Electronic Health Record Incentive Program Research Articles

The Impact of Market Factors on Meaningful Use of Electronic Health Records Among Primary Care Providers: Evidence From Florida Using Resource Dependence Theory and Information Uncertainty Perspective.

Using federal funds from the 2009 Health Information Technology for Economic and Clinical Health Act, the Centers for Medicare and Medicaid Services funded the 2011-2021 Medicaid electronic health record (EHR) incentive programs throughout the country. Identify the market factors associated with Meaningful Use (MU) of EHRs after primary care providers (PCPs) enrolled in the Florida-EHR incentives program through Adopting, Improving, or Upgrading (AIU) an EHR technology. Retrospective cohort study using 2011-2018 program records for 8464 Medicaid providers. MU achievement after first-year incentives. The resource dependence theory and the information uncertainty perspective were used to generate key-independent variables, including the county's rurality, educational attainment, poverty, health maintenance organization penetration, and number of PCPs per capita. All the county rates were converted into 3 dichotomous measures corresponding to high, medium, and low terciles. Descriptive and bivariate statistics were calculated. A generalized hierarchical linear model was used because MU data were clustered at the county level (level 2) and measured at the practice level (level 1). Overall, 41.9% of Florida Medicaid providers achieved MU after receiving first-year incentives. Rurality was positively associated with MU ( P <0.001). Significant differences in MU achievements were obtained when we compared the "high" terciles with the "low" terciles for poverty rates ( P =0.002), health maintenance organization penetration rates ( P =0.02), and number of PCPs per capita ( P =0.01). These relationships were negative. Policy makers and health care managers should not ignore the contribution of market factors in EHR adoption.

The impact of county-level factors on meaningful use of electronic health records (EHRs) among primary care providers.

This study examines the impact of county-level factors on "meaningful use" (MU) of electronic health records (EHRs) for 8415 primary care providers (PCPs) that enrolled in the Florida Medicaid EHR Incentive Program through adopting, improving, or upgrading (AIU) a certified EHR technology. PCPs received incentive payments at enrollment and if they used their EHRs in meaningful ways; ways that benefit patients and providers alike they received additional payments. We conducted a retrospective cohort study of these providers over the 2011-2018 period while linking their records to other state data. We used the core constructs of the resource dependence theory (RDT), a well-established organization theory in business management, to operationalize the county-level variables. These variables were rurality, poverty, educational attainment, managed care penetration, changes in population, and number of PCPs per capita. The unit of analysis was provider-years. For practical and computational purposes, all the county variables were dichotomized. We used analysis of variance (ANOVA) to test for differences in MU attestation rates across each county variable. Odds ratios and corresponding 95% confidence intervals were derived from pooled logistic regressions using generalized estimated equations (GEE) with the binomial family and logit link functions. Clustered standard errors were used. Approximately 42% of these providers attested to MU after receiving first-year incentives. Rurality and poverty were significantly associated with MU. To some degree, managed care penetration, change in population size, and number of PCPs per capita were also associated with MU. Policy makers and healthcare managers should not ignore the contribution of county-level factors in the diffusion of EHRs among physician practices. These county-level findings provide important insights about EHR diffusion in places where traditionally underserved populations live. This county-perspective is particularly important because of the potential for health IT to enable public health monitoring and population health management that might benefit individuals beyond the patients treated by the Medicaid providers.

Successes and Barriers of Health Information Exchange Participation Across Hospitals in South Carolina From 2014 to 2020: Longitudinal Observational Study.

The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation. This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals. This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated. Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68%), difficulty in finding patient health information (27/40, 68%), adapting different vendor platforms (26/40, 65%), difficulty matching or identifying same patients between systems (23/40, 58%), and providers that do not typically exchange patient data (23/40, 58%). HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information.

Provider participation in the Florida Medicaid Promoting Interoperability program: Practice characteristics, meaning use attestations, and incentive payments

ObjectiveThe objective of this study was to quantify the rate of provider participation beyond year 1 incentive in the Florida Medicaid Promoting Interoperability (PI) program, formerly the Electronic Health Record Incentive program, and identify the provider and practice characteristics associated with Meaningful Use attestations. Methods and materialsWe conducted a retrospective cohort study using the 2011–2018 records from the PI program, Provider Participation Database. Bivariate associations between Meaningful Use and categorical and ordinal variables were tested using Chi-square and Mantel-Haenszel Chi-square, respectively, with results informing logistic regressions. Adjusted odds ratios and 95 % confidence intervals are reported. ResultsWe found that 42.56 % of Florida Medicaid providers achieved Meaningful Use after receiving first-year incentives. Logistic regression showed that pediatricians represented the largest percentage of providers who achieved Meaningful Use (65.06 %) while dentists had the lowest Meaningful Use (7.78 %). We also found that certain geographic areas and various EHR vendors were associated with higher rates of providers Meaningful Use attestation. DiscussionAlthough the PI program successfully influenced the adoption of a basic EHR system, low Meaningful Use attestations have inadvertently created a digital “advanced use” divide among providers who serve large numbers of Medicaid patients. This is concerning because advanced EHR functions are necessary precursors to address unmet socioeconomic needs to reduce health disparities. ConclusionFlorida has distributed over $100 million to Medicaid providers who ultimately did not achieve Meaningful Use after collecting their first-year incentive. Policy interventions that can promote advanced EHR use functions are necessary to optimize technology in low-resourced practice settings where the potential benefits are greater.

Practice and market factors associated with provider volume of health information exchange.

To assess the practice- and market-level factors associated with the amount of provider health information exchange (HIE) use. Provider and practice-level data was drawn from the Meaningful Use Stage 2 Public Use Files from the Centers for Medicare and Medicaid Services, the Physician Compare National Downloadable File, and the Compendium of US Health Systems, among other sources. We analyzed the relationship between provider HIE use and practice and market factors using multivariable linear regression and compared primary care providers (PCPs) to non-PCPs. Provider volume of HIE use is measured as the percentage of referrals sent with electronic summaries of care (eSCR) reported by eligible providers attesting to the Meaningful Use electronic health record (EHR) incentive program in 2016. Providers used HIE in 49% of referrals; PCPs used HIE in fewer referrals (43%) than non-PCPs (57%). Provider use of products from EHR vendors was negatively related to HIE use, while use of Athenahealth and Greenway Health products were positively related to HIE use. Providers treating, on average, older patients and greater proportions of patients with diabetes used HIE for more referrals. Health system membership, market concentration, and state HIE consent policy were unrelated to provider HIE use. HIE use during referrals is low among office-based providers with the capability for exchange, especially PCPs. Practice-level factors were more commonly associated with greater levels of HIE use than market-level factors. This furthers the understanding that market forces, like competition, may be related to HIE adoption decisions but are less important for use once adoption has occurred.

COVID-19 and the Silver Lining in Health Care Technology.

COVID-19 and the Silver Lining in Health Care Technology.

Progress and Challenges with Connecting Hospitals with the Public Health System

Improving the health information technology (HIT) infrastructure of the public health system is critical for public health activities and population health management. To strengthen the public health HIT infrastructure, CMS included specific public health reporting capabilities in the Meaningful Use (MU) criteria that comprised the Electronic Health Record (EHR) incentive program for hospitals, now called the Promoting Interoperability (PI) program.Evidence suggests that these incentives have improved hospitals’ public health reporting capabilities, but recent data show that only 60% of hospitals have achieved MU standards, suggesting that barriers remain for electronic integration of hospitals with public health agencies. While progress is promising and may be indicative of improvements in electronic data exchange capabilities, the specific issues that hospitals continue to face are unclear and there remains limited understanding of approaches that may improve hospital public health reporting capabilities.This study uses cross‐sectional data from the 2017 American Hospital Association (AHA) Annual Survey and Information Technology (AHAIT) supplement, which reports the challenges hospitals face in submitting data to public health agencies. Four nonmutually exclusive options included data standards issues, technical capacity issues, uncertainty of who to send data to, and an open‐ended option. Open‐ended responses were qualitatively coded by type of challenge (ie, technology, organization, or environment); responsible/affected party (ie, hospital, public health agency, vendor, or multiple); and the specific issue described. Multivariate logistic regression was used to identify characteristics of hospitals associated with experiencing any challenge.Acute‐care, nonfederal hospitals responding to both the 2017 AHA and AHAIT supplemental surveys.Among 2,794 hospitals included, 1,713 (61%) reported experiencing at least one challenge in reporting health data to a public health agency. Of hospitals experiencing challenges, the vast majority reported organizational issues (85% or 1,458) at public health agencies (84% or 1,226), specifically the technical capacity of public health agencies. Hospital system members (adjusted odds ratio (AOR) 0.80; 95% Confidence Interval (CI) 0.65‐0.98) were less likely to experience challenges, whereas for‐profit hospitals (AOR 1.47; 95% CI 1.07‐2.03), being in the West (AOR 1.72; 95% CI 1.28‐2.30), possessing basic (AOR 1.56; 95% CI 1.06‐2.31) or comprehensive (AOR 1.57; 95% CI 1.06‐2.31) EHRs, and participating in an HIE (AOR 1.87; 95% CI 1.58‐2.22) were associated with increased likelihood of experiencing challenges.Challenges remain in facilitating data exchange between hospitals and public health agencies. Hospitals with more advanced EHRs and HIE were more likely to experience challenges. These hospitals may have technological capabilities that exceed those of public health agencies. Hospitals and public health agencies may also be in competition for a technically trained workforce, and data suggest that both may be experiencing shortages of staff with essential expertise.Efforts to alleviate barriers to hospital reporting of health data to public health agencies should target technological, organizational, and environmental issues. Responses include improvements in the data standards that facilitate exchange; funding for public health agencies to improve their technological capabilities, workforce training programs, and clarifications for PI policy specifications and reporting.

Association of the Meaningful Use Electronic Health Record Incentive Program With Health Information Technology Venture Capital Funding

Although the Health Information Technology for Economic and Clinical Health (HITECH) Act has accelerated electronic health record (EHR) adoption since its passage, clinician satisfaction with EHRs remains low, and the association of HITECH with health care information technology (IT) entrepreneurship has remained largely unstudied. To determine whether the passage of the HITECH Act was associated with an increase in key measures of health care IT entrepreneurship. This economic evaluation of venture capital (VC) activity in the US from 2000 to 2019 examined funding trends in health care IT, EHR-related companies, and all VC investments before and after the passage of HITECH. A difference-in-differences analysis compared investments in health care IT companies with those of companies in 3 categories: general health care (non-IT), IT (non-health care), and all US VC transactions. Data were analyzed from September 2018 to August 2019. Venture capital funding received by US companies before and after the HITECH Act. Venture capital investment in health care IT companies and the proportion of those investments going to seed-stage companies, a proxy for very early-stage entrepreneurship and innovation. The data included 70 982 investments, of which 9425 (13.3%) were seed stage, 10 706 (15.1%) were early stage, and 50 851 (71.6%) were growth stage. After passage of the HITECH Act, investment in both health care IT companies and EHR-related companies increased at a rate much faster (13.0% and 11.4%, respectively) than VC as a whole (6.9%). In addition, the proportion of investments going to seed-stage health care IT companies increased compared with both overall VC investments and non-IT health care investments. Health care IT companies saw increased probabilities of transactions being seed-stage of 5.1% (SE, 2.2%; 95% CI, 0.8% to 9.3%; P = .02) compared with the entire sample of VC transactions and 13.6% (SE, 1.9%; 95% CI, 9.9% to 17.2%; P < .001) compared with non-IT health care VC transactions. Health care IT had essentially 0 increased probability of a transaction being seed stage compared with IT companies outside health care (-0.8% probability; SE, 2.4%; 95% CI, -5.4% to 3.9%; P = .75). Although widespread clinician dissatisfaction with EHR systems remains a challenge, the HITECH Act's incentive program may have catalyzed early-stage entrepreneurship in health care IT, suggesting an important role for incentives in promoting innovation.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics. We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016. Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics. Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Medicare Incentive Payments to United States Ophthalmologists for Use of Electronic Health Records: 2011–2016

To investigate ophthalmologists' rate of attestation to meaningful use (MU) of their electronic health record (EHR) systems in the Medicare EHR Incentive Program and their continuity and success in receiving payments in comparison with other specialties. Administrative database study. Eligible professionals participating in the Medicare EHR Incentive Program. Based on publicly available data sources, subsets of payment and attestation data were created for ophthalmologists and for other specialties. The number of eligible professionals attesting was determined using the attestation data for each year and stage of the program. The proportion of attestations by EHR vendor was calculated using all attestations for each vendor. Numbers of ophthalmologists attesting by year and stage of the Medicare EHR Incentive Program, incentive payments, and number of attestations by EHR vendor. In the peak year of participation, 51.6% of ophthalmologists successfully attested to MU, compared with 37.1% of optometrists, 50.2% of dermatologists, 54.5% of otolaryngologists, and 64.4% of urologists. Across the 6 years of the program, ophthalmologists received an average of $17 942 in incentive payments compared with $11 105 for optometrists, $16 617 for dermatologists, $20 203 for otolaryngologists, and $23 821 for urologists. Epic and Nextgen were the most frequently used EHRs for attestation by ophthalmologists. Ophthalmology as a specialty performed better than optometry and dermatology, but worsethanotolaryngology and urology, in terms of the proportion of eligible professionals attesting to MU ofEHRs.Ophthalmologists were more likely to remain in the program after their initial year of attestation comparedwithall eligibleproviders. The top 4 EHR vendors accounted for 50% of attestations by ophthalmologists.

Hospital adoption of interoperability functions

BackgroundThe seamless transmission of patient health information across health care settings, commonly referred to as interoperability, is a focal point of federal electronic health record (EHR) incentive programs. The objective of this study was to examine the extent to which interoperability functions outlined in Promoting Interoperability Stage 3 (PI3) requirements have been adopted by US hospitals, and barriers to interoperability. MethodsWe conducted a cross-sectional analysis of 2781 non-federal, acute-care hospitals responding to the 2015 American Hospital Association Information Technology (IT) Supplement survey. We described the percentage of hospitals that adopted PI3 functionalities, identified hospital characteristics associated with adoption, and compared barriers to interoperability between hospitals that have and have not adopted PI3 functionalities. ResultsOnly 16.7% of hospitals had adopted all six core functionalities required to meet PI3 objectives. Over 70% of hospitals had implemented at least four of six functionalities, while 1.8% implemented none. Major teaching (adjusted odds ratio [aOR]=1.66), system affiliated (aOR=1.63), and regional health information exchange participating hospitals (aOR=1.86) were more likely to adopt PI3 functionalities, while for-profit hospitals (OR=0.11) were less likely. Hospitals that adopted PI3 functionalities more frequently reported experiencing barriers to interoperability, including the receiving provider's ability and interest to send/receive data. ConclusionsWhile only a small proportion of hospitals had implemented all six PI3 functionalities at the time the requirements were finalized, the vast majority had already implemented most of the required functionalities. Still, several barriers stand in the way of achieving seamless interoperability, many of which lie outside hospitals’ control.

Early Implementation of Malnutrition Clinical Quality Metrics to Identify Institutional Performance Improvement Needs

The Centers for Medicare and Medicaid Services (CMS) is part of the federal government and the largest health care payer in the United States. 1 About CMS. Centers for Medicare and Medicaid Services website. https://www.cms.gov/About-CMS/About-CMS.html. Accessed January 3, 2018. Google Scholar The CMS writes regulations to ensure they only pay for high-quality, safe health care. To better measure quality in the U.S. health care system, the CMS developed electronic clinical quality measures (eCQMs), which became available for voluntary use in 2013. 2 eCQMs. eCQI Resource Center. The Office of the National Coordinator of Health Information Technology, Centers for Medicare and Medicaid Services. https://ecqi.healthit.gov/ecqms. Accessed January 3, 2018. Google Scholar Effective calendar year (CY) 2016, hospitals are required to electronically report clinical quality measures (CQMs) as a part of hospital inpatient quality reporting (IQR) and the electronic health record (EHR) incentive programs (more commonly known as “meaningful use” of the EHR). Hospitals that successfully submit eCQM data will fulfill the Medicare requirements for both programs with one submission. The CMS approves which eCQMs are accepted for any given CY, as well as the minimum number on which a hospital must report. Starting in CY 2017, there were 15 available eCQMs from which to choose, and hospitals were required to report on a minimum of eight. This has changed to four for CY 2018. 3 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the LongTerm Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Fed Regist. 2017; 82 (Updated August 14, 2017. Accessed January 3, 2018): 38001https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf Google Scholar

Preferences of older adults and their families for Meaningful Use clinical summaries.

This study assessed the perceptions of older adults regarding the plan of care (POC) contained in the clinical summary mandated by the Electronic Health Records (EHR) Incentive Program. A qualitative descriptive design was selected for this study. Older adults (≥65) with chronic cardiac diagnoses were invited to participate. The investigator shadowed the physician during the patient encounter, interviewed the patients following their encounter, and asked patients to complete standard health literacy and cognitive screening tools and the Patient Activation Measure. Directed content analysis was used to analyze transcripts. Patients (n=40) found the clinical summary useful for sharing information with family members and other physicians, reminding and informing, and for engaging in behavior change. Seventy-six percent reported that they would not go online to access the clinical summary for multiple reasons, including not being "computer savvy" and privacy concerns. Participant recommendations for a re-designed, improved clinical summary are included. The clinical summary helps patients and families communicate among health care professionals in a complex, disjointed health care system that often burdens patients with that responsibility. The majority of participants were happy with the paper version and offered multiple reasons for not wanting online access that may help us to focus on more compelling reasons for patient portal use. Qualitatively, it appears that the clinical summary is a useful tool for engaging people with chronic disease in self-management. The participants in this study told us what many of us already know to be true; that the documentation we provide patients and families is less than ideal.

Assessing the value of the Meaningful Use Clinical Summary for patients and families with pediatric asthma

ABSTRACTElectronic clinical summaries are innovations supported by the Electronic Health Record Incentive Program, known as “Meaningful Use” (MU). The MU clinical summary documents the shared understanding of the plan of care for patients and assists families in managing asthma-related health care. The purpose of this analysis was to identify the communicative value of the summaries to patients and families. Readability measurements, content analysis, and descriptive statistics were employed in a review of twenty clinical summaries and compared with provider encounter notes. The average age of the patients from whom we collected clinical summaries was six years old. The average reading level of the summaries was ninth grade. Neither summaries nor health education contained visual images. There was a total of nine different asthma diagnoses. A full list of diagnoses was present in 45% of summaries. The average medications per patient was 5.75, and there were multiple medication changes noted (dosage adjustment, add, discontinued). Allergies, vital signs, and smoking status were reliably reported (99-100%). Provider orders present included medication, follow up, and return to the clinic instructions. The plan of care was replicated on 45% of summaries. There was variable reporting of various asthma guidelines. Opportunities to improve the clinical summary include using plain language to promote readability, action, understanding, and health literacy, training providers to standardize their documentation and include asthma action plans, and configuring EHR settings to ensure diagnoses and plan of care is carried over from provider notes to the summary.

Adoption of Electronic Health Records and Perceptions of Financial and Clinical Outcomes Among Ophthalmologists in the United States

Assessing the rate of electronic health record (EHR) adoption and ophthalmologists' perceptions on financial and clinical productivity is important in understanding how to direct future design and health care policy. To assess adoption rate and perceptions of financial and clinical outcomes of EHRs among ophthalmologists in the United States. Population-based, cross-sectional study. A random sample of 2000 ophthalmologists was generated on the basis of mailing address zip codes from the 2015 American Academy of Ophthalmology US active membership database, which included more than 18 000 ophthalmologists. A survey was sent by email to assess adoption rate of EHRs, perceptions of financial and clinical productivity, and engagement with Medicare and Medicaid programs that incentivize the use of EHRs. The survey was conducted between 2015 and 2016. Adoption rate of EHRs and perceptions of financial and clinical productivity. The adoption rate of EHRs among surveyed ophthalmologists (348 respondents) was 72.1%. The responding ophthalmologists perceived that their net revenues and productivity have declined and that practice costs are higher with EHR use. Of those who attested for stage 1 of the EHR incentive program, 83% had already or were planning to attest to stage 2, but 9% had no plans. The adoption of EHRs by ophthalmologists has more than doubled since a 2011 survey and is similar to that of primary care physicians (79%). In comparison with 2 previous surveys of ophthalmologists, respondents had more negative perceptions of EHR productivity outcomes and effect on practice costs, although financial data were not collected in this survey to support these opinions. These negative perceptions suggest that more attention should be placed on improving the efficiency and usability of EHR systems.

Are all certified EHRs created equal? Assessing the relationship between EHR vendor and hospital meaningful use performance.

The federal electronic health record (EHR) certification process was intended to ensure a baseline level of system quality and the ability to support meaningful use criteria. We sought to assess whether there was variation across EHR vendors in the degree to which hospitals using products from those vendors were able to achieve high levels of performance on meaningful use criteria. We created a cross-sectional national hospital sample from the Office of the National Coordinator for Health Information Technology EHR Products Used for Meaningful Use Attestation public use file and the Centers for Medicare & Medicaid Services Medicare EHR Incentive Program Eligible Hospitals public use file. We used regression models to assess the relationship between vendor and hospital performance on 6 Stage 2 Meaningful Use criteria, controlling for hospital characteristics. We also calculated how much variation in performance is explained by vendor choice. We found significant associations between specific vendor and level of hospital performance for all 6 meaningful use criteria. Epic was associated with significantly higher performance on 5 of the 6 criteria; relationships for other vendors were mixed, with some associated with significantly worse performance on multiple criteria. EHR vendor choice accounted for between 7% and 34% of performance variation across the 6 criteria. A nontrivial proportion of variation in hospital meaningful use performance is explained by vendor choice, and certain vendors are more often associated with better meaningful use performance than others. Our results suggest that policy-makers should improve the certification process by including more "real-world" scenario testing and provider feedback or ratings to reduce this variation. Hospitals can use these results to guide interactions with vendors. Vendor choice accounts for a meaningful proportion of variation in hospital meaningful use performance, and specific vendors are consistently associated with higher or lower performance across criteria.

The Relationship Between Magnet Designation, Electronic Health Record Adoption, and Medicare Meaningful Use Payments.

The objective of this study was to examine the relationship between nursing excellence and electronic health record adoption. Of 6582 US hospitals, 4939 were eligible for the Medicare Electronic Health Record Incentive Program, and 6419 were eligible for evaluation on the HIMSS Analytics Electronic Medical Record Adoption Model. Of 399 Magnet hospitals, 330 were eligible for the Medicare Electronic Health Record Incentive Program, and 393 were eligible for evaluation in the HIMSS Analytics Electronic Medical Record Adoption Model. Meaningful use attestation was defined as receipt of a Medicare Electronic Health Record Incentive Program payment. The adoption electronic health record was defined as Level 6 and/or 7 on the HIMSS Analytics Electronic Medical Record Adoption Model. Logistic regression showed that Magnet-designated hospitals were more likely attest to Meaningful Use than non-Magnet hospitals (odds ratio = 3.58, P < .001) and were more likely to adopt electronic health records than non-Magnet hospitals (Level 6 only: odds ratio = 3.68, P < .001; Level 6 or 7: odds ratio = 4.02, P < .001). This study suggested a positive relationship between Magnet status and electronic health record use, which involves earning financial incentives for successful adoption. Continued investigation is needed to examine the relationships between the quality of nursing care, electronic health record usage, financial implications, and patient outcomes.

Electronic clinical quality measure reporting challenges: findings from the Medicare EHR Incentive Program's Controlling High Blood Pressure Measure.

To identify physician and practice characteristics associated with high clinical and technical performance on the electronic clinical quality measure (eCQM) that calculates the proportion of patients with hypertension who have controlled blood pressure. The study included 268 602 physicians participating in the Medicare Electronic Health Record Incentive Program between 2011 and 2014. Independent variables included delivery reform participation and physician, practice level, and area characteristics. Successful technical performance was a reported eCQM with non-zero values in both the numerator and denominator. Successful clinical performance was a reported eCQM value of ≥70% hypertension control. Physicians with longer experience using certified health information technology, participants in delivery reform programs, and specialists that traditionally manage hypertension were 5%-15% more likely to achieve 70% control. Physicians in smaller and rural practices and a subset of physicians unlikely to primarily manage hypertension were more likely to submit measures with a zero value in either the numerator or denominator. More physicians are using eCQMs to track and report their quality improvement efforts. This research presents the first examination of national eCQM data to identify physician and practice-level characteristics associated with performance. With careful selection of measures relevant to the clinician's specialty, complete data entry, and support for continuous quality improvement, health care professionals can excel technically and clinically. As care delivery transitions from fee-for-service to quality- and value-based models, high performers may realize financial gains and better patient outcomes. These analyses suggest patterns that may inform steps to improve performance.

Smoking-Cessation Assistance: Before and After Stage 1 Meaningful Use Implementation

Brief smoking-cessation interventions in primary care settings are effective, but delivery of these services remains low. The Centers for Medicare and Medicaid Services' Meaningful Use (MU) of Electronic Health Record (EHR) Incentive Program could increase rates of smoking assessment and cessation assistance among vulnerable populations. This study examined whether smoking status assessment, cessation assistance, and odds of being a current smoker changed after Stage 1 MU implementation. EHR data were extracted from 26 community health centers with an EHR in place by June 15, 2009. AORs were computed for each binary outcome (smoking status assessment, counseling given, smoking-cessation medications ordered/discussed, current smoking status), comparing 2010 (pre-MU), 2012 (MU preparation), and 2014 (MU fully implemented) for pregnant and non-pregnant patients. Non-pregnant patients had decreased odds of current smoking over time; odds for all other outcomes increased except for medication orders from 2010 to 2012. Among pregnant patients, odds of assessment and counseling increased across all years. Odds of discussing or ordering of cessation medications increased from 2010 compared with the other 2 study years; however, medication orders alone did not change over time, and current smoking only decreased from 2010 to 2012. Compared with non-pregnant patients, a lower percentage of pregnant patients were provided counseling. Findings suggest that incentives for MU of EHRs increase the odds of smoking assessment and cessation assistance, which could lead to decreased smoking rates among vulnerable populations. Continued efforts for provision of cessation assistance among pregnant patients is warranted.

Abstract 028: Electronic Health Record Meaningful Use Did Not Improve Pay-for-Performance Outcomes

Objective: With the goal of improving healthcare quality, Medicare has implemented a series of pay-for-performance initiatives and allocated substantial financial resources to promote meaningful use of electronic health records (EHRs). The purpose of this study was to examine whether hospitals achieving EHR meaningful use improved hospital 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates used in Medicare pay-for-performance (P4P) initiatives. Methods: We used publically available data on Medicare EHR Incentive Program achievement (2014 to 2015) to categorize hospitals as achieving two years, one year, or no years of stage 2 meaningful use (i.e. comprehensive EHR) from 2014-2015. Using generalized linear models, we compared the change in publically reported 30-day RSMRs and RSRRs for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PN) from 2012 to 2016 by years of stage 2 meaningful use. Models were adjusted for hospital teaching status, system affiliation, ownership status, urban/rural location, bed size, and safety-net status obtained from the American Hospital Association Annual Survey and Medicare Impact File (both 2009-2011). Results: From the 4,755 hospitals participating in the Medicare EHR program, 19.8% and 46.0% had two years and one year of stage 2 meaningful use, while 34.2% never achieved stage 2 meaningful use. The Figure shows that from 2012 to 2016 thirty-day mortality for AMI decreased (-1.2% to -1.4%), increased modestly for CHF (+0.5), and increased for PN (+4.1 to +4.6%). All thirty-day readmission rates decreased during this time, with decreases greater in AMI and CHF (both -2.7% to -2.8%) than in PN (-1.3% to -1.4%). We found that there were no significant differences in risk-standardized mortality or readmission rate changes by years of stage 2 meaningful use, even after adjusting for hospital characteristics (all comparisons p&gt;0.05). Conclusions: While RSMRs and RSRRs have changed substantially from 2012 to 2016 for most conditions, changes were similar for hospitals with two years, one year, or no years of stage 2 EHR meaningful use. Our findings suggest that adoption of more comprehensive EHRs did not improve hospital P4P outcomes. Figure. Change in RSMRs and RSRRs rates by years of stage 2 meaningful use.