Contrary to conventional wisdom, only a tiny fraction of U.S. hospitals have full health information technology (HIT) systems in place to improve how they deliver care, says a new study published in the March 26 online edition of the New England Journal of Medicine. A survey of nearly 3,000 hospitals shows that less than 2 percent use comprehensive electronic health records (EHRs), and about 8 percent use a basic EHR in at least one care unit that includes physician or nurse notes. The findings are the first reliable estimates of the prevalence of HIT adoption in U.S. hospitals, and come amid concerted efforts by Congress and the Obama administration to stimulate wider use of EHRs in the health care sector.
“HIT adoption levels are abysmally low in American hospitals. We have a long way to go to achieve a health care system that is fully electronic,” says lead author Ashish Jha, M.D., an associate professor at the Harvard School of Public Health. “The $19 billion in federal help is a great start but it is only a down payment. This is a big mountain to climb,” he adds.
The study, which is based on data collected in 2008, shows that larger, urban teaching institutions are somewhat more likely to have EHRs than other hospitals, partly because they may have more financial resources at their disposal. Inadequate capital and high maintenance costs were the major barriers cited among nonadopters.
Jha conducted the study with researchers at the Institute for Health Policy and the Biostatistics Center at Massachusetts General Hospital, The Brigham and Women’s Hospital, the VA Boston Healthcare System, and the Department of Health Policy at George Washington University. The study was funded by the Robert Wood Johnson Foundation (RWJF) and the federal government’s Office of the National Coordinator for Health Information Technology.
The survey follows one released in 2008 by the same group of authors that showed that only 17 percent of doctors are using EHRs, and only 4 percent use full EHRs. “Despite the promise that HIT holds for better health, the accumulating evidence shows that many of those who deliver care have yet to be convinced,” says David Blumenthal, M.D., director of the Institute for Health Policy and senior author of this study. “This survey continues to make the case for why the federal government needs to step in and exercise its fiscal and policy muscle to spur adoption,” adds Blumenthal.
Other highlights from the study found:
Barriers to be Removed
The largest barrier to HIT adoption among hospitals still remains the cost. HIT systems are expensive and can cost between $20 million and $100 million, depending on the size of the hospital and the complexity of the system. To make matters worse, many of the financial benefits of HIT systems may not accrue to the hospital that makes the investment. If hospitals become more efficient, they could potentially even lose money in terms of lower reimbursement for insurance companies. This makes the business case for HIT far more difficult.
Another hurdle to overcome is interoperability—or allowing for easy exchange of patient care information between hospitals or from hospitals to physicians’ offices. Right now, the market is very fragmented with different standards and different vendors. The lack of ease with which information can be shared “reduces the potential value of these systems and may have a dampening effect on adoption,” says the study. Until there is more clarity in the marketplace and until these systems become far more interoperable, many hospitals will resist adopting EHRs, the authors warn.
What Can the Government Do?
The government can take steps to address this problem. Rewarding hospitals—especially those with the least access to capital— for using HIT can help stimulate the diffusion of EHRs. Other approaches that could help: Creating incentives for the support and training of more IT support staff, harmonizing interoperability standards and creating disincentives for not using HIT.
The Veterans Health Administration has had EHRs in place for more than a decade and has produced dramatic improvements in health care quality. The United Kingdom and the Netherlands also have successfully spurred HIT adoption, though, like in the United States, most of their progress has been in ambulatory care. “Few countries have yet to make substantial progress in the inpatient setting,” the authors say.
Although HIT adoption rates are pretty low, Jha is worried that the economic recession could make things worse, at least in the short term. This hasn’t been a good year for hospitals to make capital investments, he says, so it’s doubtful that much change will occur in 2009. Nevertheless, he and his co-authors say that since many institutions have parts of EHRs in place, policy interventions and financial help could increase their prevalence in hospitals over the long term.
“Modernizing health care systems with electronic health records is a critical piece of any health reform effort,” adds John Lumpkin, M.D., senior vice president of the Health Care Group at the Robert Wood Johnson Foundation. “While the adopted rates are discouraging, this report helps us understand the key barriers we need to overcome to achieve higher rates of HIT adoption and better health and health care for all Americans.”
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 30 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. By helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in our lifetime.
The Institute for Health Policy (IHP) at Massachusetts General Hospital (MGH) and Partners Health System is dedicated to conducting world-class research on the central health care issues of our time. The mission of the IHP is to improve the health and health care of the American people through conducting health policy and health services research, translating new health care knowledge into practice, informing and influencing public policy, and training scholars and practitioners of health policy.