NEJM: Less than 2% of hospitals have comprehensive EHRstimulus might help

Although the consensus is that EHRs have the potential to improve the efficiency and effectiveness of U.S. healthcare providers, less than 2 percent of acute-care hospitals have implemented a comprehensive EHR; further, less than 8 percent have a basic EHR in place, according to a study published online March 25 in the New England Journal of Medicine that is scheduled for publication in the April 16 print edition.

It is the first nationally representative study of the prevalence of EHR in hospitals, according to the investigators from the Harvard School of Public Health (HSPH) in Cambridge, Mass., Massachusetts General Hospital in Boston and George Washington University in Washington, D.C.

The findings are significant as Congress and the Obama administration targeted $19 billion in the federal stimulus package for improving adoption of health IT, such as EHRs, according to the authors.

"This study suggests hospitals have a long way to go in achieving widespread EHR adoption and use," said the study's lead author Ashish Jha, associate professor of health policy and management at HSPH. "The $19 billion in the stimulus bill is really just a down payment for getting us to a healthcare system that is fully electronic and can deliver the kind of care Americans deserve."

The U.S. survey, conducted in 2008, was sent to all acute-care hospitals that are members of the American Hospital Association (AHA); responses came from 2,952 hospitals, or approximately 63 percent of the membership. An panel defined a comprehensive EHR as having 24 functionalities-such as, physician notes, lab reports, medications-present in all major clinical units of a hospital. The criteria for basic EHRs were having ten functionalities in at least one major clinical unit.

The researchers hypothesized that large hospitals and major teaching hospitals would have a higher prevalence of EHR and public hospitals might have lower adoption rates, under the assumption that large institutions have greater access to the capital needed to buy and implement these expensive systems.

The results showed that 1.5 percent of U.S. hospitals had implemented a comprehensive EHR and an additional 7.6 percent had a basic EHR in place, the investigators reported. Larger hospitals, major teaching hospitals and urban hospitals were more likely to have EHRs. Adoption rates of EHRs were similar between public and private institutions.

The most commonly cited barriers to adoption among hospitals without EHR were:

• Inadequate capital for purchase (73 percent);
• Concerns about maintenance costs (44 percent);
• Resistance from physicians (36 percent);
• Unclear return on investment (32 percent); and
• Lack of staff with adequate IT expertise (30 percent).
  

Jha and colleagues noted that hospitals with EHRs cited physician resistance as a major barrier, but were less likely to cite the other four as major barriers.

The lack of capital is a particularly difficult challenge for hospitals that wish to transition to an EHR system. The authors wrote that systems can cost between $20 million and $200 million, a significant investment at a time when hospitals are facing severe economic challenges due to the current recession. However, there is ample evidence that if implemented effectively, EHRs can reduce medical errors, improve quality and make healthcare more efficient.

"While EHRs alone won't fix all of the ills of the healthcare system, they are clearly a component of the broader effort to reduce costs and improve the quality of American healthcare," Jha concluded.

National Coordinator for Health IT in the Department of Health and Human Services (HHS) and the Robert Wood Johnson Foundation supported the study.