Meaningful Use of Electronic Health Records by Rural Health Clinics

Document technical information

Format pdf
Size 799.0 kB
First found Nov 13, 2015

Document content analysis

Category Also themed
Language
English
Type
not defined
Concepts
no text concepts found

Persons

Andrew F. Cooper
Andrew F. Cooper

wikipedia, lookup

David Hartley (philosopher)
David Hartley (philosopher)

wikipedia, lookup

George Bush (biblical scholar)
George Bush (biblical scholar)

wikipedia, lookup

Organizations

Places

Transcript

Maine Rural Health Research Center
Working Paper #52
Meaningful Use of Electronic Health
Records by Rural Health Clinics
February 2014
Authors
John A. Gale
David Hartley
Zach Croll
Muskie School of Public Service
University of Southern Maine
Meaningful Use of Electronic Health Records By
Rural Health Clinics
February 2014
Maine Rural Health Research Center
Working Paper #52
John A. Gale. MS
David Hartley, PhD, MHA
Zach Croll, BA
Muskie School of Public Service
University of Southern Maine
This study was funded under a Cooperative Agreement with the federal Office of Rural Health
Policy, Health Resources and Services Administration, DHHS (CA#U1CRH03716). The
conclusions and opinions expressed in the paper are the authors' and no endorsement by the
University of Southern Maine or the sponsor is intended or should be inferred.
TABLE OF CONTENTS
Introduction ..................................................................................................................... 1
Policy Context for Meaningful Use of Electronic Health Records (EHRs) ....................... 2
Understanding Meaningful Use ....................................................................................... 5
Rural Health Clinics (RHCs) and EHR Adoption ............................................................. 8
Study Description, Comparison of Survey Respondents to Overall Population of RHCs
and Study Limitations ...................................................................................................... 9
Adoption of Information Technology by RHCs .............................................................. 11
Adoption of Electronic Health Records (EHRs) by RHCs .............................................. 14
Qualification for Medicaid Incentive Payments .............................................................. 18
RHC Performance on Stage 1 Meaningful Use Measures ............................................ 19
Conclusions................................................................................................................... 23
Limitations ..................................................................................................................... 24
References .................................................................................................................... 29
TABLES
Table 1. Comparison of Survey Respondents to Overall Population of RHCs ...........................11
Table 2. Clinic Internet Access ..................................................................................................12
Table 3. Practice Management and Billing Systems ..................................................................13
Table 4. Automated Practice Management Functions ...............................................................13
Table 5. Implementation of Electronic Health Records (EHR) ...................................................14
Table 6. EHR Has Computerized Order Entry (CPOE) Function ...............................................15
Table 7. Sought Technical Assistance or Support From Area HIT Regional Extension Center 17
Table 8. Will Meaningful Use Incentives Affect Your Decision Regarding Implementation or
Updating of an EHR? ........................................................................................................18
Table 9. 30 Percent or More of Clinic Volume Attributed to Needy Individuals ..........................19
Table 10. Stage One Meaningful Use Objectives: Core Set* .....................................................26
Table 11. Stage One Meaningful Use Objectives: Menu Set* ....................................................28
FIGURES
Figure 1. Stages of Meaningful Use ........................................................................................... 6
Figure 2. Stage One Meaningful Use Objectives: Core Set ........................................................ 7
Figure 3. Stage One Meaningful Use Objectives: Menu Set ....................................................... 8
Figure 4. Percentage of RHCs Meeting or Approaching Threshold on Core Measures Set .......21
Figure 5. Percentage of RHCs Meeting or Approaching Threshold on Menu Measures Set ......22
Figure 6. Progress of RHCs on Stage 1 Meaningful Use (MU) ..................................................23
Introduction
The use of health information technology (HIT) in general, and electronic health records
(EHRs) in particular, is increasingly viewed as necessary to enable hospitals, physicians groups,
and other providers to manage and document the quality of care provided to patients. Use of an
EHR is also considered a prerequisite to cope with the demands of health reform and evolving
practice transformation opportunities such as patient-centered medical homes and accountable
care organizations. The Health Information Technology for Economic and Clinical Health Act
(HITECH) of 2009, which was enacted as part of the American Recovery & Reinvestment Act
of 2009 (hereafter collectively referred to as HITECH), committed substantial resources ($30
billion) and created financial incentives to support the adoption and meaningful use of EHRs.
As will be described in greater detail later in this paper, the term meaningful use describes the
use of EHR technology to improve the delivery of care and builds on previous policy initiatives
to modernize the U.S. health care infrastructure, in part, by promoting adoption of EHR
technology. In current usage, the term meaningful use describes two related concepts. The first
is a framework which defines the role of EHRs and health information technology in addressing
the following five health outcome priorities: 1) improving health care quality, safety, and
efficiency, and reducing health disparities; 2) engaging patients and families in their health; 3)
improving care coordination; 4) improving population and public health; and 5) maintaining
privacy and security of patient health information.1,2 Expected benefits of the meaningful use of
EHRs include: improved clinical and population health outcomes, increased transparency, and
improved patient empowerment. The second is a process through which health care
professionals and hospitals can qualify for Medicare and Medicaid incentive payments for
adopting and using EHRs to achieve specified objectives3 and demonstrate that they are using
their EHRs in ways that positively affect the care of their patients. To qualify for incentive
payments, providers must meet the Centers for Medicare and Medicaid Services (CMS) defined
minimum requirements for meaningful use by attesting to their performance on objectives
aligned with the above five priority areas.
With more than 4000 clinics serving rural residents nationwide, Rural Health Clinics (RHCs)
are an important source of primary care services in rural areas.4 Despite their important role in
the health care infrastructure of rural communities, little information is available on their rate of
EHR adoption and use, the barriers to EHR adoption they experience, or the technical assistance
Maine Rural Health Research Center
1
and support resources necessary to encourage greater rates of adoption. This study was
conducted to identify the rates of EHR adoption among a national random sample of RHCs, and
the extent to which RHCs that have adopted an EHR are likely to achieve Stage 1 meaningful
use of their EHRs.
Despite the importance of EHRs in today’s health care environment, EHR adoption rates remain
relatively low, with 40 percent of office-based physicians and 44 percent of hospitals reporting
adoption of at least a basic EHR in 2012.5 Physician practices and facilities that have adopted an
EHR are more likely to be larger organizations located in urban areas. Office-based physicians
that have adopted an EHR are more likely to be primary care physicians, practice in larger
groups (more than 11 physicians), and/or practice in organizationally-owned rather than private
practice settings.5-7
In a recent study, Hsiao and colleagues7 found that relative increases in EHR adoption were
highest among physicians who had traditionally low levels of EHR adoption (e.g., older
physicians, physicians working in solo practices). Contrary to past perceptions, they found that
rural physicians had higher rates of EHR adoption in 2012 than physicians in large urban areas.
As in previous studies, primary care physicians continued to have higher rates of adoption than
non-primary care physicians. The authors found no differences in the rates of EHR adoption
across physicians practicing in high poverty areas compared to those in low poverty areas.
However, small practices (i.e., five or fewer physicians) were less likely to have adopted an
EHR than large practices (six or more physicians). Hsiao and colleagues also found that
physicians who had adopted an EHR tended to routinely use the key capabilities of their EHRs,
specifically particularly those specified by the Stage 1 core criteria for meaningful use.
Policy Context for Meaningful Use of Electronic Health Records (EHRs)
Meaningful use of EHRs and HIT has become a national health care priority with the passage of
HITECH in 2009, providing resources to support the adoption and meaningful use of EHRs. Despite
the recent attention focused on the meaningful use of EHRs, origins of the current policy interest
date back to the early 1990s.
The Institute of Medicine (IOM) has been a leading advocate for the use of HIT in improving
patient care. In 1991, the IOM called for “nationwide implementation of computer-based patient
records.”8 In its 2001 Crossing the Quality Chasm report, the IOM recognized the potential role
2
Muskie School of Public Service
of HIT in the development and operation of systems of care that are safe, effective, patientcentered, timely, efficient, and equitable.9 The report acknowledged the relatively slow growth
in the use of HIT to improve administrative and clinical processes and identified investment in
HIT as one of the important organizational capabilities for redesigning the U.S. health care
system. The IOM called for a “renewed national commitment to building an information
infrastructure to support health care delivery, consumer health, quality measurement and
improvement, public accountability, clinical and health services research, and clinical
education.”9 The IOM further suggested the “elimination of most handwritten clinical data by
the end of the decade” as a system goal.9
The push for widespread adoption of EHRs was given a boost in 2004 by President George
Bush with the creation of the Office of the National Coordinator for Health Information
Technology (ONC) within the Department of Health and Human Services (DHHS).10 The ONC
was created in support of President Bush’s goal that most Americans would have access to an
interoperable electronic medical record by 2014. President Bush’s vision and the creation of the
ONC encouraged the formation of numerous stakeholder panels and commissions that served to
move the field forward by defining goals, standardizing language and terminology, and
standardizing data types. For example, the framework for meaningful use grew out of the work
of the National Priorities Partnership, a group convened by the National Quality Forum and
funded by the U.S. DHHS. The group identified the following national system priorities to
focus performance improvement efforts: patient engagement; reduction of racial disparities;
improved safety; increased efficiency; coordination of care; and improved population health.10,11
Privacy and security were added to the list by the Meaningful Use Work Group of CMS’s
Health IT Committee.11 The meaningful use framework lays out criteria to measure the extent to
which physicians or other clinicians with prescription privileges are using EHR technology to
positively manage the quality of care they provide.
HITECH contributed to the development of meaningful use by incentivizing adoption and
deployment of EHRs and HIT more generally by:12-14
1. Promoting HIT, including improving health care quality, safety, and efficiency, and the
application and use of HIT standards;
2. Conducting HIT testing, including pilot testing of standards, implementation
specifications, a voluntary testing program, and research and development programs;
Maine Rural Health Research Center
3
3. Funding grants/loans and demonstration programs, including:
a. Medicaid and Medicare monetary incentives for eligible health care professionals
and hospitals when they adopt and achieve meaningful use of certified EHR
technology,
b. funding to strengthen HIT infrastructure,
c. HIT implementation assistance including the creation of Regional Extension Centers
to provide EHR and meaningful use technical assistance to under-resourced
providers, and
d. other grant support for HIT;
4. Focusing on privacy/security and the Act’s relationship to other laws and reporting
requirements;
5. Establishing State Health Information Exchanges to facilitate information exchange
between providers; and
6. Encouraging HIT workforce development through community college HIT training
programs.
Medicare meaningful use incentives are available to eligible providers* through 2016
(depending on the date of adoption).15,16 HITECH also contains provisions for Medicare
penalties for eligible professionals that fail to achieve meaningful use of an EHR by 2015. For
those failing to achieve meaningful use, their Medicare payments will be reduced by one
percent in 2015, two percent in 2016, and three percent in 2017 and subsequent years.2,17 If less
than 75 percent of EPs have become meaningful users of EHRs by 2018, the adjustment will
change by one percentage point each year to a maximum of five percent.
Since RHCs submit Medicare claims as a facility to Medicare Part A, rather than under the Part
B fee schedule, individual RHC clinicians are not eligible for Medicare meaningful use
incentives. RHC clinicians who provide over 50 percent of their total encounters through the
RHC over a period of 6 months in the most recent calendar year are eligible for Medicaid
meaningful use incentives, as long as they practice in an RHC with a minimum 30 percent of its
volume attributable to “needy” individuals.15 Needy individuals are defined as such by virtue of
receiving: medical assistance from Medicaid or the Children’s Health Insurance Program
*
For purpose of Medicaid meaningful use incentives, eligible providers include: physicians; nurse practitioners; certified nursemidwives; dentists; and physician assistants who furnish services in an FQHC or RHC that is led by a physician assistant (see
reference #15). Facilities such as RHCs and Federally Qualified Health Centers (FQHCs) are not eligible to receive meaningful
use incentive payments directly; rather, their clinicians (also known as eligible providers for purposes of MU incentive
payments) are eligible to receive incentive payments for meaningful use of their EHRs. As noted above, RHCs are not eligible
for Medicare meaningful use payments based on their submission of claims as a facility rather than under the names of
individual providers. For purposes of Medicare meaningful use incentives, eligible providers are defined as doctors of medicine
or osteopathy, oral surgery or dental medicine; podiatric medicine; optometry; and chiropractic medicine (see reference #16).
4
Muskie School of Public Service
(CHIP); uncompensated care from the eligible provider; or services at either no cost or reduced
cost based on a sliding scale. This is not necessarily a disadvantage to RHCs, provided they
meet the 30 percent standard, as the Medicaid meaningful use incentives provide greater
flexibility in terms of adoption date; maximum payout is higher ($63,750 over six years
compared to $44,000 over five years from Medicare); and, unlike Medicare meaningful use
incentives, Medicaid meaningful use incentives do not decline for the first five years based on
the year of adoption.18
Understanding Meaningful Use
HITECH19 established the following three key requirements defining a “meaningful EHR user”:

Use of certified EHR technology in a meaningful manner, including the use of electronic
prescribing as determined to be appropriate by the Secretary;

Use of certified EHR technology that is connected in a manner that provides for the
electronic exchange of information to improve the quality of health care, such as
promoting coordination of care; and

Submission of information on clinical quality measures (and other such measures as
selected by the Secretary) using certified EHR technology.
These three requirements, as discussed earlier, were supplemented by the following framework
for meaningful use adapted from the national priorities and goals established by the National
Priorities Partnership (NPP):10

Improving quality, safety, efficiency, and reducing health disparities;

Engaging patients and families in their health care;

Improving care coordination;

Improving population and public health;

Ensuring adequate privacy and security protections for personal health information.
As described in its recommendations to the Health IT Policy Committee, the Meaningful Use
Workgroup used the NPP’s goals and priorities (i.e., patient engagement, reduction of racial
disparities, improved safety, increased efficiency, coordination of care, and improved
population health) for the first four elements of their meaningful use framework.11 The
Workgroup added the fifth area of privacy and security to reflect the importance of preserving
Maine Rural Health Research Center
5
the confidentiality of patient information and ensuring patient trust in the use of EHRs. The
concept of meaningful use is predicated on the belief that HIT is necessary to achieve these
priorities and goals.
As developed by the U.S. DHHS, meaningful use standards are being implemented in three
stages over the five year period 2011-2016 (see Figure 1).
Figure 1. Stages of Meaningful Use
Stage 1: 2011-2012
Data Capture and Sharing
Stage 2: 2014
Advanced Clinical Processes
Stage 3: 2016
Improved Outcomes
Criteria focus
Criteria focus
Criteria focus
Electronically capturing heath
information in a standardized format
More rigorous health information
exchange (HIE)
Improving quality, safety, and
efficiency leading to improved health
outcomes
Using that information to track key
clinical conditions
Increased requirements for eprescribing and incorporating lab
results
Decision support for national highpriority conditions
Communicating that information for
care coordination processes
Electronic transmission of patient
care summaries across multiple
settings
Patient access to self-management
tools
Initiating the reporting of clinical
quality measures and public health
information
More patient-controlled data
Access to comprehensive patient
data through patient-centered HIE
Using information to engage patients
and their families in their care
Improving population health
Source: HealthIT.gov. What Is Meaningful Use?3
Stage 1 meaningful use measures: As mentioned earlier, one aspect of meaningful use
established by HITECH involves using a certified EHR to report on clinical quality and other
measures identified by the Secretary of Health and Human Services. Through an extensive
process involving input from a variety of health care and HIT stakeholders, a set of Stage 1
meaningful use measures were identified and released by CMS on July 28, 2010.20 The
measures are summarized in Figures 2 and 3 on the following pages.
Originally, the Stage 1 measures set for eligible providers consisted of 25 measures that
included 15 required core measures and 10 menu measures.21 Beginning in 2013, a measure
related to the capacity to exchange health information between health providers was eliminated
from the core set due to provider confusion on the measure.22 To achieve Stage 1 meaningful
6
Muskie School of Public Service
use and qualify for meaningful use incentive payments, providers must meet the criteria for all
14 core measures and at least five of the remaining menu measures. Of those core and menu
measures, 16 require data submission and eight (originally nine) require yes/no attestation.
Figure 2. Stage One Meaningful Use Objectives: Core Set
Goal(s)
Objective
Measure Specifications
CPOE
More than 30 percent of patients on meds with at least one CPOE
order
Drug-drug and drug allergy
interactions
Feature implemented/turned on (yes/no)
Up to date problem list
ePrescribing
Active medication list
Improve
quality, safety,
efficiency, and
reduce health
disparities
Active medication allergy
list
Demographic information
Vital signs
Smoking status
Quality measures
Clinical decision support
Engage patients
and families in
their health
care
Improve care
coordination
More than 80 percent of patients have at least one entry (or an
indication of no known problems) recorded as structured data
More than 40 percent of prescriptions are transmitted using EHR
More than 80 percent of patients have at least one entry (or entry
indicating that patient is not on medications) recorded as structured
data
More than 80 percent of patients have at least one entry (or entry
indicating patient has no medication allergies) recorded as structured
data
More than 50 percent of patients have demographics (preferred
language, gender, race, ethnicity, date of birth) recorded as
structured data
Vital signs (height, weight, BP, body mass index (BMI), growth
charts for children 2-20 including BMI) are recorded as structured
data for more than 50 percent of patients age two and over
More than 50 percent of patients 13 years old or older have smoking
status recorded as structured data
Report ambulatory clinical quality measures to CMS or, in the case
of Medicaid EPs, the states (yes/no)
Implement one clinical decision support rule relevant to specialty or
high clinical priority with ability to track compliance with rule
(yes/no)
eHealth
summary/information
More than 50 percent of patients requesting an electronic copy of
their health information (including diagnostic test results, problem
list, medication lists, and medication allergies) receive it within three
business days
Clinical summaries
For more than 50 percent of office visits, patients receive a visit
summary within three business days
Information Exchange - No
longer required beginning
2013 (CMS 2012)
Has performed at least one test of its capability to exchange key
clinical information among providers of care and patient authorized
entities electronically (yes/no)
PHI
Protect personal health
Privacy/security information (PHI)
protection
Conduct or review a security risk analysis per 45 CFR 164.308(a)(1),
implement security updates as necessary, and correct security
deficiencies (yes/no)
Source: Community Clinics Health Network. Eligible Professional Meaningful Use Table of Contents: Core and
Menu Set Measures. 2010, November 7.21
Maine Rural Health Research Center
7
Figure 3. Stage One Meaningful Use Objectives: Menu Set
Goal(s)
Objective
Drug formulary checks
Improve
quality,
safety,
efficiency,
and reduce
health
disparities
Lab results
Patient lists/registries
Patient reminders
Engage
patients and
families in
their care
eAccess
Patient education resources
Improve
care
coordination
Medication reconciliation
Improve
population
and public
health
Immunization registries
Summary of care record
Syndromic surveillance
Measure Specifications
Implemented this function and has access to at least one
internal or external formulary during the entire EHR
reporting cycle (yes/no)
More than 40 percent of clinical lab test results (results are
either positive/negative or numerical format) are
incorporated as structured data
Generate at least one patient list based on a specific
condition for QI, reduction of disparities, research, or
outreach (yes/no)
More than 20 percent of patients 65 or older or 5 years or
younger were sent an appropriate reminder for
preventive/follow up care
At least 10 percent of patients are provided with electronic
access to their health information within four business days
of being updated in the EHR
More than 10 percent of patients are provided patientspecific educational resources using EHR technology
Medication reconciliations are performed for more than 50
percent of patients transitioned from another source of care
into the care of the EP
Provide a summary of care record for more than 50 percent
of patients transitioned/referred to another setting of care
Performed at least one test of capacity to submit electronic
immunization data to immunization registry (unless no
registry is capable) and follow up submission if the test is
successful (yes/no)
Performed at least one test of capacity to submit electronic
syndromic surveillance data to public health agencies
(unless no public health agency is capable) with follow-up
submission if the test is successful (yes/no)
Source: Community Clinics Health Network. Eligible Professional Meaningful Use Table of Contents: Core and
Menu Set Measures. 2010, November 7.21
Rural Health Clinics (RHCs) and EHR Adoption
RHCs are an important source of primary care services in rural areas, with over 4,000 clinics
operating nationwide.4 To date, no national studies on the rate of EHR adoption by RHCs have
been conducted. This study was conducted to identify the rates of EHR adoption among a
national random sample of RHCs, and the extent to which RHCs that have adopted an EHR are
likely to achieve Stage 1 meaningful use. In light of the prior studies of EHR adoption by
physicians, which suggest that small physician practices (which would include some RHCs)
may be less likely to adopt an EHR, we sought to answer the following research questions:
8
Muskie School of Public Service

What is the overall rate of EHR adoption among RHCs?

Among those RHCs that have adopted an EHR, what is the level of meaningful use of
their EHRs?

Does the rate of EHR adoption and meaningful use of EHRs vary between providerbased and independent RHCs?

Does the rate of EHR adoption and meaningful use vary by the size of the RHC (based
on the number of providers)?

How do RHCs that have adopted an EHR perform on the core and menu set meaningful
use criteria?
Study Description, Comparison of Survey Respondents to Overall Population of
RHCs and Study Limitations
The study drew a random sample of 660 RHCs from the CMS Provider of Services file. The
survey was conducted electronically using Survey Monkey, which required participants to have
a functioning email address. Data collection for the survey took place during spring and summer
of 2011. Due to an initial low response rate (67 completed surveys), the survey instrument was
revised and released again in March of 2012. Data collection with extensive follow up activity
continued through December 2012, resulting in an additional 158 completed surveys. One
difficulty encountered in fielding the survey was that clinic administrator and/or owner contact
information, including email address, is not available through public data sources such as the
Provider of Services file or the public CMS RHC list. Instead, contact information was collected
from state licensing and survey divisions, State Offices of Rural Health, state RHC associations,
and through phone calls to individual clinics. In the end, we were unable to obtain contact
information for 114 clinics from our sample.
Drafts of the survey instrument were reviewed by Bill Finerfrock, Executive Director of the
National Association of Rural Health Clinics and Ron Nelson, PAc, co-founder and pastpresident of the National Association of Rural Health Clinics, clinic administrator, and RHC
consultant. Finally, the survey was pre-tested with a small sample of RHCs and revised based
on their feedback. Based on our pre-test of the instrument, the survey took approximately 30
minutes to complete for those with an EHR, and approximately 20 minutes for those without an
EHR.
Maine Rural Health Research Center
9
Invitations to participate in the survey were sent to the identified contacts, typically either the
clinic administrator or owner, in each clinic. The invitation contained a link to Survey Monkey
that was unique to the clinic. Staff from the Muskie School of Public Service’s Survey Research
Center followed up with non-respondents at least three times by email and telephone.
Information on the survey was sent to each State Office of Rural Health and State Rural Health
Clinic Association, as well as the National Association of Rural Health Clinics. Each
organization was asked to share information on the survey with their constituents and encourage
them to participate.
As we worked through the survey, 58 clinics from our sample were excluded as the clinic had
either closed, had a phone number that was not in service, had terminated participation in the
RHC program, or had converted to another type of provider. As discussed above, we were
unable to obtain email addresses for 114 clinics in our sample despite multiple attempts and
contacts. As a result, these clinics never received an invitation to participate in the survey. This
left us with a usable sample of 488 clinics that received invitations to participate in the online
survey. Of the usable sample, our response rate for completion of the survey was 46.7 percent.
Overall, survey respondents were similar to the overall population of RHCs based on key
characteristics using the CMS Provider of Services file (see Table 1). The major differences
involved the geographic distribution of survey respondents, with a somewhat higher percentage
located in the Northeast, Midwest, and West, and somewhat fewer respondents located in the
South than the distribution of the overall population of RHCs.
Caution should be exercised in interpreting these results due to the small “n” of our analytic file
(225 clinics responded to our survey). As we undertook the analysis of subsets of the
responding clinics (e.g., clinics reporting implementation of an EHR or clinics reporting
performance on different meaningful use measures), the “n” for any given question was
substantially smaller. As a result, few of our findings are statistically significant and we have
not reported p-values. Although not statistically significant based on the small size of the
analytic file, it should be noted that we do have a rich data set on EHR adoption, performance
on Stage 1 meaningful use measures, and barriers and challenges of EHR implementation
among responding clinics.
10
Muskie School of Public Service
Table 1. Comparison of Survey Respondents to Overall Population of RHCs
Survey Respondents
All RHCs
225
3798
Independent RHCs
Provider-Based RHCs
56.0%
44.0%
54.3%
45.7%
Location in Census Region
Northeast
Midwest
South
West
6.2%
48.0%
25.8%
20.0%
3.6%
39.0%
39.5%
17.9%
Ownership Type
Government Owned
For Profit
Non-profit
12.4%
45.8%
41.8%
16.7%
45.5%
37.8%
Number of RHCs
While a total of 225 clinics responded to the survey, they did not all respond to every question
presented to them. As a result, the reported “n” varies from question to question. For sake of
clarity, we report the actual number of clinics responding to each question.
One final potential limitation is worth noting. We observed some unexpected differences
between independent and provider-based clinics in terms of their use of different technologies,
particularly practice management/billing systems. Based on their assumed access to the greater
resources of their parent hospitals, our hypothesis was that provider-based RHCs would report
equal, if not greater, use of technology compared to independent RHCs. This was not always the
case. Although we cannot explain these differences using our survey data, our experience with
provider-based clinics suggests that decisions about technology and implementation may occur
at the hospital system rather than clinic level. As such, practice management and billing services
may be conducted using the parent hospital’s system rather than a system in place at the clinic.
This would understate technology use among provider-based clinics and suggests that future
survey questions be worded in a way that accounts for this potential issue.
Adoption of Information Technology by RHCs
To establish contextual information on the information technology capacity of RHCs, we asked
about their internet access and use of practice management software to manage clinic billing
and patient account activities. In terms of internet access, almost 90 percent reported using high
speed internet options such as DSL, cable, fiber optic or wireless connectivity (see Table 2).
Maine Rural Health Research Center
11
Slightly over 2 percent of respondents had no internet access (1.3 percent) or only a dial-up
connection (0.9 percent). Close to 9 percent were unsure of the type of internet connection
available to their clinic. In general, RHCs have access to high speed internet access necessary
for the use of HIT.
Table 2. Clinic Internet Access
All RHCs
(n=224)
Independent RHCs
(n=126)
Provider-Based RHCs
(n=98)
30.8%
40.5%
18.4%
9.8%
11.1%
8.2%
Fiber optic/dedicated internet
access (T1)
33.9%
28.6%
40.8%
Wireless (3g/4g)
14.3%
11.9%
17.3%
Dial up
0.9%
1.6%
0.0%
No Internet access
1.3%
0.8%
2.0%
Not sure
8.9%
5.6%
13.3%
DSL
Cable
We also examined the use of practice management/billing systems by RHCs. Practice
management software is designed to automate one or more of the day-to-day
operations/functions of a medical practice including: capturing patient demographics;
scheduling appointments; maintaining lists of insurance payers; submitting third party claims;
preparing patient bills/statements; generating reports to assist in managing the clinic; or
preparing cost reports.
Close to 70 percent of RHCs responding to the question regarding electronic practice
management/billing systems (n=222) had such a system in use to perform practice management
functions (e.g., scheduling, patient billing, etc.) for more than 90 percent of their providers and
staff (see Table 3). Another 10 percent of RHCs had a practice management/billing system in
use for some providers and staff. Almost 21 percent had either no electronic practice
management/billing system in place or had begun installation but were not yet using the system.
In general, close to 80 percent had implemented and were using practice management software
to manage their clinic operations. Close to eight percent were in the process of implementing
their practice management system, but were not yet using it to manage operations.
12
Muskie School of Public Service
Independent RHCs were more likely than provider-based RHCs to report the use of a practice
management system (83 percent vs. 75 percent, respectively). This may be due to the fact that
provider-based clinics may not have their own practice management systems in place but,
rather, use their parent hospital’s management/billing system.
Table 3. Practice Management and Billing Systems
All RHCs
Independent RHCs
(n=222)
(n=123)
Provider-Based RHCs
(n=99)
Electronic PM/billing system in use
in more than 90 percent of practice
69.8%
72.4%
66.7%
Electronic PM/billing system in use
for some providers and staff
9.5%
10.6%
8.1%
No electronic PM/billing system
13.1%
10.6%
16.2%
Begun installation but not in use yet
7.7%
6.5%
9.1%
As shown in Table 4, independent RHCs were generally more likely than provider-based RHCs
to have implemented automated practice management functions using their practice
management/billing software. As above, this may reflect provider-based clinics’ use of their
parent hospital’s practice management or billing system, as opposed to using a clinic-specific
system of their own. As such, they may be less likely to report in-house implementation of the
above practice management functions. At the same time, some of these practice management
functions may be conducted at the hospital or system level rather than at the clinic level.
Table 4. Automated Practice Management Functions
All RHCs Independent RHCs
(n = 176)
(n = 102)
Provider-Based RHCs
(n = 74)
Patient registration
79.0%
76.5%
82.4%
Patient scheduling
84.7%
84.3%
85.1%
Patient accounts receivable
83.0%
83.3%
82.4%
Electronic billing to 3rd party payers
86.4%
88.2%
83.8%
Reporting and analysis
78.4%
85.3%
68.9%
Insurance verification
58.5%
56.9%
60.8%
Produce interim cost reports
23.3%
23.5%
23.0%
Produce reports to manage clinic/
complete cost reports
73.9%
78.4%
67.6%
Maine Rural Health Research Center
13
Adoption of Electronic Health Records (EHRs) by RHCs
Fifty-nine percent of respondents reported having implemented the use of an EHR for at least
some of their providers and staff, with 52 percent reporting its use for 90 percent or more of
their practice (see Table 5). Independent RHCs were more likely to have an EHR in use in at
least some of their practice (69 percent) than provider-based clinics (47 percent). Notably, more
provider-based clinics (26 percent) were in the process of installing their EHRs (but not yet
using them) compared to independent clinics (8 percent). Once fully implemented, the
percentage of independent RHCs compared to provider-based RHCs using an EHR will be
comparatively similar. Overall, 25 percent of respondents had no EHR capacity.
Table 5. Implementation of Electronic Health Records (EHR)
All RHCs
(n=217)
Independent
RHCs (n=121)
Provider-Based
RHCs (n=96)
EHR in use in more than 90 percent
of practice
51.6%
59.5%
41.7%
EHR in use for some providers and
staff
7.4%
9.1%
5.2%
16.1%
8.3%
26.0%
24.9%
23.1%
27.1%
Begun installation but not in use yet
No EHR
Most commonly implemented brands of EHRs: Over 50 different EHR platforms were
represented among survey participants. The six most commonly used EHR systems by vendor
were:

AllscriptsMisys (n=19)

eClinicalWorks (n=15)

Epic Systems Corporation (n=15)

McKesson Provider Technologies (n=9)

e-MDs (n=8)

GE Healthcare/Centricity (n=8)
Characteristics of RHCs without an EHR: Most of the responding clinics (25 percent)
without an EHR tended to be smaller facilities with 63.5 percent reporting one or fewer full
time physicians (MDs/DOs), 17 percent reporting more than one and up to three physicians; and
14
Muskie School of Public Service
19 percent reporting more than three physicians. Two thirds of RHCs without an EHR had one
or fewer full-time physician assistants, nurse practitioners, or certified nurse midwives.
Computerized Physician Order Entry (CPOE): The use of CPOE is an important component
of EHR use as it allows providers to electronically enter their instructions for the treatment of
patients under their care. These orders are electronically communicated to the medical staff or to
the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE
decreases delays in order completion, reduces errors related to handwriting or transcription,
allows order entry at the point of care or off-site, provides error-checking for duplicate or
incorrect doses or tests, and facilitates updating of the patient’s medical record.2
Almost 90 percent of respondents with an EHR had a system with built in CPOE functions, and
just over 78 percent used the functions for some or all of their providers (see Table 6). Slightly
more independent RHCs used CPOE (81 percent) than provider-based clinics (74 percent).
Table 6. EHR Has Computerized Order Entry (CPOE) Function
All RHCs
Independent RHCs
(n=134)
(n=84)
Provider-Based RHCs
(n=50)
Yes-in use for some or
all providers
78.4%
81.0%
74.0%
Yes but turned off or
not in use
11.2%
9.5%
14.0%
No
4.5%
2.4%
8.0%
Not sure
6.0%
7.1%
4.0%
Plans to Acquire an EHR: Slightly more than 37 percent of responding RHCs without an EHR
had plans to acquire and implement a system within the next 12 months, and slightly more than
46 percent had plans to acquire and implement a system more than 12 months from the time of
the survey. Over 16 percent reported no plans to acquire an EHR or were unsure of their clinics’
plans. Provider-based RHCs, which essentially operate as a department of their parent hospital
and presumably have access to the greater IT and administrative resources of that hospital, were
more likely than independent RHCs to report plans to acquire and implement an EHR within the
next 12 months (46.2 percent vs. 28.6 percent, respectively). Independent RHCs (18 percent)
Maine Rural Health Research Center
15
were more likely to report no plans to implement an EHR than were provider-based clinics (7.7
percent).
Barriers/challenges impacting plans to acquire and implement an EHR: Respondents
without an EHR reported that the most common barriers to acquiring and implementing an EHR
were the costs to acquire and maintain an EHR (80 percent), lack of capital (57 percent), and
concerns about productivity and/or income loss during transition (50 percent). Independent
clinics were more likely than their provider-based counterparts to report each type of barrier.
For example, lack of physician/provider support (46 percent vs. 7.7 percent) and
security/privacy concerns (19 percent vs. 7.7 percent) were greater challenges for independent
clinics than for provider-based clinics.
Sources of Technical Assistance and Support: To understand the extent to which RHCs are
able to access technical assistance and support around their EHR decisions, and the sources of
that technical assistance and support, we asked a series of questions related to this topic. In
particular, we were interested in the extent to which RHCs have used their Regional Extension
Centers (RECs) to support their efforts to purchase and implement an EHR. RECs were funded
under HITECH in recognition of the fact that small and rural providers (including physician
practices and hospitals) have historically faced challenges in maximizing the use of HIT to
improve quality and coordinate care.23 RECs provide free or reduced cost technical assistance
on EHR selection, implementation, and use to priority primary care providers (i.e., doctors of
medicine or osteopathy, nurse practitioners, nurse midwifes, or physician assistants with
prescriptive privileges in the locality where s/he practices family medicine, internal medicine,
pediatric medicine, or obstetrics and gynecology) who practice in: individual or small practices
of 10 providers or less; Community Health Centers, primary care clinics, or RHCs; public or
Critical Access Hospitals; or other settings that serve uninsured, underinsured, and medically
underserved populations.24
Overall, 44 percent of responding clinics reported use of their REC for technical assistance or
support related to the purchase or implementation of an EHR/HIT system. Clinics without an
EHR were more likely than those with an EHR to report having contacted their area REC for
technical assistance and support (51.2 percent vs. 39.5 percent, respectively) (see Table 7). This
finding held true for both independent and provider-based RHCs. Just under 8 percent of all
16
Muskie School of Public Service
clinics responding to this question reported that they were not aware of the REC program.
Clinics that already had an EHR were more likely to report that they were not aware of the REC
Program than clinics without an EHR (11 percent vs. 4 percent, respectively). This was also true
for both independent and provider-based RHCs.
Table 7. Sought Technical Assistance or Support from Area HIT Regional Extension
Center
All Respondents
Independent RHCs
Provider-Based RHCs
(n=203)
(n=112)
(n=91)
With EHR
W/O EHR
With EHR
W/O EHR
With EHR
W/O EHR
(n=119)
(n=84)
(n=76)
(n=36)
(n=43)
(n=48)
Yes
39.5%
51.2%
42.1%
50.0%
34.9%
52.1%
No
31.1%
33.3%
30.3%
38.9%
32.6%
29.2%
Not sure
18.5%
11.9%
15.8%
8.3%
23.3%
14.6%
Not aware
of REC
Program
10.9%
3.6%
11.8%
2.8%
9.3%
4.2%
For other types of technical assistance or support (not provided by the RECs), the source of
support varied somewhat based on the clinic type. Provider-based RHCs, which operate under
the supervision and direction of their parent hospitals, were more likely than independent RHCs
to have received technical assistance and/or support from a parent hospital, system, or provider
network (41 percent vs. 14 percent, respectively). Provider-based RHCs were also more likely
than independent RHCs to report in-house expertise (20 percent vs. 12 percent). In contrast,
independent RHCs were more likely than provider-based clinics to have received technical
assistance and/or support from a vendor (27 percent vs. 19 percent) or external organization
(e.g., quality improvement organization (34 percent vs. 14 percent). Independent RHCs were
also more likely to have not received any technical assistance or support (13 percent vs. 5
percent).
Influence of and eligibility for meaningful use incentive programs: The Medicare and
Medicaid EHR incentive programs are intended to encourage providers to adopt and implement
EHRs and, once implemented, achieve the increasingly more rigorous Stage 2 and 3 standards
of meaningful use of those systems. As discussed earlier, RHCs do not qualify for Medicare
meaningful use incentives due to the fact that they submit claims as a facility under Medicare
Part A rather than under the Medicare Part B fee schedule. As such, the Medicare meaningful
Maine Rural Health Research Center
17
use incentives are not expected to have an influence on their decisions regarding adoption and
meaningful use of an EHR. RHCs are, however, eligible for Medicaid meaningful use
incentives, provided that 30 percent or more of their volume represents services provided to
needy individuals (i.e., covered by Medicaid or CHIP or receiving uncompensated care or
discounted care based on a sliding fee scale). To assess the influence of the meaningful use
incentives on RHCs and the extent to which they are likely to qualify for Medicaid meaningful
use incentives, we asked survey respondents about the influence of meaningful use incentives
on their decisions regarding EHR implementation and the extent to which 30 percent or more of
their clinic volume represented services provided to needy individuals.
Just over 69 percent of clinics without an EHR reported that the meaningful use incentives will
affect their decision to implement an EHR (see Table 8). Slightly more than half (52 percent) of
clinics with an EHR reported that meaningful use incentives will affect their decision to update
their EHR to a certified system. These findings were consistent across independent and
provider-based RHCs.
Table 8. Will Meaningful Use Incentives Affect Your Decision Regarding Implementation
or Updating of an EHR?
All Respondents
Independent RHCs
Provider-Based RHCs
(n=166)
(n=89)
(n=77)
With EHR
W/O EHR
With EHR
W/O EHR With EHR
W/O EHR
(n=127)
(n=39)
(n=72)
(n=17)
(n=55)
(n=22)
Yes
52.0%
69.2%
51.4%
70.6%
52.7%
68.2%
No
37.0%
23.1%
40.3%
23.5%
32.7%
22.7%
Not sure
11.0%
7.7%
8.3%
5.9%
14.6%
9.1%
Qualification for Medicaid Incentive Payments
While 67.5 percent of clinics indicated that 30 percent or more of their clinic volume was
attributed to needy individuals, independent RHCs were more likely than their provider-based
counterparts to meet the 30 percent threshold (72.3 percent vs. 61.5 percent, respectively) (see
Table 9).
18
Muskie School of Public Service
Table 9. 30 Percent or More of Clinic Volume Attributed to Needy Individuals
All Respondents
Independent RHCs
Provider-Based RHCs
(n=203)
(n=112)
(n=91)
Yes
137 (67.5%)
81 (72.3%)
56 (61.5%)
No
35 (17.2%)
17 (15.2%)
18 (19.8%)
Not sure
31 (15.3%)
14 (12.5%)
17 (18.7%)
RHC Performance on Stage 1 Meaningful Use Measures
In analyzing the performance of responding RHCs on the core and menu measures sets (see
Tables 10 and 11), it is important to note that questions related to the core measures were only
asked of those 128 clinics that reported active use of their EHRs (defined by the project team as
using their EHRs for at least some, if not all, of their providers and staff). The 35 clinics that
reported having purchased or implemented an EHR but were not yet using it to manage patients
were not asked these questions, as they currently have no experience to report.
To assess RHCs’ progress towards meaningful use, we asked a multi-level question for each
measure with the following options:

Are the clinic’s eligible providers meeting the threshold criterion for the measure
necessary to achieve meaningful use?

Are the clinic’s eligible providers using the clinic’s EHR for the tasks and functions
established by the measure but without meeting the established threshold criterion
necessary to achieve meaningful use?

The clinic’s EHR has the function specified by the measure but it is turned off or not in
use.

The respondent did not know the answer to the question.

No, the clinic’s providers were not using the feature at all.
By using this multilevel response set, we are able to assess the extent to which clinics were
either meeting the criterion for meaningful use for a given measure or at least using their EHR
as specified by the measure and moving towards meeting the criterion. For purposes of the
following discussion, the clinics in this latter category are those that are “approaching” the
threshold.
Maine Rural Health Research Center
19
RHC performance on core measures set: As previously discussed, Stage 1 meaningful use
requires an eligible provider to meet the threshold standards for each of the 14 measures in the
core set and a minimum of five measures from the menu set. As noted, the Stage 1 core
measures set originally included 15 core measures, however, the measure on the capacity to
exchange information between providers was dropped beginning in 2013. As we collected data
on this measure before it was eliminated, we present the results in Table 10. This measure was
not used, however, in the calculation of the percentage of RHCs likely to achieve Stage 1
meaningful use as presented in the conclusion of this paper. The following section reviews the
performance of survey respondents with an EHR with respect to the original 15 measures in the
core set.
With the exception of their performance on reporting quality measures (44.6 percent) and the
implementation of clinical decision support rules (55.7 percent), our survey results indicate that
RHCs do well on the core measures related to the category of improving quality, safety,
efficiency, and reducing health disparities, with 78.4 percent to 93.4 percent of RHCs
reporting that they have met the criteria for the remaining nine measures in this category. An
additional 2.5 percent to 9.6 percent of RHCs are approaching, but have yet to meet, the
threshold criteria for these nine measures. In addition, 6.6 percent and 4.1 percent of RHCs,
respectively, are approaching the threshold on reporting quality measures and implementing
decision support rules. It is likely that the performance of clinics that have not met the threshold
criteria will improve as they gain experience with their EHRs.
Clinics perform less well on the measures in the remaining three categories (engaging patients
and families in their health care, improving coordination of care, and protecting the privacy
and security of personal health information) with 48.8 to 66.7 percent of clinics meeting the
threshold criteria for the measures in these categories. An additional 6.5 percent and 14.1
percent, respectively, of clinics are approaching but have not yet met the threshold criteria for
providing eHealth summary information and clinical summaries to their patients. The remaining
two measures (performing a test of information exchange capabilities and protecting personal
health information) require a yes/no response and, as such, there is no threshold response as
clinics either meet the standard or they do not.
20
Muskie School of Public Service
Figure 4 summarizes the extent to which respondents have met or are approaching the threshold
for the 14 measures in the core set.
Figure 4. Percentage of RHCs Meeting or Approaching Threshold on Core Measures Set
Includes only those RHCs actively using their EHRs (n = 128) and does not include those RHCs that have acquired
but not yet implemented their EHRs (n=35).
RHC performance on menu measures set: The results of responding clinics’ performance on
the menu set are summarized in Table 11. In general, survey participants performed less well on
the menu measures set than they did on the core measures. The results were also less consistent
across the categories of measures.
Clinics performed best on the measures related to incorporating lab results (77.4 percent
meeting the threshold and another 12.9 percent approaching the threshold); providing summary
of care records (68.3 percent meeting the threshold and another 7.5 percent approaching the
threshold); providing patient education resources (57 percent meeting the threshold and another
15.7 percent approaching the threshold); medication reconciliation (63.3 percent meeting the
threshold and another 5 percent approaching the threshold); drug formulary checks (67.2
percent meeting the threshold); and using the EHR to produce patient lists/registries (63.6
percent meeting the threshold). Performance fell off to approximately 50 percent or less for the
remaining measures, with the weakest performance for the two measures (immunization
registries and syndromic surveillance) in the population and public health performance
improvement category.
Maine Rural Health Research Center
21
Figure 5. Percentage of RHCs Meeting or Approaching Threshold on Menu Measures Set
Includes only those RHCs actively using their EHRs (n = 128) and does not include those RHCs that have acquired
but not yet implemented their ERHs (n=35).
Figure 5 summarizes the extent to which respondents have reached the threshold or are
approaching the threshold for the 10 measures in the menu set. Almost 67 percent of responding
RHCs met or were approaching the threshold for five or more of the menu criteria. Although
eligible providers are only required to meet the criteria for five of the ten menu set measures to
achieve Stage 1 meaningful use, most of the Stage 1 menu measures will become core measures
with higher thresholds under the Stage 2 criteria to demonstrate meaningful use. As the Stage 2
measures for eligible providers could be effective as early as calendar year 2014 for early
demonstrators (2011 or 2012) of meaningful use, it is important to note that more than twothirds of responding clinics have met or are approaching the threshold criteria for the minimum
five measures necessary to achieve Stage 1 meaningful use, with slightly over 10 percent
reporting activity on nine to ten measures. The number and percentage of responding clinics
meeting the standard for each of the ten menu set measures is shown in Table 11.
Likelihood of RHCs achieving meaningful use of their EHRs: Finally, we estimated the
percentage of clinics likely to achieve Stage 1 meaningful use of their EHRs based on meeting
the criteria for all fourteen measures in the core set and meeting the criteria on five of the ten
measures in the menu set. We also estimated the percentage of clinics that are “near”
meaningful use by virtue of having implemented the activities (and approaching or meeting the
threshold) for 12 of the 14 core measures and four of five menu measures. Of the 128 clinics
22
Muskie School of Public Service
reporting their performance on the full set of core and menu measures, close to 11 percent (14
clinics) have met the standards for meaningful use and approximately 38 percent (48 clinics) are
near to achieving meaningful use based on either meeting or approaching the threshold criteria
as described above (see Figure 6). It is likely that this second group will eventually meet
meaningful use as they gain experience with their EHRs.
Figure 6. Progress of RHCs on Stage 1 Meaningful Use (MU)
“Near” meaningful use
clinics are those that
have met or are
approaching the
threshold criteria for
12 of the 14 core
measures and four of
five menu measures.
Conclusions
Moving forward, it is clear that some RHCs are unlikely to adopt an EHR or will struggle with
implementation. Approximately 25 percent of responding clinics have not adopted an EHR and
close to 17 percent of that group have no plans to implement an EHR or are unsure of their
plans. As noted earlier, a significant proportion of this group (close to 64 percent) are very small
clinics with few providers. This is a group that would benefit from the services of their local
REC in terms of assessing the feasibility of acquiring and implementing an EHR.
Although support from the RECs would be helpful to this group, the barriers to the acquisition
and implementation of an EHR (for those without an EHR) extend beyond information and
technical support and include acquisition and maintenance costs, lack of capital, and concerns
about loss of productivity and income during the implementation and learning phase. These are
substantial barriers, particularly for the small clinics that account for close to two-thirds of those
Maine Rural Health Research Center
23
clinics without an EHR, and are much harder to solve. Without an EHR, the ability of these
clinics to survive in our evolving health care environment is likely to be compromised.
It is also clear that even those clinics that have adopted EHRs need additional technical
assistance to support the expanded use of their EHRs. In general, clinics that have implemented
and are actively using their EHRs do well on measures related to internal patient care (i.e., the
measures related to improving, safety, and efficiency and reducing health disparities). Areas of
needed support include: engaging patients and families in their health care (for measures related
to sharing and accessing patient information); improving coordination of care through the
exchange of patient information with other providers and medication reconciliation; protecting
the privacy and security of personal health information; improving population and public health
(for measures focused on reporting to disease and immunization registries); and improving
quality of care by encouraging public reporting of quality measures and the use of clinical
decision support rules. Their performance on the measures related to practice transformation
and population health activities suggests the need for additional technical assistance and
incentives to encourage RHCs to improve their performance in these areas and to prepare them
for evolving pay for performance and population health reimbursement strategies.
Finally, it is worth noting that Stage 1 is the introductory phase of the three stage
implementation of meaningful use. The requirements for the number of measures met and the
level of performance increase with Stages 2 and 3, as do the expectations related to public
reporting of quality data and improved outcomes. As such, this speaks to RHCs’ need for
additional technical assistance and support during Stage 1 to enhance their ability to use their
EHRs to their fullest capacity. Doing so will provide a strong foundation to cope with the
demands of Stages 2 and 3 meaningful use.
Limitations
Caution should be exercised in interpreting these results, particularly the results related to EHR
adoption, as respondents are likely to be early adopters of technology. This may overstate the
level of EHR use by RHCs, as it is likely that those RHCs that have not adopted an EHR were
less likely to complete our survey. As reported in the study description, our response rate was
46.7 percent. Due to the small “n” for our analytic file, few of our findings are statistically
significant and we have not reported p-values. In consideration of these factors: small sample,
24
Muskie School of Public Service
moderate response rate, and possible response bias, our findings should be interpreted as a pilot
study. As this paper is released, we are nearing completion of a more narrowly focused survey
with a much larger sample. With more than 800 respondents and a higher response rate, we are
hopeful that findings from that survey will be more robust.
Maine Rural Health Research Center
25
Table 10. Stage One Meaningful Use Objectives: Core Set*
Goal(s)
% RHCs
Under Threshold
(n varies by row)
Objective
Measure Specifications
CPOE (n=104)
More than 30 percent of patients on meds with at least one
CPOE order
88.5%
6.7%
Drug-drug and drug allergy
interactions (n=125)
Feature implemented/turned on (yes/no)
88.8%
N/A
Up to date problem list
(n=121)
More than 80 percent of patients have at least one entry (or an
indication of no known problems) recorded as structured data
89.3%
9.1%
78.4%
9.6%
93.4%
6.6%
ePrescribing (n=125)
Active medication list
(n=121)
Improve
quality,
safety,
efficiency,
and reduce
health
disparities
% RHCs
Attaining
Threshold
(n varies by row)
More than 40 percent of prescriptions are transmitted using
EHR
More than 80 percent of patients have at least one entry (or
entry indicating that patient is not on medications) recorded as
structured data
Active medication allergy
list (n=121)
More than 80 percent of patients have at least one entry (or
entry indicating patient has no medication allergies) recorded
as structured data
92.6%
7.4%
Demographic information
(n=120)
More than 50 percent of patients have demographics
(preferred language, gender, race, ethnicity, date of birth)
recorded as structured data
91.7%
2.5%
Vital signs (n=121)
Vital signs (height, weight, BP, body mass index (BMI),
growth charts for children 2-20 including BMI) are recorded
as structured data for more than 50 percent of patients age two
and over
84.3%
5.0%
84.3%
7.4%
44.6%
6.6%
55.7%
4.1%
Smoking status (n=121)
Quality measures (n=121)**
Clinical decision support
(n=97)***†
26
More than 50 percent of patients 13 years old or older have
smoking status recorded as structured data
Report ambulatory clinical quality measures to CMS or, in the
case of Medicaid EPs, the states (yes/no)
Implement one clinical decision support rule relevant to
specialty or high clinical priority with ability to track
compliance with rule (yes/no)
Muskie School of Public Service
% RHCs
Attaining
Threshold
(n varies by row)
% RHCs
Under Threshold
(n varies by row)
Goal(s)
Objective
Measure Specifications
Engage
patients and
families in
their health
care
eHealth
summary/information
(n=121)
More than 50 percent of patients requesting an electronic copy
of their health information (including diagnostic test results,
problem list, medication lists, and medication allergies)
receive it within three business days
57.9%
6.5%
Clinical summaries (n=121)
For more than 50 percent of office visits, patients receive a
visit summary within three business days
48.8%
14.1%
Improve
care
coordination
Information Exchange
(n=120)‡
Has performed at least one test of its capability to exchange
key clinical information among providers of care and patient
authorized entities electronically (yes/no)
52.5%
N/A
PHI Privacy
/ Security
protection
Protect personal health
information (PHI) (n=120)
Conduct or review a security risk analysis per 45 CFR
164.308(a)(1), implement security updates as necessary, and
correct security deficiencies (yes/no)
66.7%
N/A
Source: CMS. Eligible Professional Meaningful Use Table of Contents: Core and Menu Set Objectives, Stage 1. 2013, June 26.22
*Table does not include responses for clinic not using the function specified by the measures or did not know the answer. As a result, the rows total less than
100%
** Respondents in the “Under Threshold” category are those reporting quality measures using paper records not their EHRs.
***Respondents in the “Under Threshold” category are those using clinic decision support rules but are unable to track compliance with the rule.
†This question was only asked of Wave 2 survey respondents. A different version of the question was asked in Wave 1 and the results are not comparable.
‡Beginning in 2013, this measure was no longer required to achieve Stage 1 meaningful use.
Maine Rural Health Research Center
27
Table 11. Stage One Meaningful Use Objectives: Menu Set*
Goal(s)
Objective
Ambulatory Measure Specification
% RHCs
Attaining
Threshold
(n varies by row)
% RHCs
Under
Threshold
(n varies by
row)
Implemented this function and has access to at least one
internal or external formulary during the entire EHR
67.2%
N/A
Improve
reporting cycle (yes/no)
quality,
More than 40 percent of clinical lab test results (results
safety,
Lab results (n=124)
are either positive/negative or numerical format) are
77.4%
12.9%
efficiency,
incorporated as structured data
and reduce
Generate at least one patient list based on a specific
health
Patient lists/registries (n=121)
condition for QI, reduction of disparities, research, or
63.6%
N/A
outreach
(yes/no)
disparities
More than 20 percent of patients 65 or older or 5 years or
Patient reminders (n=121)
younger were sent an appropriate reminder for
46.3%
N/A
preventive/follow up care
At least 10 percent of patients are provided with
Engage
eAccess (n=121)
electronic access to their health information within four
36.4%
9.1%
patients and
business days of being updated in the EHR
families in
More than 10 percent of patients are provided patientPatient education resources (n=121)
57.0%
15.7%
their care
specific educational resources using EHR technology
Medication reconciliations are performed for more than
Improve
Medication reconciliation (n=120)
50 percent of patients transitioned from another source of
63.3%
5.0%
care into the care of the EP
care
Provide summary of care record for more than 50 percent
coordination Summary of care record (n=120)
68.3%
7.5%
of patients transitioned/referred to another setting of care
Performed at least one test of capacity to submit
electronic immunization data to immunization registry
Immunization registries (n=120)
39.2%
N/A
Improve
(unless no registry is capable) and follow up submission
if the test is successful (yes/no)
population
Performed at least one test of capacity to submit
and public
electronic syndromic surveillance data to public health
health
Syndromic surveillance (n=120)
9.2%
N/A
agencies (unless no public health agency is capable) with
follow-up submission if the test is successful (yes/no)
*Table does not include responses for clinic not using the function specified by the measures or did not know the answer. As a result, the rows total less than
100%. Source: Centers for Medicare and Medicaid Services. Eligible Professional Meaningful Use Table of Contents: Core and Menu Set Objectives, Stage 1.
2013, June 26.22
Drug formulary checks (n=125)
28
Muskie School of Public Service
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Centers for Disease Control and Prevention. Meaningful Use: Introduction. 2012,
October 11. Available at: http://www.cdc.gov/ehrmeaningfuluse/introduction.html.
Accessed December 11, 2013.
HealthIT.gov. EHR Incentives & Certification: Meaningful Use Definition & Objectives.
n.d., Available at: http://www.healthit.gov/providers-professionals/meaningful-usedefinition-objectives. Accessed December 11, 2013.
HealthIT.gov. Policymaking, Regulation, and Strategy: Meaningful Use. n.d., Available
at: http://www.healthit.gov/policy-researchers-implementers/meaningful-use. Accessed
September 18, 2013.
Centers for Medicare and Medicaid Services. Rural Health Clinic. Baltimore, MD: U.S.
Department of Health and Human Services, Centers for Medicare & Medicaid Services,
Medicare Learning Network; January, 2013. Rural Health Fact Sheet Series.
Robert Wood Johnson Foundation, Mathematica Policy Research, Harvard School of
Public Health. Health Information Technology in the United States 2013: Better
Information Systems for Better Care. Princeton, NJ: Robert Wood Johnson
Foundation;2013.
DesRoches CM, Campbell EG, Rao SR, et al. Electronic Health Records in Ambulatory
Care--a National Survey of Physicians. N Engl J Med. Jul 3 2008;359(1):50-60.
Hsiao C-J, Jha AK, King J, Patel V, Furukawa MF, Mostashari F. Office-Based
Physicians Are Responding to Incentives and Assistance by Adopting and Using
Electronic Health Records. Health Aff (Millwood). August 1, 2013;32(8):1470-1477.
Institute of Medicine (U.S.). Committee on Improving the Patient Record. The ComputerBased Patient Record: An Essential Technology for Health Care. Washington, DC:
National Academies Press;1991.
Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing
the Quality Chasm : A New Health System for the 21st Century. Washington, D.C.:
National Academy Press; 2001.
National Quality Forum. Wired for Quality: The Intersection of Health IT and Healthcare
Quality. Washington, DC: National Quality Forum; March, 2008. Issue Brief.
Meaningful Use Workgroup. Meaningful Use: A Definition. Recommendations from the
Meaningful Use Workgroup to the Health IT Policy Committee. Washington, DC: U.S.
Department of Health and Human Services; June 16, 2009.
athenahealth, Inc. A Summary of the HITECH Act. Watertown, MA: athenahealth, Inc.;
March, 2009. Whitepaper.
Blumenthal D. Stimulating the Adoption of Health Information Technology. N Engl J
Med. Apr 9 2009;360(15):1477-1479.
Committee on Ways and Means. Health Information Technology for Economic and
Clinical Health Act or HITECH Act. Washington, DC: U.S. House of Representatives,
Committees on Energy and Commerce, Ways and Means, and Science and Technology;
January 16, 2009.
Maine Rural Health Research Center
29
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
30
Centers for Medicare and Medicaid Services. Introduction to the Medicaid EHR Incentive
Program for Eligible Professionals. 2012, Available at:
http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/EHR_Medicaid_Guide_Reme
diated_2012.pdf. Accessed December 11, 2013.
Centers for Medicare and Medicaid Services. Medicare Electronic Health Record
Incentive Payments for Eligible Professionals [Tip Sheet].2013, May. Available at:
http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/MLN_MedicareEHRProgram_
TipSheet_EP.pdf. Accessed December 11, 2013.
Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs;
Electronic Health Record Incentive Program - Stage 2; Rules and Regulations. Fed
Regist. September 4 2012;77(171):53968-54162.
Centers for Medicare and Medicaid Services. EHR Incentive Programs. 2013, November
6. Available at: http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprogram
s/. Accessed December 11, 2013.
Health Information Technology for Economic and Clinical Health (HITECH) Act, Title
XIII of Division a and Title IV of Division B of the American Recovery and
Reinvestment Act of 2009 (ARRA), Pub L. 111-5, 123 STAT 115, (February 17, 2009).
Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs:
Electronic Health Record Incentive Program; Final Rule. Fed Regist. July 28
2010;75(144):44314-44588.
Community Clinics Health Network. Eligible Professional Meaningful Use Table of
Contents: Core and Menu Set Measures. 2010, November 7. Available at:
http://www.cchealthnetwork.com/media/16819/e%20packet%20for%20aqicc%20training
.pdf. Accessed September 18, 2013.
Centers for Medicare and Medicaid Services. Eligible Professional Meaningful Use
Table of Contents: Core and Menu Set Objectives, Stage 1. 2013, June 26. Available at:
https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/downloads/EP-MU-TOC.pdf. Accessed
September 18, 2013.
HealthIT.gov. Frequently Asked Questions: Are There Penalties for Providers Who Don’t
Switch to Electronic Health Records (EHR)? n.d., Available at:
http://www.healthit.gov/providers-professionals/faqs/are-there-penalties-providers-whodon%E2%80%99t-switch-electronic-health-record. Accessed December 11, 2013.
HealthIT.gov. Frequently Asked Questions: What Kinds of Providers Do Regional
Extension Centers Work With? . n.d., Available at: http://www.healthit.gov/providersprofessionals/faqs/what-kinds-providers-do-regional-extension-centers-work. Accessed
December 11, 2013.
Muskie School of Public Service
Maine Rural Health Research Center
Recent Working Papers
WP50. Talbot, J.A., & Coburn, A.F. (2013, March). Challenges and Opportunities for Improving Mental
Health Services in Rural Long-Term Care.
WP 49. Anderson, N., Neuwirth, S., Lenardson, J.D., & Hartley, D. (2013, June). Patterns of care for rural and
urban children with mental health problems.
WP48. Gale, J.A., Lenardson, J.D., Lambert, D., & Hartley, D. (2012, March). Adolescent alcohol use: Do risk and
protective factors explain rural-urban differences. (Working Paper #48).
WP47. Published as: Ziller, E.C., Lenardson, J.D., & Coburn, A.F. (2012). Health care access and use among
the rural uninsured. Journal of Health Care for the Poor and Underserved, 23(3), 1327-1345.
WP46. Anderson, N., Ziller, E.C., Race, M.M., Coburn, Andrew F. (2010). Impact of employment transitions on
health insurance coverage of rural residents.
WP45. Lenardson, J.D., Ziller, E.C., Lambert, D., Race, M.M., & Yousefian, A. (2010). Access to mental health
services and family impact of rural children with mental health problems.
WP44. Hartley, D., Gale, J., Leighton, A., & Bratesman, S. (2010). Safety net activities of independent Rural Health
Clinics
WP43. Gale, J., Shaw, B., Hartley, D., & Loux, S. (2010). The provision of mental health services by Rural Health
Clinics
WP42. Race, M., Yousefian, A., Lambert, D., & Hartley, D. (2009, September). Mental health services in rural
jails.
WP41. Lenardson, J., Race, M., & Gale, J.A. (2009, December). Availability, characteristics, and role of detoxification
services in rural areas.
WP40. Published as: Ziller, E.C., Anderson, N.J., & Coburn, A.F. (2010). Access to rural mental health
services: Service use and out-of-pocket costs. Journal of Rural Health, 26(3), 214-24. doi :
10.1111/j.1748-0361.2010.00291.x
WP39. Lambert, D., Ziller, E., Lenardson, J. (2008). Use of mental health services by rural children.
WP38. Morris, L., Loux, S.L., Ziller, E., Hartley, D. Rural-urban differences in work patterns among adults with
depressive symptoms.
WP37. Published as: Yousefian, A., Ziller, E., Swartz, J., & Hartley, D. (2009). Active living for rural youth:
Addressing physical inactivity in rural communities. Journal of Public Health Management and Practice:
Special Issue on Rural Public Health, 15(3), 223-231.
WP36. Published as: Hartley, D., Loux, S., Gale, J., Lambert, D., & Yousefian, A. (2010, June). Inpatient
psychiatric units in small rural hospitals. Psychiatric Services, 61(6), 620-623.
WP 35a. Lenardson, J. D., & Gale, J. A. (2007, August). Distribution of substance abuse treatment facilities across the
rural-urban continuum.
WP35b. Published as: Lambert, D., Gale, J.A., & Hartley, D. (2008, Summer). Substance abuse by youth and
young adults in rural America. Journal of Rural Health, 24(3), 221-8.
WP34. Published as: Ziller, E.C., Coburn, A.F., Anderson, N.J., & Loux, S.L. (2008). Uninsured rural families.
The Journal of Rural Health, 24(1), 1-11.
Established in 1992, the Maine Rural Health Research Center draws on the
multidisciplinary faculty and research resources and capacity of the Cutler Institute for
Health and Social Policy within the USM Muskie School of Public Service. Rural health
is one of the primary areas of research and policy analysis focus within the Institute, and
the Center builds upon the Institute's strong record of research, policy analysis, and
policy development that addresses critical problems in health care.
The Maine Rural Health Research Center's mission is to inform health care
policymaking and the delivery of rural health services through high quality, policy
relevant research, policy analysis and technical assistance on rural health issues of
regional and national significance. For over 20 years, the Maine Rural Health Research
Center’s research agenda has focused on some of the most intractable health access
problems facing rural residents, especially those with mental health and substance
abuse issues and those facing financial barriers due to lack of insurance and underinsurance.
Maine Rural Health Research Center
Muskie School of Public Service
University of Southern Maine
PO Box 9300
Portland, ME 04104-9300
207-780-4430
207-228-8138 (fax)
http://usm.maine.edu/muskie/cutler/mrhrc

Similar documents

×

Report this document