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Evidence linking electronic health record (EHR) adoption to better care is mixed. More nuanced measures of adoption, particularly those that capture the common incremental approach of adding functions over time in US hospitals, could help elucidate the relationship between adoption and outcomes. We used data for the period 2008-13 to assess the relationship between EHR adoption and thirty-day mortality rates. We found that baseline adoption was associated with a 0.11-percentage-point higher rate per function. Over time, maturation of the baseline functions was associated with a 0.09-percentage-point reduction in mortality rate per year per function. Each new function adopted in the study period was associated with a 0.21-percentage-point reduction in mortality rate per year per function. We observed effect modification based on size and teaching status, with small and nonteaching hospitals realizing greater gains. These findings suggest that national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time.

The extent to which recent large increases in hospitals' adoption of electronic health record (EHR) systems can be attributed to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 is uncertain and debated. Because only short-term acute care hospitals were eligible for the act's meaningful-use incentive program, we used national hospital data to examine the differential effect of HITECH on EHR adoption among eligible and ineligible hospitals in the periods before (2008-10) and after (2011-15) implementation of the program. We found that annual increases in EHR adoption rates among eligible hospitals went from 3.2 percent in the pre period to 14.2 percent in the post period. Ineligible hospitals experienced much smaller annual increases of 0.1 percent in the pre period and 3.3 percent in the post period, a significant difference-in-differences of 7.9 percentage points. Our results support the argument that recent gains in EHR adoption can be attributed specifically to HITECH, which suggests that the act could serve as a model for ways to drive the adoption of other valuable technologies., (Project HOPE—The People-to-People Health Foundation, Inc.)

The diffusion of health information exchange (HIE), in which clinical data are electronically linked to patients in many different care settings, is a top priority for policy makers. To drive HIE, community and state efforts were federally funded to broadly engage providers in exchanging data in ways that improved patient care. To assess the current landscape, we conducted a national survey of community and state HIE efforts soon after federal funding ended. We found 106 operational HIE efforts that, as a group, engaged more than one-third of all US providers in 2014. However, the number of operational HIE efforts is down from 119 in 2012, representing the first decline observed since the tracking of these efforts began in 2006. Only half of operational efforts reported being financially viable, and all efforts reported a variety of barriers to continuation. These findings raise important questions about whether the current vision for HIE efforts will allow for the broad exchange of clinical data, or whether alternative approaches would be more successful., (Project HOPE—The People-to-People Health Foundation, Inc.)

Achieving nationwide adoption of electronic health records (EHRs) remains an important policy priority. While EHR adoption has increased steadily since 2010, it is unclear how providers that have not yet adopted will fare now that federal incentives have converted to penalties. We used 2008-14 national data, which includes the most recently available, to examine hospital EHR trends. We found large gains in adoption, with 75 percent of US hospitals now having adopted at least a basic EHR system--up from 59 percent in 2013. However, small and rural hospitals continue to lag behind. Among hospitals without a basic EHR system, the function most often not yet adopted (in 61 percent of hospitals) was physician notes. We also saw large increases in the ability to meet core stage 2 meaningful-use criteria (40.5 percent of hospitals, up from 5.8 percent in 2013); much of this progress resulted from increased ability to meet criteria related to exchange of health information with patients and with other physicians during care transitions. Finally, hospitals most often reported up-front and ongoing costs, physician cooperation, and complexity of meeting meaningful-use criteria as challenges. Our findings suggest that nationwide hospital EHR adoption is in reach but will require attention to small and rural hospitals and strategies to address financial challenges, particularly now that penalties for lack of adoption have begun., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: We determined adoption rates of pediatric-oriented electronic health record (EHR) features by US children's hospitals and assessed perceptions regarding the suitability of commercial EHRs for pediatric care and the influence of the meaningful use incentive program on implementation of pediatric-oriented features., Materials and Methods: We surveyed members of the Children's Hospital Association. We measured adoption of 19 pediatric-oriented features and asked whether commercial EHRs include key pediatric-focused capabilities. We inquired about the meaningful use program's relevance to pediatrics and its influence on EHR implementation priorities., Results: Of 164 general acute care children's hospitals, 100 (61%) responded to the survey. Rates of comprehensive (across all pediatric units) adoption ranged from 37% (age-, gender-, and weight-adjusted blood pressure percentiles and immunization contraindication warnings) to 87% (age in appropriate units). Implementation rates for several features varied significantly by children's hospital type. Nearly 60% of hospitals reported having EHRs that do not contain all features essential for high-quality care. A majority of hospitals indicated that the meaningful use program has had no effect on their adoption of pediatric features, while 26% said they have delayed or forgone incorporation of such features because of the program., Conclusions: Children's hospitals are implementing pediatric-focused features, but a sizable proportion still finds their systems suboptimal for pediatric care. The meaningful use incentive program is failing to promote and in some cases delaying uptake of pediatric-oriented features., (© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: Recent studies fail to find a consistent relationship between adoption of electronic health records (EHRs) and improved hospital performance. We sought to examine whether the quality of hospital management modifies the association between EHR adoption and outcomes related to cost and quality., Study Design: Retrospective study of a random sample of US acute care hospitals., Methods: Management quality was assessed via phone interviews with clinical managers predominantly from cardiac units in a random sample of 325 hospitals using a validated scale of management practices in 4 areas: operations, performance monitoring, target setting, and talent management. American Hospital Association InformationTechnology Supplement data captured whether or not these hospitals had at least a basic EHR. Acute myocardial infarction (AMI) outcomes included risk-adjusted 30-day mortality, average length-of-stay, and average payment per discharge measured using MedPAR data. Ordinary least squares regressions assessed whether management quality modifies the relationship between EHR adoption and AMI outcomes., Results: While we found no association between EHR adoption and our outcomes, management quality modified the relationship in the predicted direction. For length of stay, the coefficient on the interaction between EHR and management was -1.48 (P = .05) and for payment, it was -7786.74 (P = .014). We did not find strong evidence of effect modification for mortality (coefficient = -0.05; P = .37)., Conclusions: Coupled with ongoing policy efforts to achieve nationwide EHR adoption is a growing unease that our national investment may not result in better, more efficient care. Our study is among the first to offer empirical evidence that management quality may help explain why some hospitals see substantial gains from EHR adoption while others do not.

The national effort to promote the adoption and meaningful use of electronic health records (EHRs) is well under way. However, 2014 marks an important transition: For many hospitals, penalties will be assessed in fiscal year 2015 for failing to meet federal meaningful-use criteria by the end of fiscal year 2014. We used recent data from the American Hospital Association Annual Survey of Hospitals--IT Supplement to assess progress and challenges. EHR adoption among US hospitals continues to rise steeply: 59 percent now have at least a basic EHR. Small and rural hospitals continue to lag behind their better resourced counterparts. Most hospitals are able to meet many of the stage 2 meaningful-use criteria, but only 5.8 percent of hospitals are able to meet them all. Several criteria, including sharing care summaries with other providers and providing patients with online access to their data, will require attention from EHR vendors to ensure that the necessary functions are available and additional effort from many hospitals to make certain that these functionalities are used. Policy makers may want to consider new targeted strategies to ensure that all hospitals move toward meaningful use of EHRs., (Project HOPE—The People-to-People Health Foundation, Inc.)

The United States is making substantial investments to accelerate the adoption and use of interoperable electronic health record (EHR) systems. Using data from the 2009-13 Electronic Health Records Survey, we found that EHR adoption continues to grow: In 2013, 78 percent of office-based physicians had adopted some type of EHR, and 48 percent had the capabilities required for a basic EHR system. However, we also found persistent gaps in EHR adoption, with physicians in solo practices and non-primary care specialties lagging behind others. Physicians' electronic health information exchange with other providers was limited, with only 14 percent sharing data with providers outside their organization. Finally, we found that 30 percent of physicians routinely used capabilities for secure messaging with patients, and 24 percent routinely provided patients with the ability to view online, download, or transmit their health record. These findings suggest that although EHR adoption continues to grow, policies to support health information exchange and patient engagement will require ongoing attention., (Project HOPE—The People-to-People Health Foundation, Inc.)

The recent uptick in hospital adoption of electronic health records (EHRs) has been accompanied by growing concerns among some policy makers that hospitals may use these systems to select billing codes that reflect more intensive care or a sicker patient population in order to generate more revenue through higher reimbursements. Such "upcoding" would increase overall health care spending. We used national data to examine whether new adoption of EHRs was associated with increases in coded patient acuity or Medicare payments. We found that hospitals that adopted EHRs increased billing to Medicare, but at a rate comparable to that of matched controls of non-EHR adopters. In our difference-in-differences models, patient acuity and payment per discharge were essentially the same between adopters and nonadopters. We also failed to find a relationship between adoption and either patient acuity or payment within groups of hospitals that may be more likely to use EHRs to increase coding and revenue, such as for-profit hospitals and those in highly competitive markets. Thus, we found no empirical evidence to suggest that hospitals are systematically using EHRs to increase reimbursement. Our findings should reduce concerns that EHR adoption by itself will increase the costs of hospital care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: To develop benchmark measures of health information and communication technology (ICT) use to facilitate cross-country comparisons and learning., Materials and Methods: The effort is led by the Organisation for Economic Co-operation and Development (OECD). Approaches to definition and measurement within four ICT domains were compared across seven OECD countries in order to identify functionalities in each domain. These informed a set of functionality-based benchmark measures, which were refined in collaboration with representatives from more than 20 OECD and non-OECD countries. We report on progress to date and remaining work to enable countries to begin to collect benchmark data., Results: The four benchmarking domains include provider-centric electronic record, patient-centric electronic record, health information exchange, and tele-health. There was broad agreement on functionalities in the provider-centric electronic record domain (eg, entry of core patient data, decision support), and less agreement in the other three domains in which country representatives worked to select benchmark functionalities., Discussion: Many countries are working to implement ICTs to improve healthcare system performance. Although many countries are looking to others as potential models, the lack of consistent terminology and approach has made cross-national comparisons and learning difficult., Conclusions: As countries develop and implement strategies to increase the use of ICTs to promote health goals, there is a historic opportunity to enable cross-country learning. To facilitate this learning and reduce the chances that individual countries flounder, a common understanding of health ICT adoption and use is needed. The OECD-led benchmarking process is a crucial step towards achieving this.

The US health care system is in the midst of an enormous change in the way health care providers and hospitals document, monitor, and share information about health and care delivery. Part of this transition involves a wholesale, but currently uneven, shift from paper-based records to electronic health record (EHR) systems. We used the most recent longitudinal survey of US hospitals to track how they are adopting and using EHR systems. Only 44 percent of hospitals report having and using what we define as at least a basic EHR system. And although 42.2 percent meet all of the federal stage 1 "meaningful-use" criteria, only 5.1 percent could meet the broader set of stage 2 criteria. Large urban hospitals continue to outpace rural and nonteaching hospitals in adopting EHR systems. The increase in adoption overall suggests that the positive and negative financial incentives currently in place across the US health care system are working as intended. However, achieving a nationwide health information technology infrastructure may require efforts targeted at smaller and rural hospitals.

Policy makers are actively promoting the electronic exchange of health information to improve the quality and efficiency of health care. We conducted a national survey of organizations facilitating health information exchange, to assess national progress. We found that 30 percent of hospitals and 10 percent of ambulatory practices now participate in one of the 119 operational health information exchange efforts across the United States, substantial growth from prior surveys. However, we also found that 74 percent of health information exchange efforts report struggling to develop a sustainable business model. Our findings suggest that despite progress, there is a substantial risk that many current efforts to promote health information exchange will fail when public funds supporting these initiatives are depleted.

Expanding the use of interoperable electronic health record (EHR) systems to improve health care delivery is a national policy priority. We used the 2010-12 National Ambulatory Medical Care Survey--Electronic Health Records Survey to examine which physicians in what types of practices are implementing the systems, and how they are using them. We found that 72 percent of physicians had adopted some type of system and that 40 percent had adopted capabilities required for a basic EHR system. The highest relative increases in adoption were among physicians with historically low adoption levels, including older physicians and those working in solo practices or community health centers. As of 2012, physicians in rural areas had higher rates of adoption than those in large urban areas, and physicians in counties with high rates of poverty had rates of adoption comparable to those in areas with less poverty. However, small practices continued to lag behind larger practices. Finally, the majority of physicians who adopted the EHR capabilities required to obtain federal financial incentives used the capabilities routinely, with few differences across physician groups.

Objectives: To assess the level of hospital participation in the first 18 months of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, and to identify whether vulnerable hospitals lag behind., Study Design: Retrospective study of participation among the 4938 Medicare-certified hospitals from the beginning of the incentive payment period (June 2011) through December 2012., Methods: We used multivariate models to examine which types of hospitals qualified for financial incentives either through attesting to meaningful use of EHRs or by meeting the "Adopt-Implement-Upgrade" (AIU) option that requires demonstrating progress toward achieving meaningful use. We focused on small, Critical Access, and safety-net hospitals., Results: We found that more than 75% of all eligible US hospitals have qualified for financial incentives in the first 18 months of the program. Nearly two-thirds of these hospitals (52% of all hospitals) attested to meaningful use while the remaining one-third (24% of all hospitals) were paid under the AIU option only. Small hospitals were less likely than large hospitals to qualify for incentive payments (odds ratio [OR] = 0.49, 95% confidence interval [CI] 0.36-0.68; P < .001 across categories). Critical Access hospitals also had lower odds of incentive payment (OR = 0.69, 95% CI 0.57-0.84, P < .001). Safety-net hospitals were more likely to qualify for payments overall (OR = 2.51; 95% CI 1.92-3.38, P < .001), but did so primarily through AIU., Conclusions: There is broad participation in the federally led incentive program to promote nationwide EHR uptake. Lower rates of participation among smaller hospitals and Critical Access hospitals merit close monitoring to ensure that broad adoption is achieved.

Unlabelled: OBJECTIVES To assess electronic health record (EHR) adoption and meaningful use among US children's hospitals through 2011 and compare these outcomes with adult hospitals and among subgroups of children's hospitals. We hypothesized that children's hospitals would show progress since our initial evaluation of health information technology (HIT) implementation in 2008., Methods: We identified children's hospitals using the membership directory of the Children's Hospital Association and analyzed their responses from 2008 to 2011 to the American Hospital Association's annual HIT survey. EHR adoption rates were determined by using previously specified definitions of the essential functionalities comprising an EHR. Achievement of meaningful use was evaluated based on hospitals' ability to fulfill 12 core meaningful use criteria. We compared these outcomes in 2011 between children's and adult hospitals and among subgroups of children's hospitals., Results: Of 162 children's hospitals, 126 (78%) responded to the survey in 2011. The proportion of children's hospitals with an EHR increased from 21% (in 2008) to 59% (in 2011). In 2011, 29% of children's hospitals met the 12 core criteria in our meaningful use proxy measure. EHR adoption rates and meaningful use were significantly higher for children's hospitals than for adult hospitals as a whole but similar for children's and adult major teaching hospitals. Among children's hospitals, major teaching hospitals were significantly more likely to have an EHR., Conclusions: Children's hospitals have achieved substantial gains in HIT implementation although minor teaching and nonteaching institutions are not keeping pace.

In industries outside healthcare, highly skilled employees enable substantial gains in productivity after adoption of information technologies. The authors explore whether the presence of highly skilled, autonomous clinical support staff is associated with higher performance among physicians with electronic health records (EHRs). Using data from a survey of general internists, the authors assessed whether physicians with EHRs were more likely to be top performers on cost and quality if they worked with nurse practitioners or physician assistants. It was found that, among physicians with EHRs, those with highly skilled, autonomous staff were far more likely to be top performing than those without such staff (OR 7.0, 95% CI 1.7 to 34.8, p=0.02). This relationship did not hold among physicians without EHRs (OR 1.0). As we begin a national push towards greater EHR adoption, it is critical to understand why some physicians gain from EHR use and others do not.

To achieve the goal of comprehensive health information record keeping and exchange among providers and patients, hospitals must have functioning electronic health record systems that contain patient demographics, care histories, lab results, and more. Using national survey data on US hospitals from 2011, the year federal incentives for the meaningful use of electronic health records began, we found that the share of hospitals with any electronic health record system increased from 15.1 percent in 2010 to 26.6 percent in 2011, and the share with a comprehensive system rose from 3.6 percent to 8.7 percent. The proportion able to meet our proxy criteria for meaningful use also rose; in 2011, 18.4 percent of hospitals had these functions in place in at least one unit and 11.2 percent had them across all clinical units. However, gaps in rates of adoption of at least a basic record system have increased substantially over the past four years based on hospital size, teaching status, and location. Small, nonteaching, and rural hospitals continue to adopt electronic health record systems more slowly than other types of hospitals. In sum, this is mixed news for policy makers, who should redouble their efforts among hospitals that appear to be moving slowly and ensure that policies do not further widen gaps in adoption. A more robust infrastructure for information exchange needs to be developed, and possibly a special program for the sizable minority of hospitals that have almost no health information technology at all.

The US government has dedicated substantial resources to help certain providers, such as short-term acute care hospitals and physicians, adopt and meaningfully use electronic health record (EHR) systems. We used national data to determine adoption rates of EHR systems among all types of inpatient providers that were ineligible for these same federal meaningful-use incentives: long-term acute care hospitals, rehabilitation hospitals, and psychiatric hospitals. Adoption rates for these institutions were dismally low: less than half of the rate among short-term acute care hospitals. Specifically, 12 percent of short-term acute care hospitals have at least a basic EHR system, compared with 6 percent of long-term acute care hospitals, 4 percent of rehabilitation hospitals, and 2 percent of psychiatric hospitals. To advance the creation of a nationwide health information technology infrastructure, federal and state policy makers should consider additional measures, such as adopting health information technology standards and EHR system certification criteria appropriate for these ineligible hospitals; including such hospitals in state health information exchange programs; and establishing low-interest loan programs for the acquisition and use of certified EHR systems by ineligible providers.

Objectives: To update the status of electronic health record (EHR) adoption in US hospitals and assess their readiness for "Meaningful Use" (MU)., Study Design: We used data from the 2010 American Hospital Association Annual Information Technology Survey. The survey was first conducted in 2007 and is made available both online and through the mail to all non-federal acute-care hospitals in the United States., Methods: We measure the percentages of applicable hospitals that have adopted "basic" and "comprehensive" EHRs as defined in previous literature. Additionally, we report the percentage of hospitals planning to apply for MU in the near term, and assess hospitals' readiness for the program and how readiness varies by key characteristics., Results: We received responses from 2902 hospitals (64% of all non-federal acute-care hospitals). More than 15% have adopted at least a "basic" EHR, representing nearly 75% growth since 2008. Approximately two-thirds plan to apply for MU before 2013; however, only 4.4% had implemented each of the "core" MU functionalities we measured. Hospitals closer to achieving MU are more likely to be larger non-profits (P <.001) and vary by other key characteristics. Certain functionalities included in MU, such as computerized provider order entry, electronic generation of quality measures, and electronic access to records for patients are proving more challenging to implement for all hospitals., Conclusions: Broad enthusiasm exists among hospitals for participation in MU. However, adoption will have to accelerate above its current pace for readiness to match intention. Gaps in adoption show bringing all hospitals along is the key policy challenge.

Background: To receive financial incentives for meaningful use of electronic health records, physicians and hospitals will need to engage in health information exchange (HIE). For most providers, joining regional organizations that support HIE is the most viable approach currently available., Objective: To assess the state of HIE in the United States through regional health information organizations (RHIOs)., Design: Survey., Setting: All RHIOs in the United States., Participants: 179 U.S.-based RHIOs that facilitated HIE as of December 2009., Measurements: Number of operational RHIOs, the subset of operational RHIOs that supported stage 1 meaningful use, and the subset that supported robust HIE; number of ambulatory practices and hospitals participating in RHIOs; and number of financially viable RHIOs., Results: Of 197 potential RHIOs, 179 (91%) reported their status and 165 (84%) returned completed surveys. Of these, 75 RHIOs were operational, covering approximately 14% of U.S. hospitals and 3% of ambulatory practices. Thirteen RHIOs supported stage 1 meaningful use (covering 3% of hospitals and 0.9% of practices), and none met an expert-derived definition of a comprehensive RHIO. Overall, 50 of 75 RHIOs (67%) did not meet the criteria for financial viability., Limitations: Survey data were self-reported. The sample may not have included all HIE efforts, particularly those of individual providers who set up their own data-exchange agreements., Conclusion: These findings call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care., Primary Funding Source: Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services.

Objective: To examine variation in the adoption of electronic health record (EHR) functionalities and their use patterns, barriers to adoption, and perceived benefits by physician practice size., Design: Mailed survey of a nationally representative random sample of practicing physicians identified from the Physician Masterfile of the American Medical Association. Measurements We measured, stratified by practice size: (1) availability of EHR functionalities, (2) functionality use, (3) barriers to the adoption and use of EHR, and (4) impact of the EHR on the practice and quality of patient care., Results: With a response rate of 62%, we found that < 2% of physicians in solo or two-physician (small) practices reported a fully functional EHR and 5% reported a basic EHR compared with 13% of physicians from 11+ group (largest group) practices with a fully functional system and 26% with a basic system. Between groups, a 21-46% difference in specific functionalities available was reported. Among adopters there were moderate to large differences in the use of the EHR systems. Financial barriers were more likely to be reported by smaller practices, along with concerns about future obsolescence. These differences were sizable (13-16%) and statistically significant (p < 0.001). All adopters reported similar benefits. Limitations Although we have adjusted for response bias, influences may still exist., Conclusion: Our study found that physicians in small practices have lower levels of EHR adoption and that these providers were less likely to use these systems. Ensuring that unique barriers are addressed will be critical to the widespread meaningful use of EHR systems among small practices.

Objective: To determine whether patterns of electronic health record (EHR) adoption and “meaningful use” vary between high-, intermediate-, and low-quality US hospitals., Study Design: We used data from the Hospital Quality Alliance program to designate hospitals as high quality (performance in the top decile nationally), low quality (bottom decile), and intermediate quality (all others). We examined EHR adoption and meaningful use using national survey data., Methods: We used logistic regression models to determine the frequency with which hospitals in each group adopted individual EHR functions and met meaningful use criteria, and factor analyses to examine adoption patterns in high- and low-quality hospitals., Results: High-quality hospitals were more likely to have all clinical decision support functions. High-quality hospitals were also more likely to have computerized physician order entry for medications compared with intermediate- and low-quality hospitals. Among those who had not yet implemented components of clinical decision support, two-thirds of low-quality hospitals reported no concrete plans for adoption. Finally, high-quality hospitals were more likely to meet many of the meaningful use criteria such as reporting quality measures, implementing at least 1 clinical decision support rule, and exchanging key clinical data., Conclusions: We found higher rates of adoption of key EHR functions among high-quality hospitals, suggesting that high quality and EHR adoption may be linked. Most low-quality hospitals without EHR functions reported no plans to implement them, pointing to challenges faced by policy makers in achieving widespread EHR adoption while simultaneously improving quality of care.

Objective: To assess adoption of electronic health records (EHRs) and clinical functionalities, involvement in health information exchange, and barriers to and facilitators of adoption among children's hospitals in the United States., Design: Survey presented as an information technology supplement to the American Hospital Association's annual member survey., Setting: General acute care children's hospitals in 2008, identified using the membership directory of the National Association of Children's Hospitals and Related Institutions., Participants: Chief information officers or equivalent hospital leaders., Main Exposures: Potential barriers to or facilitators of EHR adoption., Main Outcome Measures: Rates of EHR adoption, determined using expert-formulated definitions based on presence of essential functionalities, and rates of implementation for individual functionalities and participation in health information exchange., Results: Of 155 children's hospitals, 108 (69.7%) responded to the survey. Only 2.8% had a comprehensive EHR, whereas an additional 17.9% had a basic system. Adoption of individual functionalities varied widely; comprehensive implementations of computerized provider order entry for medications and many forms of decision support were reported by fewer than half. In all, 15.7% of hospitals exchanged health information electronically. Hospital characteristics were not associated with EHR adoption or participation in health information exchange. Hospitals identified financing as the most important target for policy strategies., Conclusions: Most children's hospitals lack the minimum functionalities needed for a basic EHR. Ensuring access to adequate financial resources will be critical for inclusion of children's hospitals in efforts to expand EHR use.

Given the substantial federal financial incentives soon to be available to providers who make "meaningful use" of electronic health records, tracking the progress of this health care technology conversion is a policy priority. Using a recent survey of U.S. hospitals, we found that the share of hospitals that had adopted either basic or comprehensive electronic records has risen modestly, from 8.7 percent in 2008 to 11.9 percent in 2009. Small, public, and rural hospitals were less likely to embrace electronic records than their larger, private, and urban counterparts. Only 2 percent of U.S. hospitals reported having electronic health records that would allow them to meet the federal government's "meaningful use" criteria. These findings underscore the fact that the transition to a digital health care system is likely to be a long one.

Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.