Electronic Health Records

By Emily B. Jones and Michael F. Furukawa

doi: 10.1377/hlthaff.2013.1274

Adoption And Use Of Electronic

HEALTH AFFAIRS 33,
NO. 7 (2014): 1254–1261
©2014 Project HOPE—
The People-to-People Health
Foundation, Inc.

Health Records Among Federally

Qualified Health Centers Grew
Substantially During 2010–12
Emily B. Jones (Emily.Jones@
hhs.gov) was a public health ABSTRACT Federally qualified health centers play an important role in
analyst in the Office of the
National Coordinator for
providing health care to underserved populations. Recent substantial
Health Information Technology federal investments in health information technology have enabled
(ONC), Department of Health
and Human Services, in
health centers to expand their use of electronic health record (EHR)
Washington, D.C., when this systems, but factors associated with adoption are not clear. We examined
article was written. She is
now a social science analyst 2010–12 administrative data from the Health Resources and Services
in the HHS Office of the Administration’s Uniform Data System for more than 1,100 health
Assistant Secretary for
Planning and Evaluation. centers. We found that in 2012 nine out of ten health centers had
adopted a EHR system, and half had adopted EHRs with basic
Michael F. Furukawa is a
senior staff fellow in the capabilities. Seven in ten health centers reported that their providers
Center for Delivery, were receiving meaningful-use incentive payments from the Centers for
Organization, and Markets at
the Agency for Healthcare Medicare and Medicaid Services (CMS). Only one-third of health centers
Research and Quality, in
Rockville, Maryland. He was
had EHR systems that could meet CMS’s stage 1 meaningful-use core
director of the Office of requirements. Health centers that met the stage 1 requirements had more
Economic Analysis, Evaluation,
and Modeling at the ONC
than twice the odds of receiving quality recognition, compared with
when this article was written. centers with less than basic EHRs. Policy initiatives should focus
assistance on EHR capabilities with slower uptake; connect providers
with technical assistance to support implementation; and leverage the
connection between meaningful use and quality recognition programs.

H
ealth information technology
(IT) has been a major policy fo-
cus in recent years across pro-
vider types and settings, includ-
ing federally qualified health
centers.1,2 Evidence suggests that health IT can
improve the efficiency, safety, and quality of pa-
tient care.3 Health IT may also enable health cen-
ters to reduce disparities in care processes and
health outcomes.4,5 Despite the potential of
health IT, its rate of adoption has been low
throughout the health care system, especially
among smaller practices, in rural areas, and
among providers who care chiefly for under-
served populations.6,7 This creates concerns
about how to address the digital divide.8
Substantial federal investments have been fo-
cused on health centers to reduce disparities and
avoid expanding the digital divide. For more
than two decades the Health Resources and Ser-
vices Administration (HRSA) has supported
health IT through funding, partnerships, and
programs targeted at infrastructure, improve-
ment, and innovation.9,10
More recently, the Health Information Tech-
nology for Economic and Clinical Health
(HITECH) Act of 2009 authorized nearly $30 bil-
lion in incentives and assistance to advance the
adoption and use of interoperable electronic
health record (EHR) systems. As of 2011 eligible
hospitals and professionals, including providers
affiliated with health centers, can receive incen-
tive payments from the Medicaid and Medicare
EHR Incentive Programs of the Centers for Medi-

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care and Medicaid Services (CMS) for the “mean-
ingful use” of certified EHR technology. In addi-
tion, the Medicaid program offers the first of
three incentive payments to eligible profession-
als and hospitals for adopting, implementing, or
upgrading to a certified EHR system, to support
hospitals and providers during the adoption
process.
HITECH offers technical assistance for mean-
ingful use through Regional Extension Centers
in partnership with HRSA and state and local
initiatives.11 HITECH has also created programs
to train health care providers and other staff to
help implement health IT.
EHR adoption and use of capabilities related to
federal meaningful-use criteria have grown rap-
idly among office-based physicians and acute
care hospitals since 2010.12,13 Participation in
the CMS meaningful-use program has also been
robust: More than half of the eligible providers
had collectively received $21.6 billion in incen-
tive payments as of February 2014.14 Health IT
adoption among health centers has been increas-
ing over time.15–17 However, fewer than half of
health centers used electronic records systems
in all sites in 2011, instead of a mix of electronic
and paper records systems.18,19
This study sought to answer the following
questions. First, how did health center adoption
and use of EHR systems change from 2010 (the
year before the start of the incentives) to 2012
(the second year of incentive payments)? Sec-
ond, are there disparities in EHR adoption
among health centers related to health center
size; rural location and region; and patient de-
mographic characteristics such as income, race
or ethnicity, and insurance status? Third, how
did the adoption of computerized capabilities
related to meaningful-use objectives change
from 2010 to 2012? Fourth, what proportion
of health centers employed providers who re-
ceived incentive payments and used EHR sys-
tems with capabilities that could meet the stage
1 core meaningful-use requirements in 2012?
And fifth, was the adoption of an EHR system
with capabilities for the stage 1 meaningful-use
requirements associated with a health center’s
receiving quality recognition from third-party
organizations?
Our findings have important policy implica-
tions for monitoring progress toward the wide-
spread adoption of health IT among health cen-
ters. The findings also highlight opportunities
for targeted policy interventions and assistance.
Study Data And Methods
We used administrative data from the Uniform
Data System (UDS) for the period 2010–12. The
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
UDS data are collected by the Bureau of Primary
Health Care at HRSA. Annual reporting on a
calendar-year basis is required for grantees un-
der section 330 of the Public Health Service Act.
Health center grantee organizations report in-
formation in response to questions on health
center operations, patients’ demographic char-
acteristics, and location.
Information on EHR adoption, the extent of
EHR use, and computerized capabilities for
meaningful use has been collected by the UDS
since 2010. Information on providers’ participa-
tion in the EHR incentive programs and quality
recognition status was added in 2012. Our anal-
ysis included all federally qualified health cen-
ters, totaling 1,123 organizations in 2010, 1,128
in 2011, and 1,198 in 2012.
Adoption Of Electronic Records And
Meaningful-Use Objectives We analyzed two
measures of EHR adoption—the adoption of any
EHR system and the adoption of a basic EHR
system—for comparability with national esti-
mates of adoption among office-based physi-
cians and acute care hospitals that also used
these measures.12 Adoption of any EHR system
was defined as an affirmative response to the
question, “Does your center currently have an
EHR system (do not include billing record sys-
tems) installed and in use?” Adoption of a basic
EHR system was defined as having seven comput-
erized capabilities: recording patient history and
demographic information; maintaining patient
problem lists; recording clinical notes; maintain-
ing medication lists; incorporating laboratory
results into the EHR; incorporating radiology
results into the EHR; and entering prescription
orders electronically.
We also examined whether health centers used
computerized capabilities related to selected
meaningful-use objectives. We focused on twen-
ty-four capabilities across six outcome domains.
The capabilities were all fifteen core objectives
for stage 1 meaningful use; seven capabilities
related to objectives that will be in stage 2 when
it goes into effect; and two capabilities related to
clinical quality measures. Use of each capability
was based on responses to the question, “Does
your EHR provide the following meaningful-use
functions and are you using them?”
We defined adoption of each capability based
on an affirmative response that “the system has
this capability and it is being used by medical
providers.” Responses of “the system does not
have this capability,” “turned off or not used,”
and “unknown” were classified as not having
adopted the capability. For a table displaying
EHR capabilities associated with basic EHR sys-
tems and the stage 1 meaningful-use core objec-
tives, see online Appendix A.20
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Electronic Health Records
We specified key health center characteristics
that previous studies found were associated with
disparities in the adoption of EHR systems.12,15
Variables were created for health center size
(number of sites); income status (percentage
of patients whose family incomes were at or be-
low the federal poverty level); insurance status
(percentage of uninsured patients); race or eth-
nicity (percentage of the health center’s patients
who reported race or ethnicity information and
who said that they were Hispanic or Latino or
said that they were not Hispanic or Latino but
were black or African American); metropolitan
status (urban versus rural); and region (North-
east, Midwest, South, or West) as measured by
the location of the grantee organization.
Meaningful Use And Quality Recognition
In 2012 the UDS data captured information on
health center providers’ participation in mean-
ingful use. Meaningful-use participation was
based on whether health centers reported that
their providers were receiving meaningful-use
incentive payments, planned to apply for such
payments in the next year, or did not meet the
requirements or did not plan to apply.
To assess readiness for stage 1 meaningful use,
we created a count measure (ranging from 0 to
15) of the number of capabilities required to
meet stage 1 core objectives that each health cen-
ter had adopted. Health centers’ quality recogni-
tion status was based on responses to the ques-
tion, “Has your health center received national
and/or state quality recognition, either accredi-
tation or patient-centered medical home recog-
nition, for one or more sites?” Health centers
with affirmative responses were categorized as
having received quality recognition.
Analysis Using unadjusted numbers, we ex-
amined changes from 2010 to 2012 in adoption
rates for any EHR system and for a basic EHR
system and in having computerized capabilities
◀
79
related to meaningful-use objectives. Among
EHR users, we examined changes in the extent
% of EHR use and readiness to meet the stage 1
meaningful-use requirements.
Used EHR at all sites
Using multivariate logistic regression, we an-
In 2012, 79.3 percent of
health centers reported
alyzed health center characteristics associated
using their EHR system at with the adoption of a basic EHR in 2010 and
all sites, up from 2012, as well as changes from 2010 to 2012. Us-
50.7 percent in 2010.
ing logistic regression estimates, we calculated
predicted EHR adoption rates for each health
center characteristic, adjusting for other health
center and patient demographic characteristics.
Multivariate logistic regression was used to ana-
lyze the association between quality recognition
status and the degree of EHR adoption and read-
iness for meaningful use of health IT in 2012,
adjusting for other health center characteristics.
Limitations The analysis had some limita-
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Disparities in the
adoption of basic EHR
systems were
observed with regard
to some health center
characteristics.
tions. The measures of EHR adoption and use
of specific functionalities were self-reported and
may be biased upward.
Also, the UDS data captured the extent of EHR
use for each grantee organization, but data on
adoption for each care delivery site were not
available. However, bias due to this lack is likely
minimal, since most health center grantee or-
ganizations used their EHR systems in all sites
and for all providers.
The measure created to serve as a proxy for
meaningful-use readiness was constructed using
information on the use of specific functionali-
ties. Thus, the measure may not reflect whether
or not providers actually met all criteria for the
EHR incentive programs or qualified for an in-
centive payment.
Our analysis was limited in scope, and our
methods did not permit us to make causal con-
clusions. We did not attempt to analyze the full
range of factors associated with EHR adoption
and meaningful use. Thus, we did not examine
factors such as IT staffing.
The UDS data lacked information on owner-
ship, cash reserves, date of adoption of certified
EHR technology, and future plans for health IT
adoption, among other factors. Information on
affiliation with Health Center Controlled Net-
works was not available in the data, and a list
of health centers that participated in these tech-
nical assistance networks during the study peri-
od was not available to us. These are important
topics for future research.
Study Results
Adoption Trends, 2010–12 EHR adoption
among health centers increased significantly
from 2010 to 2012 (see Appendix B).20 In 2012,
90.0 percent of health centers had adopted an
EHR system, and 49.5 percent reported having
capabilities that met the criteria for a basic EHR
system—up from 64.8 percent and 29.7 percent,
respectively, in 2010. Exhibit 1
The extent of EHR use also grew significantly.
Extent Of Electronic Health Record (EHR) System Use Among Federally Qualified Health
In 2012, 79.3 percent of health centers reported Centers, 2010–12
that their EHR system was used at all sites and
for all providers, up from 50.7 percent in 2010
(Exhibit 1).
Disparities In Adoption Disparities in the
adoption of basic EHR systems were observed
with regard to some health center characteristics
(Exhibit 2). In 2010 health centers with the larg-
est share of Hispanic and non-Hispanic black
patients and centers located in rural areas had
significantly lower adoption rates than centers
with smaller caseloads of Hispanic and non-
Hispanic black patients and centers in urban
areas. These differences had disappeared by
2012, since relative growth in EHR adoption
among rural health centers and those with large SOURCE Authors’ analysis of data from the Uniform Data System, 2010–12.
proportions of minority patients was high.
However, new disparities in EHR adoption by
health center size, income status, and region
were evident in 2012 (Exhibit 2). The largest

Exhibit 2

Federally Qualified Health Centers’ Adoption Of Electronic Health Record (EHR) Systems, By Health Center Characteristics,
2010 And 2012
Basic EHR adoption rate (adjusted %)a
Relative change in basic
2010 2012b EHR adoption rate (%)
All centers 29.8 49.6 66.7
Number of sites
1–3 28.0 46.6 66.2
4–7 30.9 48.4 56.6
8 or more 31.2 55.4** 77.5
Percent of patients at or below poverty
63.5 or less 31.2 55.5 77.7
63.6–78.3 31.2 48.4* 55.0
78.4–100.0 26.8 45.1** 68.2
Percent of uninsured patients
28.6 or less 30.8 51.0 65.5
28.7–45.0 28.1 49.3 75.4
45.1–100.0 30.3 48.6 60.2
Percent of Hispanic and non-Hispanic black patients
23.0 or less 35.7 51.9 45.6
23.1–64.3 30.1 48.3 60.6
64.4–100.0 23.8*** 48.6 104.0
Metropolitan status
Urban 33.1 52.4 58.4
Rural 26.3** 46.5 76.3
Region
Northeast 29.5 47.4 60.4
Midwest 33.1 60.2*** 81.7
South 28.3 51.3 81.3
West 28.9 44.8 54.9

SOURCE Authors’ analysis of data from the Uniform Data System for 2010 and 2012. NOTE Significance denotes difference from the
reference category (the first listed category for each characteristic). aBasic EHR adoption rates are adjusted percentages based on
multivariate logistic regression that includes all characteristics listed. bThe basic EHR adoption rate in 2012 was significantly different
from the rate in 2010 for each subgroup examined (p < 0:05). *p < 0:10 **p < 0:05 ***p < 0:01

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 Electronic Health Records
health centers (those with eight or more sites)
had a significantly higher rate of EHR adoption
than the smallest health centers (those with one
to three sites). Health centers with the largest
share of patients whose family incomes were
below the federal poverty level had a lower rate
of EHR adoption than centers with smaller per-
centages of low-income patients. And the adop-
tion rate in the Midwest of 60.2 percent was
higher than the rate in other regions.
Meaningful-Use Objectives Adoption of
computerized capabilities related to meaning-
ful-use objectives grew rapidly from 2010 to
2012, with relative changes ranging from 39 per-
cent to 93 percent. See Appendix C for growth
from 2010 to 2012; Appendix D shows 2012
means for the capabilities, stratified by basic
EHR status.20
The highest relative growth occurred in capa-
bilities to engage patients and their families in
their care; improve care coordination; and im-
prove population and public health. For exam-
ple, 85.1 percent of health centers had the capa-
bility to provide clinical summaries for patients
for each office visit in 2012—a relative increase of
63 percent. Computerized capabilities for reduc-
ing health disparities and improving quality and
safety had relatively high adoption rates in 2012,
with fourteen capabilities used by at least 80 per-
cent of health centers.
However, some capabilities that will be re-
quired for stage 2 meaningful use had relatively
low levels of adoption in 2012. For example,
36.1 percent of the centers said that they had
electronic reporting to immunization registries,
and 55.8 percent said that they had computer-
ized provider order entry for radiology tests.
Across outcome domains, adoption rates re-
Exhibit 3
Readiness To Meet Stage 1 Meaningful-Use Criteria Among Federally Qualified Health
Centers, 2010–12
SOURCE Authors’ analysis of data from the Uniform Data System, 2010–12. NOTE “Objectives” are
the core objectives that are required to meet the criteria for stage 1 meaningful use.
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mained lowest for capabilities related to popula-
tion and public health.
Provider Participation And Readiness For
Meaningful Use Health center providers’ par-
ticipation in the meaningful-use programs was
strong in 2012: 69.5 percent of the centers re-
ported that their providers were receiving mean-
ingful-use incentive payments as a result of the
center’s EHR system. Furthermore, 18.7 percent
of health centers had providers that planned to
apply for incentive payments in the next year.
Only 1.8 percent of the centers reported their
providers did not meet the requirements or
did not plan to apply.
The proportion of health centers using EHRs
that were ready for stage 1 meaningful use more
than doubled from 2010 to 2012 (Exhibit 3). In
2012, 36.7 percent of centers used EHRs with
capabilities that met the requirements for all
of the core stage 1 meaningful-use objectives.
Another 27.5 percent used EHRs that failed to
meet only one requirement—most frequently,
the capability to exchange key clinical informa-
tion with other providers for care coordination.
Quality Recognition In 2012, 33.1 percent of
health centers reported receiving quality recog-
nition at the national level, the state level, or
both. When we adjusted for health center char-
acteristics, we found that EHR adoption was as-
sociated with a significantly higher likelihood of
receiving quality recognition (Exhibit 4). Cen-
ters with EHRs that met all stage 1 meaningful-
use objectives had 2.4 times greater odds of re-
ceiving any quality recognition, relative to cen-
ters that lacked even a basic EHR system. Health
center size (number of sites), region, rural loca-
tion, and patient race or ethnicity and income
were also associated with quality recognition
status.
Discussion
We found substantial growth in health centers’
EHR adoption and use from 2010 to 2012. By
2012 nine in ten health centers had adopted
some type of EHR system, and half had all of
the capabilities required for a basic system.
The EHR system was used by all providers and
at all sites in most of the health centers that
had EHRs.
The adoption of some capabilities included in
the meaningful-use program’s stage 1 core crite-
ria has increased rapidly. However, the adoption
of other capabilities remains relatively low. Pro-
viders’ participation in the incentive programs
was high during our study period, but only one-
third of health centers had EHRs that were ready
for stage 1 meaningful use. This is possible be-
cause under the Medicaid meaningful-use pro-
gram, eligible providers can qualify for the first Exhibit 4
incentive payment for adopting, implementing,
Association Of Electronic Health Record (EHR) Adoption And Quality Recognition Status
or upgrading to a certified EHR system; pro- Among 1,198 Federally Qualified Health Centers, 2012
viders are not required to have EHRs that meet
all of the stage 1 meaningful-use requirements to Adjusted odds
ratio
qualify for the first payment.
Disparities in EHR adoption by location and by Number of sites
patients’ race or ethnicity narrowed in the study 1–3 1.000
4–7 1.631***
period. However, in 2012 we observed new dis-
8 or more 2.914****
parities in adoption by health center size, pover-
Percent of patients at or below poverty
ty status of health center patients, and region.
63.5 or less 1.000
Larger size may facilitate EHR adoption through
63.6–78.1 0.674**
pooled resources and organizational learning. 78.2–100.0 0.601***
Organizational changes may also be contribut- Percent of uninsured patients
ing to the increase in EHR adoption: Health cen- 28.7 or less 1.000
ter size grew significantly from 2010 to 2012 28.8–45.3 0.932
(Appendix E).20 45.4–100.0 0.727*
Disparities by income and region are consis- Percent of Hispanic and non-Hispanic black patients
tent with national trends.21 Policies should focus 22.8 or less 1.000
interventions to assist health centers in high 22.9–64.4 1.354
poverty areas and in states with relatively low 64.5–100.0 1.533**
EHR adoption rates. In addition, participation Metropolitan status
in initiatives such as the Health Center Con- Urban 1.000
trolled Network program should be encouraged Rural 0.660**
to help health centers make the work-flow Region
changes necessary to use health IT to improve Northeast 1.000
clinical care. Midwest 2.107****
The highest adoption rates we found were for South 0.912
West 0.784
capabilities that support safety and quality im-
Electronic records adoption status
provement. This finding may reflect health cen-
ters’ previous experience with electronic systems Less than basic EHR 1.000
Basic EHR with less than all meaningful-use stage 1 core
for compliance with quality-related grant report-
objectives 1.577***
ing requirements,22 receipt of support for tech- EHR with all meaningful-use stage 1 core objectives 2.351****
nical assistance with using health IT to improve
quality through Health Center Controlled Net-
works,23 and earlier initiatives that used regis- SOURCE Authors’ analysis of data from the Uniform Data System for 2010 and 2012. NOTES “Quality
recognition status” is defined by whether the health center received quality recognition—either
tries24,25 and data warehouses26 to improve clini-
accreditation or patient-centered medical home recognition—at the national or state level or
cal performance and reduce health disparities.4 both for one or more sites. The adjusted odds ratios indicate the likelihood of having achieved
Adoption of some capabilities remained rela- quality recognition status. Significance denotes difference from the reference category (the first
tively low, particularly those related to care co- listed category for each characteristic). *p < 0:10 **p < 0:05 ***p < 0:01 ****p < 0:001
ordination and population or public health. One
explanation for the low adoption of care coordi-
nation capabilities is that the stage 1 meaningful- larly those related to patient engagement and
use criteria do not require the actual exchange of care coordination.29
information, only a test of the EHR’s ability to Health centers with basic EHRs or EHRs ready
exchange information. Low rates of electronic for stage 1 meaningful use were much more likely
reporting to immunization registries may reflect to have been recognized for quality, compared to
registries’ inability to accept data instead of health centers without basic EHRs or EHRs
health centers’ EHR capabilities.27 capable of meeting stage 1 meaningful-use re-
Although participation in the incentive pro- quirements. Public and private initiatives have
grams was high among providers employed by focused on the alignment of meaningful-use
health centers, fewer than half of health centers capabilities and new care delivery models, par-
had EHRs that were ready to meet all stage 1 core ticularly patient-centered medical homes.30,31
criteria. Since health centers are not eligible for HRSA’s national strategy to improve quality in
meaningful-use incentives at the facility level, health centers involves universal EHR adop-
policies should target assistance to health cen- tion32 as a basis for each health center to partici-
ters that have not yet adopted EHRs28 and ad- pate in quality or patient-centered medical home
dress what may be inhibiting the adoption of recognition programs.33 Since meaningful use of
capabilities with relatively low uptake, particu- EHRs is foundational for quality recognition,

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Electronic Health Records

policies should focus on targeted assistance to

overcome barriers to adoption and achieving The highest adoption
meaningful-use objectives.
rates we found were
Conclusion
for capabilities that
The adoption and use of EHR systems by feder-
ally qualified health centers have grown signifi-
support safety and
cantly since the passage of HITECH. The highest quality improvement.
relative growth in adoption from 2010 to 2012
was in capabilities required for meaningful-use
incentives. Despite strong growth overall, dis-
parities in 2012 EHR adoption were observed
for smaller health centers, for those serving
higher caseloads of low-income patients, and Our findings highlight key areas for continued
by region. Most health centers had some pro- policy focus, particularly in targeting assistance
viders receiving incentive payments. However, to those groups falling behind and focusing ef-
since the first payment is available prior to meet- forts on capabilities with slower uptake. Comply-
ing the stage 1 requirements to help adopt, im- ing with meaningful-use requirements may play
plement, or upgrade the EHR system, health a key role in enabling quality recognition among
centers’ readiness to meet the meaningful-use health centers. ▪
program requirements was more limited.

The views expressed in this article are

those of the authors and do not
necessarily reflect those of the US
Department of Health and Human
Services.

NOTES
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