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.
- CHA —
- Children’s Hospital Association
- CPOE —
- computerized provider order entry
- EHR —
- electronic health record
- EMRAM —
- Electronic Medical Record Adoption Model
- HIT —
- health information technology
- HITECH —
- Health Information Technology for Economic and Clinical Health
What’s Known on This Subject:
Electronic health record (EHR) uptake by US hospitals has been slow, including among children’s hospitals. The Health Information Technology for Economic and Clinical Health program, which began in 2011, offers incentives for adoption and meaningful use of EHRs.
What This Study Adds:
Using an annual survey, we evaluated how children’s hospitals have progressed in EHR adoption from 2008 through the start of the Health Information Technology for Economic and Clinical Health program and assessed their ability to meaningfully use EHRs.
Improving pediatric health care quality is a national policy priority. Under the 2009 Children’s Health Insurance Program Reauthorization Act, a Pediatric Quality Measures Program was established and charged with defining evidence-based quality measures for use by Medicaid and the Children’s Health Insurance Program, which together cover nearly 40 million children.1–3 The success of efforts to measure and improve quality will depend on the presence of a robust information infrastructure. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act tries to make this infrastructure a reality by creating financial incentives for physicians and hospitals to adopt and meaningfully use electronic health records (EHRs).4
EHRs facilitate delivery of high-quality care.5 They allow collection of data required to evaluate care processes and outcomes and provide feedback on performance.6 EHRs aid providers in organizing and integrating information, safely managing medications and other interventions, and making decisions guided by evidence and patient preferences.7–9 Such support is vital for the care of pediatric patients, whose health conditions and needs vary widely by age and developmental stage.10,11 Recognizing that providers at children’s hospitals, which serve an increasingly complex, chronically ill population, would find EHRs especially useful,12 policymakers ensured that pediatric providers and hospitals were eligible for incentives under HITECH through state Medicaid programs.13
We previously found that in 2008, the year before the passage of HITECH, few children’s hospitals possessed EHRs: only 3% of hospitals had a comprehensive EHR system, while an additional 18% had a basic system.14 We are unaware of any data on how adoption rates among children’s hospitals have changed since HITECH was passed. Given the importance of EHRs as a tool to advance the broader quality agenda within pediatrics, understanding how these hospitals have fared under HITECH is critical. We therefore sought to answer 4 questions: (1) How have EHR adoption rates changed among children’s hospitals between 2008 and 2011? (2) How are children’s hospitals performing on metrics of meaningful use? (3) How do children’s hospitals compare with adult hospitals in EHR adoption and meaningful use? (4) Are subgroups of children’s hospitals falling behind in EHR adoption?
Survey Development and Administration
Development of the survey, which is administered by the American Hospital Association, was described previously.15 Since 2008, the survey has been sent annually, both online and by mail, to the chief executive officers of all US hospitals, who typically assign it to their most knowledgeable staff members (usually the chief information officer or equivalent). Nonresponding hospitals are encouraged to participate via multiple mailings and telephone calls. The survey analysis was considered exempt from human subjects review by the institutional review boards of Boston Children’s Hospital and the Harvard School of Public Health.
Identification of Children’s Hospitals
We identified children’s hospitals among the survey respondents using the Children’s Hospital Association (CHA) member directory. Among the 162 general acute care hospitals in our primary study population, there were 42 freestanding children’s hospitals; 76 nonfreestanding hospitals, referred to as “children’s hospitals within hospitals”; and 44 associate hospitals, a membership category requiring a minimum daily pediatric census of 45, pediatric graduate education program, and recognition as a pediatric referral center.16 We also performed a secondary analysis of EHR adoption that included CHA specialty hospitals (ie, those that care for specific conditions such as burns, orthopedic conditions, or neurologic conditions) and rehabilitation hospitals. Each institution received a single annual survey.
Questions assessed adoption of 24 individual clinical EHR functionalities (Appendix Table 1), with implementation measured as (1) not planned, (2) being considered or planned within the next year, (3) begun in at least 1 unit, (4) complete in at least 1 unit, or (5) complete across all units. Starting in 2010, the survey also included questions addressing the criteria hospitals must meet to achieve “meaningful use” under the EHR incentive program (Appendix Table 2).
We used the same definitions of basic and comprehensive EHR systems used in previous studies, thereby allowing for assessment of adoption trends over time and comparisons between children’s and adult hospitals. These definitions incorporate functionalities that are considered universally important to clinical care, including within pediatrics.11,17 A basic EHR must include 10 core functionalities, including physician notes, nursing assessments, problem and medication lists, laboratory and radiology reports, and computerized provider order entry (CPOE) for medications, fully implemented in at least 1 clinical unit (Appendix Table 1). A comprehensive EHR must include those plus a broader set of 14 additional functionalities, implemented across all units.
Achievement of Meaningful Use
To achieve meaningful EHR use under stage 1 of the EHR incentive program, hospitals must fulfill 14 core criteria, as well as at least 5 of 10 additional measures called menu criteria.13 Because many functionalities required for meaningful use differ from those required for a basic or comprehensive EHR, we evaluated meaningful use separately from EHR adoption, focusing on 12 meaningful use criteria that were well addressed by survey questions. The full list is provided in the accompanying Appendix (Appendix Table 2). These 12 criteria have been used previously to create a “proxy” measure for a hospital’s ability to meet the meaningful use standards.18
We compared characteristics of children’s hospitals that responded and did not respond to the survey. Although we found no significant differences, we used a logistic regression model with hospital characteristics as covariates to predict each hospital’s likelihood of responding to the survey. Subsequently, as is convention, we used the inverse of these propensity values as weights to correct for potential nonresponse bias in all analyses.
To measure EHR adoption progress from 2008 to 2011, we calculated adoption rates for basic and comprehensive EHRs during each year. Questions used to assess EHR adoption remained consistent across all 4 years of the survey. To analyze meaningful use achievement, we calculated the proportion of hospitals that could meet each of the 12 core meaningful use criteria assessed by the survey and the proportions satisfying fewer criteria. We focused on full implementation across all hospital units for the meaningful use analysis because children’s hospitals within hospitals and associate hospitals did not complete a separate survey from their parent institutions, preventing us from being certain that instances of partial adoption (ie, in at least 1 but not all units) included pediatric units. Because questions about many of the meaningful use functionalities were not asked until the 2010 survey, we assessed progress in meaningful use by determining the change from 2010 to 2011 in the proportion of hospitals fulfilling all 12 core measures.
We also assessed implementation in 2011 of 6 EHR functionalities considered to be likely to have an impact on quality of care,19 4 of which are included in the meaningful use criteria and 2 are not. We again focused on comprehensive adoption (ie, implementation across all units) of these functionalities for the reason stated previously.
Next, we gauged rates of EHR adoption and meaningful use by children’s hospitals against those of adult hospitals. Adult hospitals were identified among survey respondents as those that described their primary service as “general medical and surgical” and were not CHA members. We compared children’s and adult hospitals overall, but because children’s hospitals are predominantly teaching institutions and teaching status is known to predict EHR adoption,18,20 we also specifically compared children’s and adult major teaching hospitals. “Major teaching hospital” is defined for all hospitals by membership in the Council of Teaching Hospitals and Health Systems.
Last, to determine whether subgroups of children’s hospitals lag behind others in HIT adoption, we used multivariate logistic regression to evaluate how 5 hospital characteristics (type of children’s hospital, size, region, ownership, and teaching status) relate to EHR adoption or achievement of meaningful use.
We used the t test and logistic regression for bivariate analyses and logistic regression for multivariate analyses. A 2-sided P < .05 was used as the criterion for statistical significance.
Of 162 general acute care CHA hospitals surveyed in 2011, 126 (78%) responded. Respondents and nonrespondents did not differ significantly in teaching status, size, geographic region, ownership, or children’s hospital type (Appendix Table 3). Consistent with the overall composition of general acute care children’s hospitals, all but 2 respondents were teaching institutions, with three-quarters categorized as major teaching hospitals. Three-quarters were large. One-quarter of hospitals were freestanding, and half were children’s hospitals within hospitals.
The proportion of children’s hospitals with either a basic or comprehensive EHR increased from 21% in 2008 to 59% in 2011 (Fig 1A). Inclusion of specialty and rehabilitation hospitals did not substantively change the results (2011 adoption rate for any EHR: 57%). Gains in overall EHR adoption rates were steady, with increases of ∼16% from 2008 to 2009 and 11% in each subsequent year. Over the 3-year period, the comprehensive EHR adoption rate increased from 3% to 19%, whereas the basic EHR adoption rate increased from 18% to 40%.
In 2011, 29% of hospitals fulfilled 12 core meaningful use criteria (Fig 2), a proportion that had doubled from 14% in 2010. Another 30% of hospitals met 9 to 11 criteria in 2011, whereas 12% of hospitals met 4 or fewer (Fig 2). In 2011, the meaningful use functionalities in place for the greatest proportions of hospitals were medication allergy lists (87%), a clinical decision support rule (86%), medication lists (85%), and key demographics (85%) (Appendix Table 4). Among hospitals achieving 9 to 11 criteria in 2011, the functionalities most often lacking were quality measure reporting, drug-drug and drug-allergy interaction checks, and problem lists (Appendix Table 4).
Adoption of Individual EHR Functionalities
When we examined adoption of 6 clinically important EHR functionalities, we observed that comprehensive implementation rates varied among functionalities (Fig 3). The adoption rate for physician notes (40%), a functionality not included in the meaningful use criteria, was significantly lower than for CPOE for medications (68%) and 3 types of clinical decision support (56% to 66%), all of which are meaningful use functionalities (P ≤ .001). Likewise, the adoption rate for bar coding for drug administration (48%), another functionality not included in the meaningful use criteria, was significantly lower than for CPOE for medications and 2 of the types of clinical decision support (P ≤ .02).
HIT Adoption by Children’s Versus Adult Hospitals
In 2011, a significantly greater proportion of children’s hospitals than adult hospitals had adopted at least a basic EHR (59% vs 27%, P < .0001) or comprehensively implemented the 12 core meaningful use functionalities we evaluated (29% vs 11%, P < .0001).18 When we limited our analysis to children’s and adult major teaching hospitals, we found similar rates of adoption of at least a basic EHR (60% vs 53% in 2011, P = .36) (Fig 1B) and of comprehensive implementation of all 12 meaningful use functionalities (32% vs 28% in 2011, P = .15) (Table 1).
HIT Adoption by Subgroups of Children’s Hospitals
On multivariate analysis of 2011 EHR adoption rates, only teaching status was related to EHR adoption (P = .03), with minor teaching hospitals significantly less likely to have an EHR than major teaching hospitals (P = .009) (Table 2). Neither teaching status nor other hospital characteristics were significantly related to achievement of all 12 vs <12 core meaningful use criteria (Appendix Table 5).
Using the official federal definition of an EHR, we found that the rate of EHR adoption among US children’s hospitals has nearly tripled since 2008, reaching ∼60% in 2011. The proportion of hospitals with a comprehensive EHR rose most dramatically, increasing more than sixfold, such that by 2011, nearly 1 in 5 children’s hospitals had achieved this high level of HIT capability. Children’s hospitals have demonstrated corresponding gains in their meaningful use of EHRs: in 2011, nearly 30% met the 12 core meaningful use criteria assessed by our survey, a proportion up twofold from just the year prior. Among children’s hospitals, gains in adoption have been widespread, encompassing all types and sizes of children’s hospitals, although major teaching hospitals continue to outstrip other children’s hospitals. These findings are encouraging, particularly because essential EHR functionalities, such as CPOE, data extraction for quality measurement, and clinical decision support, when implemented well by children’s hospitals, provide crucial benefits, including improvements in evidence-based practice, increased medication safety, and even associated reductions in mortality.21–23
In our previous analysis of EHR implementation, using 2008 survey data, we found that children’s hospitals were further ahead than adult hospitals (adoption rate for any EHR: 21% vs 9%).14 We posited that children’s hospitals’ relative HIT sophistication might be attributed to their being mostly large, urban, and teaching institutions, all characteristics associated with EHR adoption.18,20,24,25 Our current analysis provides further support for the importance of teaching status in EHR adoption. The adoption rate for children’s hospitals continues to far exceed that of adult hospitals overall, but children’s and adult major teaching hospitals have similar adoption rates. The gap between children’s and adult hospitals appears attributable to the vast majority of children’s hospitals’ being teaching institutions. In addition, organizations such as CHA and the American Academy of Pediatrics have played a vital role in advancing EHR adoption among children’s hospitals by providing technical expertise and facilitating collaboration among children’s hospitals for advocacy and HIT development.26
We found that children’s hospitals may be prioritizing functionalities needed for meaningful use over other functionalities. For 6 functionalities believed to be important for quality of care, adoption rates for the 2 that are not part of meaningful use (physician notes and bar coding for medication administration) were, on average, 19% lower than for the 4 that are part of meaningful use (CPOE for medications and 3 types of clinical decision support). These findings offer indirect evidence that the meaningful use program is likely influencing decisions by children’s hospitals regarding which functionalities to adopt. While this may not be surprising, it warrants close attention to ensure that hospitals do not forgo key functionalities just because they are not included in the meaningful use regulations.
Although children’s hospitals have made progress in EHR adoption, ∼40% of children’s hospitals still lacked even a basic EHR in 2011, and 70% did not meet our proxy for meaningful use. Several features of the Medicaid EHR incentive program may limit its effectiveness in driving HIT implementation by these hospitals. The incentive payments are administered individually by each state Medicaid program, and state participation is optional.27 Hospitals can therefore receive incentives only if and when their states start an incentive program. More than half of states did not have their incentive program running by September 2011.28 In addition, unlike the Medicare program, the Medicaid program requires only purchase, implementation, or upgrading of a certified system in the first year of participation and does not require demonstration of meaningful use until the second year and beyond.13 Furthermore, the Medicaid program does not penalize hospitals that do not become meaningful users.13
Although our study is the first of which we are aware to examine changes in EHR adoption by children’s hospitals over time, data from the Healthcare Information Management and Systems Society Electronic Medical Record Adoption Model (EMRAM), which scores hospitals based on 1 of 8 stages of increasingly advanced HIT capabilities, reveal findings consistent with ours. As of 2010, 54% of children’s hospitals had reached EMRAM stage 4 (similar to our definition of a basic EHR) or higher, as compared with only 19% of adult hospitals.29 Also consistent with our findings, 2012 Health Information and Management Systems Society data show that teaching/academic hospitals have higher EMRAM scores than nonacademic hospitals (mean score, 4.5 vs 3.4, respectively).25
Our study had multiple limitations. Because children’s hospitals within hospitals and associate hospitals did not complete a separate survey from their parent institutions, we could not tell whether EHR functionalities had been adopted in pediatric units unless hospitals reported comprehensive (across all units) implementation. As a result, we used a threshold of comprehensive implementation to judge whether hospitals met meaningful use criteria, a standard more stringent than the actual requirements for most of the meaningful use measures.13 In addition, of the 14 core capabilities required for meaningful use, the survey did not address 2 capabilities (demonstration of electronic information exchange and health information security), so we cannot be certain what proportion of hospitals would actually qualify for incentives. The survey also did not ask directly how the EHR incentive program has influenced adoption priorities or what challenges, if any, hospitals have encountered in attempting to join Medicaid incentive programs. An unavoidable limitation was limited power to detect differences between subgroups of children’s hospitals because of the small number of children’s hospitals overall.
Finally, although our study addressed adoption of important EHR functionalities, we did not evaluate their effectiveness. The survey did not ask about unintended consequences that may result from poorly designed or badly implemented EHRs, such as degradation of documentation quality,30 introduction of medication errors,31 and delay of critical care processes.32 It also did not assess whether EHRs were suited for pediatric care. Most EHR systems were initially designed for adult patients and require customization for child health, as detailed in a key report by the American Academy of Pediatrics’ Council on Clinical Information Technology.33 Without features such as pediatric normal values for vital signs and laboratory results, growth charts for all age groups, drug-dosing support and dose-range checking based on age and weight, and problem lists and clinical decision support that incorporate pediatric diagnoses, EHRs may fail to support, or may possibly hamper, effective care.33
Children’s hospitals are doing relatively well with HIT adoption, but they remain an important sector to monitor in coming years: 40% of children’s hospitals still do not have even a basic EHR, and benefits from Medicaid incentives may be limited by state Medicaid programs’ ability to administer them. Even for hospitals making progress in implementing EHRs, challenges remain in adapting systems for pediatrics and using them to drive improvements in care. Whether the EHR incentive program encourages these tasks will depend on how well later stages of meaningful use incorporate pediatric capabilities. Although our findings represent good news in EHR adoption among children’s hospitals, we need to monitor whether the HITECH program drives adoption of systems that facilitate the care of children and adolescents.
- Accepted January 4, 2013.
- Address correspondence to Mari M. Nakamura, MD, MPH, Division of Infectious Diseases, 300 Longwood Avenue, Enders 7, Boston, MA, 02115. E-mail:
Dr Nakamura conceptualized and designed the study, carried out the analyses and interpreted the study findings, and wrote the manuscript; Dr Harper interpreted the study findings and reviewed and revised the manuscript; Dr Jha conceptualized and designed the study, interpreted the study findings, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Robert Wood Johnson Foundation, grant number 68754.
- ↵Agency for Healthcare Research and Quality. Pediatric Quality Measures Program (PQMP) Centers of Excellence Grant Awards. Available at: www.ahrq.gov/chipra/pqmpfact.pdf. Accessed July 15, 2012
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- ↵US Congress. American Recovery and Reinvestment Act of 2009 (Public Law 111-5). Available at: www.gpo.gov/fdsys/pkg/PLAW-111publ5/content-detail.html. Accessed August 30, 2010
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- ↵Blumenthal D, DesRoches C, Donelan K, et al. Health information technology in the United States: where we stand, 2008. Available at: www.rwjf.org/pr/product.jsp?id=31831. Accessed February 2, 2011
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- ↵HIMSS Analytics. Current EMRAM scores. Available at: www.himssanalytics.org/emram/scoreTrends.aspx. Accessed July 15, 2012
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- ↵Burke T, Stewart A, Cartwright-Smith L. Meaningful use & Medicaid—challenges for states and providers. LegalNotes. 2010. Available at: www.rwjf.org/files/research/71847.pdf. Accessed July 15, 2012
- ↵Centers for Medicare and Medicaid Services. State EHR incentive program launch times and HIT Web sites. 2012. Available at: www.cms.gov/apps/files/statecontacts.pdf. Accessed July 13, 2012
- ↵National Association of Children's Hospitals. Office of the National Coordinator for Health Information Technology Strategic Plan (NACH comment letter). Available at: www.childrenshospitals.net/AM/Template.cfm?Section=Health_IT1&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=56808. Accessed July 16, 2012
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- Copyright © 2013 by the American Academy of Pediatrics