities (U.S. DHHS, 2012b):

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