NCHS Data Brief, Number 143, January 2014

NCHS Data Brief

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No. 143

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January 2014

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Use and Characteristics of Electronic Health Record Systems

Among Ofce-based Physician Practices:

United States, 2001–2013

Chun-Ju Hsiao, Ph.D., and Esther Hing, M.P.H.

Key ndings

• In 2013, 78% of ofce-based

physicians used any type of

electronic health record (EHR)

system, up from 18% in 2001.

• In 2013, 48% of ofce-based

physicians reported having a

system that met the criteria for

a basic system, up from 11%

in 2006. The percentage of

physicians with basic systems

by state ranged from 21% in

New Jersey to 83% in North

Dakota.

• In 2013, 69% of ofce-based

physicians reported that they

intended to participate (i.e.,

they planned to apply or already

had applied) in “meaningful

use” incentives. About 13%

of all ofce-based physicians

reported that they both intended

to participate in meaningful use

incentives and had EHR systems

with the capabilities to support

14 of the Stage 2 Core Set

objectives for meaningful use.

• From 2010 (the earliest year

that trend data are available)

to 2013, physician adoption

of EHRs able to support

various Stage 2 meaningful

use objectives increased

signicantly.

The Health Information Technology for Economic and Clinical Health

(HITECH) Act of 2009 authorized incentive payments to increase physician

adoption of electronic health record (EHR) systems (1

,2). The Medicare and

Medicaid EHR Incentive Programs are staged in three steps, with increasing

requirements for participation. To receive an EHR incentive payment,

physicians must show that they are “meaningfully using” certied EHRs by

meeting certain objectives (3,4). This report describes trends in the adoption

of EHR systems from 2001 through 2013, as well as physicians’ intent to

participate in the EHR Incentive Programs and their readiness to meet 14 of

the Stage 2 Core Set objectives for meaningful use in 2013.

Keywords: health information technology • National Ambulatory Medical

Care Survey

Adoption of basic EHR systems by ofce-based physicians

increased 21% between 2012 and 2013.

Figure 1. Percentage of office-based physicians with EHR systems: United States, 2001–2013

NOTES: EHR is electronic health record. “Any EHR system” is a medical or health record system that is either all or partially

electronic (excluding systems solely for billing). Data for 2001–2007 are from in-person National Ambulatory Medical Care Surve

(NAMCS) interviews. Data for 2008–2010 are from combined files (in-person NAMCS and mail survey). Estimates for 2011–2013

data are based on the mail survey only. Estimates for a basic system prior to 2006 could not be computed because some items

were not collected in the survey. Data include nonfederal, office-based physicians and exclude radiologists, anesthesiologists,

and

pathologists.

SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey, Electronic

Health Records Survey.

Percent

Basic system

Any EHR system

2013201220112010200920082007200620052004200320022001

18.2

17.3 17.3

10.5

11.8

16.9

21.8

27.9

33.9

39.6

48.1

20.8

23.9

29.2

34.8

42.0

48.3

51.0

57.0

71.8

78.4

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• Use of any type of EHR system by ofce-based physicians increased from 18% in 2001 to

48% in 2009 and 78% in the 2013 estimates; 2009 is the year the HITECH Act authorized

incentive payments to increase EHR adoption (Figure 1).

• In 2013, 48% of ofce-based physicians reported having a system that met the criteria for

a basic system, up from 11% in 2006—the rst year that information on basic systems is

available.

Adoption of basic EHR systems and any EHR system varied widely across

states.

• In 2013, the percentage of physicians who had a system meeting the criteria for a basic

system ranged from 21% in New Jersey to 83% in North Dakota (Figure 2).

• The percentage of physicians who had a system meeting the criteria for a basic system was

lower than the national average (48%) in eight states (Connecticut, Maryland, Nevada, New

Jersey, Oklahoma, Vermont, West Virginia, and Wyoming) and higher than the national

average in nine states (Iowa, Massachusetts, Minnesota, North Dakota, Oregon, South

Dakota, Utah, Washington, and Wisconsin).

• In 2013, the percentage of physicians using any type of EHR system ranged from 66% in

New Jersey to 94% in Minnesota (data not shown).

53.8

50.1

52.1

Significantly lower than national average

Not significantly different than national average

Significantly higher than national average

42.3

60.6

64.9

33.0

50.7

82.9

58.1

45.0

42.6

53.0

47.1

65.5

75.5

58.7

54.0

40.2

46.9

52.1

47.6

41.8

37.1

47.2

21.2

30.1

40.0

70.6

45.5

37.0

54.6

46.9

37.1

65.5

38.8

53.1

67.9

*31.0

39.6

39.2

51.1

42.8

51.2

47.7

41.9

36.9

41.5

Figure 2. Percentage of office-based physicians with a basic EHR system, by state: United States, 2013

* Estimate does not meet standards of reliability or precision.

NOTES: EHR is electronic health record. Significance tested at

p < 0.05.

SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey, Electronic Health Records Survey.

39.4

36.9

45.6

National average: 48.1

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Sixty-nine percent of physicians intended to participate in the Medicare or

Medicaid EHR Incentive Programs as of 2013.

• In 2013, 69% of physicians intended to participate (i.e., they planned to apply or already

had applied) in the Medicare or Medicaid Incentive Program, while 19% of physicians

were uncertain and 12% were not going to apply (Figure 3). The percentage of physicians

participating in either the Medicare or Medicaid Incentive Program increased 5% from 2012

(66%) to 2013 (69%) (5).

• About 13% of all ofce-based physicians reported that they both intended to participate in

meaningful use incentives and had EHR systems with the capabilities to support 14 of the

17 Stage 2 Core Set objectives for meaningful use (see the Table for the 17 Stage 2 Core Set

objectives).

• Of physicians intending to participate in the EHR Incentives Programs, 19% had EHR

systems with the capabilities to support 14 of the 17 Stage 2 Core Set objectives for

meaningful use.

• About 56% of all physicians intended to participate in the EHR Incentive Programs but did

not have EHR systems with the capabilities to support 14 of the Stage 2 Core Set objectives

for meaningful use. This percentage accounts for about four-fths of physicians intending to

participate in the EHR Incentive Programs (81%).

NOTES: EHR is electronic health record. “Intends to participate” includes those intending to apply and those who already applie

SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey, Electronic Health Records Survey.

Figure 3. Physicians’ readiness for 14 Stage 2 Core Set objectives, by intention to participate in the EHR Incentive

Programs: United States, 2013

Not

applying

11.8%

Uncertain if

applying

19.1%

Intends to

participate,

not ready

56.0%

Intends to

participate,

ready

13.1%

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From 2010 through 2013, physician adoption of EHRs able to support

seven Stage 2 meaningful use objectives for which 2010 data are available

increased signicantly.

• Increased adoption occurred for all seven of the capabilities for which trend data from 2010

are available. Adoption increased 12% for the objective recording patient demographics and

increased 80% for the objective sending prescriptions electronically (calculated from

Figure 4).

• In 2013, the adoption of computerized capabilities supporting seven Stage 2 Core objectives

for meaningful use ranged from 39% (submitting electronic data to immunization registries

or information systems) to 83% (recording patient demographics) (Figure 4).

NOTES:

All trends were significant (p < 0.05). See the Table for the 17 Stage 2 Core Set objectives.

SOURCE: CDC/NCHS, National

Ambulatory Medical Care Survey, Electronic Health Records Survey.

Figure 4. Percentage of physicians with computerized capabilities to meet selected Stage 2 Core Set objectives:

United States, 2010–2013

Percent

100

2013201220112010

Ordering prescriptions

Ordering lab tests

Sending prescriptions to

the pharmacy electronically

Recording patient history and

demographic information

Providing reminders for guideline-

based interventions

Providing warnings of drug

interactions or contraindications

Reporting to immunization

registries electronically

74.3

57.2

48.5

43.8

43.6

37.9

26.9

83.0

82.6

78.7

73.8

68.9

56.8

39.1

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Summary

In 2013, the National Ambulatory Medical Care Survey (NAMCS) EHR Survey showed that

about 78% of ofce-based physicians used any EHR system. Since 2006 (rst year for which

data are available), the percentage of physicians who reported having an EHR system that met the

criteria for a basic system increased 336%—from 11% in 2006 to 48% in 2013.

Adoption of a basic EHR system varied greatly by state. Adoption ranged from 21% in New

Jersey to 83% in North Dakota.

To qualify for the Stage 2 meaningful use incentive in 2014, eligible physicians must meet all

17 of the Stage 2 Core objectives for meaningful use and 3 of the 6 Menu Set objectives, using

certied EHR systems (3). In this report, estimates of physicians’ readiness to meet meaningful

use measures were limited to 14 of the 17 computerized capabilities that support the Stage 2 Core

objectives.

In 2013, 69% of physicians reported intending to participate (having already applied or intending

to apply) in the Medicare or Medicaid EHR Incentive Programs. However, only 13% of all

physicians reported that they intended to participate in the EHR Incentive Programs and had

an EHR system with the capabilities to support 14 of the 17 Stage 2 Core Set objectives for

meaningful use. This may be an overestimate of the percentage meeting the Stage 2 requirements,

because some physicians with systems supporting the 14 core objectives examined in this report

may have a system that does not support the remaining 3 objectives, or 3 of the 6 Menu Set

objectives required for payment.

From 2010 through 2013, physician adoption of 7 of the 17 capabilities required for Stage 2

Core objectives for meaningful use increased signicantly. Computerized capabilities to send

prescriptions to the pharmacy electronically and to provide warnings of drug interactions or

contraindications had the largest increases.

Denitions

Physician ofce: A place where nonfederally employed physicians provide direct patient care

in the 50 states and the District of Columbia; excludes radiologists, anesthesiologists, and

pathologists.

Any EHR system: Obtained from “yes” responses to the question, “Does this practice use

electronic medical records or electronic health records (not including billing records)?” In

this report, “yes” responses are reported as having any EHR system. In recent years, the terms

“electronic medical record” and EHR have been used interchangeably.

Basic EHR system: A system that has all of the following functionalities: patient history and

demographics, patient problem lists, physician clinical notes, comprehensive list of patients’

medications and allergies, computerized orders for prescriptions, and ability to view laboratory

and imaging results electronically (6). Having a comprehensive list of patients’ medications and

allergies was asked as two separate questions in 2010 (one about medications and the other about

allergies), but the questions were collapsed in 2011 and in subsequent years (7).

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Intent to apply for Medicare or Medicaid EHR Incentive Programs: Obtained from “yes, we

already applied” and “yes, we intend to apply” responses to the question: “Medicare and

Medicaid offer incentives to practices that demonstrate ‘meaningful use of health IT.’ At this

practice, are there plans to apply for these incentive payments?”

Demonstrating meaningful use: The Medicare and Medicaid EHR Incentive Programs

provide incentive payments to physicians as they demonstrate meaningful use of certied

EHR technology. The Centers for Medicare & Medicaid Services established the objectives

for meaningful use in three stages that physicians must meet in order to receive an incentive

payment. In 2014, physicians may receive incentive payments for Stage 2 if they meet 17 Core

Set objectives and 3 of 6 Menu Set objectives, using certied EHR systems. The full list of

Stage 2 objectives and measures is published (3). The 2013 NAMCS survey obtains information

on only14 of the 17 objectives. Trend information from 2010 is available for only 7 of the 17

objectives. The Table presents Stage 2 meaningful use Core Set objectives and corresponding

2013 NAMCS EHR survey items.

Table. Meaningful use Stage 2 Core Set objectives and corresponding NAMCS, EHR survey items

Objective

2013 NAMCS, EHR survey items on

computerized capabilities

Use computerized provider order entry for medication,

laboratory, and radiology orders

Ordering prescriptions and ordering lab rests

Generate and transmit permissible prescriptions

electronically

Sending prescription orders electronically to the pharmacy

Record patient demographics Recording patient history and demographic information

Record and chart vital signs changes Recording and charting vital signs

Record smoking status Recording patient smoking status

Use clinical decision support Providing reminders for guideline-based interventions or

screening tests and providing warnings of drug

interactions or contraindications

Provide patients the ability to view online, download, and

transmit their health information

Providing patients the ability to view online, download, or

transmit information from their medical record

Provide clinical summaries for patients for each ofce visit Providing patients with clinical summaries for each visit

Incorporate clinical lab-test results into Certied EHR

Technology as structured data

EHR automatically graphing a specic patient’s lab results

over time

Generate lists of patients by specic conditions Generating lists of patients with particular health conditions

Use clinically relevant information to identify patient-

specic education resources and provide those

resources to the patient

Identifying educational resources for patient’s specic

conditions

Perform medication reconciliation for patients referred to

the eligible provider (EP)

Reconciling lists of patient medications to identify the most

accurate list

Capability to submit electronic data to immunization

registries or immunization information systems

Electronic reporting to immunization registries

Use secure electronic messaging to communicate with

patients

Exchanging secure messages with patients

Protect electronic health information through appropriate

technical capabilities

…

Use clinically relevant information to identify patients for

preventive and follow-up care and send these patients

reminders

…

Provide a summary care record for patients referred by EP …

… Category not applicable; no corresponding survey item.

NOTE:

NAMCS, EHR survey is National Ambulatory Medical Care Survey, Electronic Health Records Survey.

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Data source and methods

NAMCS, which is conducted by the Centers for Disease Control and Prevention’s National

Center for Health Statistics, is an annual, nationally representative survey of ofce-based

physicians that collects information on physician and practice characteristics, including the

adoption and use of EHR systems. The universe of NAMCS physicians comprises those classied

as providing direct patient care in ofce-based practices, as well as clinicians in community

health centers. Radiologists, anesthesiologists, and pathologists are excluded.

Since 2008, a supplemental mail survey on EHR systems has been conducted in addition to the

core NAMCS, which is an in-person survey. In 2008 and 2009, samples of physicians in the core

NAMCS and the supplemental mail survey, stratied by specialty, were chosen from selected

geographic areas. Starting in 2010, the NAMCS EHR mail-survey sample size was increased

vefold to allow for state-level estimates and to produce stand-alone estimates without needing to

be combined with the core NAMCS.

The 2013 estimates are from the NAMCS EHR survey with a sample of 10,302 physicians.

Nonrespondents to the mail survey received follow-up telephone calls. The 2013 NAMCS EHR

survey was conducted from February through June 2013. The unweighted response rate of the

2013 NAMCS EHR survey was 70% (67% weighted). A copy of the 2013 survey is available

from the NCHS website at http://www.cdc.gov/nchs/ahcd/ahcd_survey_instruments.htm#namcs.

Physicians’ updated practice location information was used to generate state-level estimates.

Estimates of intent to apply for incentives exclude about 1.3% of cases with missing information.

Estimates of physician readiness to meet Stage 2 objectives were obtained by identifying

physicians with EHRs that had all of the computerized capabilities listed in the Table.

Statements of differences in estimates are based on statistical tests with signicance at the

p < 0.05 level. Terms relating to differences such as “increased” or “decreased” indicate that the

differences are statistically signicant. Lack of comment regarding the difference does not mean

that the difference was tested and found to be not signicant.

About the authors

Chun-Ju Hsiao is with the Agency for Healthcare Research and Quality, and Esther Hing is with

the National Center for Health Statistics.

References

1. Centers for Medicare & Medicaid Services. EHR incentive programs. Available from:

https://www.cms.gov/ehrincentiveprograms/.

2. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records.

N Engl J Med 363(6):501–4. 2010.

3. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; electronic

health record incentive program—stage 2. Final rule. Fed Regist 77(171):53967–4162. 2012.

NCHS Data Brief

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No. 143

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January 2014

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4. Centers for Medicare & Medicaid Services. Medicare and Medicaid

programs; electronic health record incentive program. Final rule. Fed Regist

75(144):44314–588. 2010.

5. Hsiao CJ, Hing E. Use and characteristics of electronic health record

systems among ofce-based physician practices: United States, 2001–2012.

NCHS data brief, no 111. Hyattsville, MD: National Center for Health

Statistics. 2012.

6. Robert Wood Johnson Foundation. Health information technology in the

United States: Where we stand, 2008. 2008.

7. Hsiao CJ, Hing E, Socey TC, Cai B. Electronic health record systems and

intent to apply for meaningful use incentives among ofce-based physician

practices: United States, 2001–2011. NCHS data brief, no 79. Hyattsville,

MD: National Center for Health Statistics. 2011.

Suggested citation

Hsiao C-J, Hing E. Use and characteristics

of electronic health record systems among

office-based physician practices:

United States, 2001–2013. NCHS data brief,

no 143. Hyattsville, MD: National Center

for Health Statistics. 2014.

All material appearing in this report is in

the public domain and may be reproduced

or copied without permission; citation as to

source, however, is appreciated.

National Center for Health

Statistics

Charles J. Rothwell, M.S., M.B.A., Director

Jennifer H. Madans, Ph.D., Associate

Director for Science

Division of Health Care Statistics

Clarice Brown, M.S., Director