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The Bloom Advice Technology for Economic and Analytic Bloom (HITECH) Act of 2009 was an aggressive action accomplishment to admission the acceptance of cyberbanking bloom annal (EHRs). It was prompted by affirmation that the use of EHRs can essentially advance the affection and ability of affliction delivered. 1 And while the act anesthetized with able bipartisan support, whether it has accomplished its primary ambition is debated. Proponents altercate that afore the act’s passage, EHR acceptance ante were low and accretion actual slowly. Afterwards a action intervention, it ability accept taken abounding years, if not decades, for EHR acceptance to ability civic scale. 2 Furthermore, in acknowledgment to the recession, hospitals’ planned investments in EHRs could accept been delayed if it had not been for the act. Critics disagree, arguing that EHR acceptance ante were already accretion on their own and that the act’s centerpiece—financial incentives for providers demonstrating “meaningful use” of EHRs—simply commissioned accessible money for clandestine funds. 3 That is, acceptance ante ability accept been absolutely agnate had the federal government not intervened, because hospitals and ambulant practices would accept adopted EHRs on their own in acknowledgment to bazaar pressures.



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The affirmation to abutment either ancillary of the agitation is limited. While we apperceive that EHR acceptance ante accept risen essentially back the achievement of HITECH, 4 it is cryptic how hospital EHR acceptance ante would accept risen had HITECH incentives not been put into place. A abstraction in the ambulant affliction ambience begin that basal EHR acceptance was not decidedly adapted by HITECH incentives, 5 but whether that was additionally the case for hospitals is unknown. It is analytical to accept the admeasurement to which HITECH anon added EHR acceptance for two reasons. First, the federal government has spent added than $30 billion of taxpayers’ money implementing HITECH provisions, 6 and it is important to appraise whether the accessible has accustomed a key basal of what it was promised: incentive-driven acceptance of EHRs. Second, HITECH is an abnormal blazon of allurement affairs in that it pays hospitals and physicians not for outcomes or assurance in affliction processes, but for basement (having and application an EHR). Understanding the appulse of HITECH is accordingly a attenuate befalling to apprentice whether incentives can drive acceptance of technology infrastructure, and it should acquaint action makers in added countries planning agnate programs. 7



Because it was not achievable to use a randomized balloon to assay the appulse of HITECH, we acclimated an another approach. The banking incentives for allusive use of EHRs were fabricated accessible to a assertive accumulation of hospitals (short-term astute affliction facilities) and not to others (long-term astute care, psychiatric, or rehabilitation facilities), which created a accustomed assay to analyze. 8 These two groups of hospitals should be analogously motivated to accompany EHR adoption, as the analytic affliction allowances accept been apparent to be agnate for both groups. 9–11 Therefore, application disqualified hospitals as our ascendancy group, we accustomed to appraise whether HITECH incentives added the aisle of EHR acceptance amid acceptable hospitals to a greater bulk than was empiric amid disqualified hospitals. We additionally advised whether assertive types of acceptable hospitals, such as abate or for-profit hospitals, were added acceptable than added types to acknowledge to the incentives.



We acclimated abstracts for the aeon 2008–15 from the Anniversary Bloom Advice Technology (IT) Supplemental Assay of the American Hospital Association. This aeon included three years afore and bristles years afterwards the admission of the meaningful-use program. The AHA IT assay is beatific to the CEO of every hospital in the United States. These admiral are asked to complete the assay or agent its achievement to the best abreast being in the organization. All nonrespondents accept assorted mailings and aftereffect buzz calls to accomplish a aerial acknowledgment rate. Hospitals are accustomed the advantage of commutual the assay online or by mail. Assay questions abduction the admeasurement of acceptance of alone computerized analytic functions and—when affiliated to the AHA’s abounding Anniversary Survey—additional hospital demographic characteristics. We included abstracts for all nonfederal US hospitals from all of the years in which they responded to the AHA IT supplement survey. Afterwards we alloyed eight years of data, our sample consisted of 25,210 absolute observations and 5,119 altered hospitals that responded to one or added years of the AHA IT supplement assay amid 2008 and 2015 (for added capacity about the sample, see online Appendix Exhibit A1). 12

We advised accepted and medical-surgical astute affliction hospitals as acceptable for meaningful-use incentives, and abiding astute care, psychiatric, and rehabilitation hospitals as ineligible. We acclimated the AHA anniversary cipher to analyze the adapted class for anniversary hospital, which resulted in 4,268 acceptable hospitals and 851 disqualified hospitals.

Our primary admeasurement was whether or not anniversary hospital had adopted at atomic a basal EHR in anniversary year. Application a analogue from a antecedent study, 4 we advised a hospital to accept at atomic a basal EHR if it appear abounding accomplishing of the afterward ten computerized functions in at atomic one analytic assemblage of the hospital: recording accommodating demographic information, physician notes, nursing assessments, accommodating botheration lists, accommodating medication lists, and acquittal summaries; examination class reports, radiologic reports, and analytic assay results; and acclimation medications.

We captured hospital characteristics, including arrangement affiliation, buying (private for-profit, clandestine not-for-profit, or public), admeasurement (based on the cardinal of beds), region, teaching cachet (nonteaching or accessory teaching, back no disqualified hospitals were aloft teaching hospitals—that is, associates of the Council of Teaching Hospitals), rural or burghal location, and admeasurement of Medicaid admissions. We accepted that system-affiliated, clandestine for-profit, small, rural, and nonteaching hospitals would acknowledge added acerb to meaningful-use incentives.

We conducted a difference-in-differences of abruptness assay in which we compared the aberration amid slopes of EHR acceptance ante afore (2008–10) and afterwards (2011–15) accomplishing of meaningful-use incentives for acceptable against disqualified hospitals.

As a robustness test, we apprenticed the disqualified hospital allegory accumulation to alone abiding astute affliction hospitals, since—compared to psychiatric and rehabilitation hospitals—they are arguably added agnate to accepted acute-care hospitals. As a added robustness test, we compared acceptance ante amid the subset of acceptable and disqualified hospitals that did not accept a basal EHR in the aeon 2008–10. Back four of the ten basal EHR functions were broadly adopted in 2008 (recording accommodating demographic advice and accommodating medication lists, and examination class letters and radiologic reports), we advised hospitals not to accept a basal EHR if they lacked one or added of the actual six basal EHR functions: recording physician notes, nursing assessments, acquittal summaries, and accommodating botheration lists; examination analytic assay results; and acclimation medications. As a third robustness test, we included hospital margins (as appear on Medicare bulk reports) to acclimatize for differences amid acceptable and disqualified hospitals in agreement of assets that ability be accessible to acquirement an EHR.

Our final robustness tests accustomed to abode the abeyant for overestimating the appulse of HITECH by declining to acclimatize for hospitals that were alive against EHR acceptance afore accomplishing of meaningful-use incentives and completed acceptance afterwards the incentives were available. Hospital EHR acceptance about occurs incrementally over assorted years, 13 and our capital analytic admission gave HITECH acclaim for all hospitals that aboriginal accomplished the basal EHR beginning in the aeon afterwards accomplishing of the incentives—even if extensive that beginning was the assiduity of affairs fabricated afore implementation.

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We accordingly created a new admeasurement that captured both basal EHR acceptance and basal EHR accomplishing if a hospital either appear abounding accomplishing of the ten computerized functions in at atomic one analytic assemblage or appear that it was “beginning to implement” one or added functions “in at atomic one unit” or “have assets to apparatus in the abutting year.” We afresh reran our primary model, substituting this capricious in the years afore the meaningful-use allurement affairs (2008–10) so that HITECH did not accept acclaim for hospitals that completed accomplishing of an EHR afterwards the allurement affairs began but had already planned to apparatus the EHR afore the incentives became available. We acclimated a added admission to abode this affair by active our primary archetypal afresh but alive the pre-post date advanced one year (that is, we compared 2008–11 to 2012–15). This admission requires the able acceptance that all new basal EHR acceptance in the one year afterward allusive use incentives’ availability would accept occurred on its own.

To actuate the cogwheel appulse of HITECH on EHR acceptance based on hospital type, we conducted stratified analyses by arrangement affiliation, ownership, size, teaching status, and burghal against rural location. We afresh compared the differences amid slopes of EHR acceptance ante afore and afterwards accomplishing of meaningful-use incentives for acceptable and disqualified hospitals aural anniversary category.

All models acclimated accustomed atomic squares regressions, with hospital-level absorption to anniversary for again observations. We chose accustomed atomic squares corruption over logistic corruption to accredit us to anon adapt after-effects in agreement of percentages of EHR adoption. Models were adapted for nonresponse bent by application weights acquired from a corruption archetypal that predicted the likelihood of responding to the AHA IT assay based on hospital characteristics. We additionally ran an unweighted set of results.

Our abstraction had several important limitations. First, disqualified hospitals are altered from acceptable hospitals in agreement of their accommodating populations and the affliction they deliver. Therefore, disqualified hospitals are not the absolute ascendancy group. However, because allusive use is a civic program, we lacked another allegory groups. Furthermore, accustomed that all hospitals charge to accomplish basal analytic tasks such as medication acclimation and botheration tracking, we accepted that the two groups of hospitals would be analogously motivated to accompany EHR adoption.

Second, although the all-embracing acknowledgment ante for the AHA IT supplement are aerial for a civic institutional survey, nonresponders may accept differed from responders. We acclimated the statistical address declared aloft to anniversary for this abeyant bias. However, these adjustments were not perfect.

Finally, we were not able to disentangle the aftereffect of the assorted alone apparatus of HITECH on EHR adoption. While the meaningful-use allurement affairs was the centerpiece of HITECH, commutual programs such as the Regional Extension Center affairs and the EHR acceptance program—alone or in aggregate with the meaningful-use program—could accept apprenticed an admission in EHR adoption.

Compared to acceptable hospitals, disqualified hospitals were added acceptable to be baby (72 percent against 50 percent), amid in the South (50 percent against 38 percent), nonteaching (86 percent against 75 percent), for accumulation (63 percent against 17 percent), burghal (84 percent against 45 percent), and affiliated with a bloom affliction arrangement (71 percent against 59 percent) ( Exhibit 1 ). Disqualified hospitals additionally had a hardly lower allotment of admissions from Medicaid, compared to acceptable hospitals.

Exhibit 1 Hospitals acceptable and disqualified for meaningful-use incentives to accept at atomic a basal cyberbanking bloom record, by called characteristics

Among acceptable hospitals, EHR acceptance ante added by an boilerplate of 3.2 percent annually in the aeon afore accomplishing of the meaningful-use incentives (Exhibits 2 and 3). In the aeon afterwards implementation, the boilerplate anniversary admission was 14.2 percent, absorption a change of 11.1 allotment points. In comparison, amid disqualified hospitals, the admission afore accomplishing was 0.1 percent, and the admission afterwards accomplishing was 3.3 percent. The difference-in-differences of the abruptness was 7.9 allotment points.

Back we compared acceptable hospitals alone to abiding astute affliction hospitals, our after-effects were similar: The change from pre- to post-implementation amid acceptable hospitals was 11.1 allotment credibility (from 3.1 percent to 14.3 percent; p < 0.001 ), while the change amid abiding astute affliction hospitals was 2.9 allotment credibility (from 1.9 percent to 4.8 percent; p = 0.156 ) (Appendix Exhibit A2). 12 The difference-in-differences of the abruptness was 8.3 allotment credibility ( p < 0.001 ).

Back we compared alone acceptable and disqualified hospitals that did not accept an EHR afore accomplishing of the meaningful-use incentives, we begin that the EHR acceptance bulk for acceptable hospitals added by 16.5 percent per year, on average, compared to 5.5 percent for disqualified hospitals (Appendix Exhibit A3). 12 This reflects a difference-in-differences of 10.9 allotment credibility ( p < 0.001 ).

Both our archetypal that included hospital margins as a ascendancy and our unweighted archetypal produced after-effects that were about identical to our primary results, with differences-in-differences of 7.97 allotment credibility and 7.60 allotment points, appropriately ( p < 0.001 for both) (Appendix Exhibits A4 and A5). 12

Finally, in our archetypal that commissioned basal EHR acceptance for either basal EHR acceptance or planned accomplishing in the aeon afore meaningful-use incentives, the difference-in-differences decreased to 3.86 allotment credibility ( p < 0.05 ) (Appendix Exhibit A6). 12 In our archetypal that confused the pre-post date advanced by one year, the difference-in-differences decreased to 4.9 allotment credibility ( p < 0.001 ) (Appendix Exhibit A7). 12

Back we advised whether the difference-in-differences of abruptness assorted based on arrangement affiliation, buying type, size, burghal or rural location, and teaching status, the alone cogent aberration that we empiric was for buying blazon ( Exhibit 4 ). Amid clandestine for-profit hospitals, the difference-in-differences of the abruptness was 13.3 allotment points, decidedly greater than the 1.8-percentage-point difference-in-differences amid clandestine not-for-profit hospitals.

Exhibit 4 Differences in changes over time by accommodation for meaningful-use incentives amid percentages of hospitals that adopted at atomic a basal cyberbanking bloom almanac system, by hospital characteristics

SOURCE Authors’ assay of abstracts for 2008–15 from the American Hospital Association’s Anniversary Bloom Advice Technology Supplemental Survey. NOTES The display shows the after-effects of a difference-in-differences assay that compared acceptance of cyberbanking bloom almanac (EHR) systems by hospitals acceptable to participate in the allusive use of EHRs allurement affairs (implemented in 2011 beneath the Bloom Advice Technology for Economic and Analytic Bloom [HITECH] Act of 2009) and those disqualified to participate, afore and afterwards the program’s implementation. For example, amid system-affiliated acceptable hospitals, compared to system-affiliated disqualified hospitals, acceptable hospitals had 7.9 percent point greater acceptance in 2011–15, compared to in 2008–10. Baby is beneath than 100 beds. Medium is 100–499 beds. Ample is 500 or added beds. “Minor teaching status” is hospitals accustomed to participate in address or internship training by the Accreditation Council for Graduate Medical Education. The absurdity confined appearance 95% aplomb intervals. The alone class in which the difference-in-differences were altered from anniversary added was ownership, with for-profit clandestine decidedly greater than not-for-profit clandestine ( p < 0.001 ).

HITECH is a altered action action that offered hospitals banking incentives in the anatomy of benefit payments to acceleration the bulk of EHR adoption. Alike admitting the ample empiric admission in EHR acceptance amid acceptable hospitals afterwards meaningful-use incentives were alien is acute affirmation of HITECH’s effectiveness, it is accessible that abounding hospitals would accept adopted EHRs afterwards the action intervention. By application disqualified hospitals as a ascendancy group, we begin that HITECH can be accustomed with accretion the bulk of EHR acceptance by 8 allotment credibility per year. A bourgeois appraisal that did not accord HITECH acclaim for any acceptance that was planned afore accomplishing of the allurement affairs bargain the aftereffect admeasurement to 4 allotment credibility per year. For action makers, our after-effects are acceptable account and advance that HITECH could serve as a archetypal for active the acceptance and use of added admired technologies. However, our after-effects do not betoken that HITECH has been an amateur success. Real challenges remain, decidedly in the domains of interoperability and usability. Nonetheless, dispatch the civic timeline of hospitals’ EHR acceptance was a key aboriginal footfall against digitizing the bloom affliction arrangement and facilitating the alteration to advantageous for value.

Our after-effects accession the catechism of whether the anniversary 8-percentage-point admission attributable to HITECH is abundant and reflects acceptable bulk for the $20.9 billion that was paid to hospitals through 2015 (with added allotment paid to acceptable professionals) 6 as a aftereffect of their affair meaningful-use criteria. Accustomed that the akin of EHR acceptance amid acceptable hospitals in 2010 was 15 percent, an admission of 8 allotment credibility per year suggests that in bristles years the incentives confused US hospitals accomplished the half-way mark. There are acceptable actual few added behavior that accept apprenticed such abundant change in such a abbreviate period. It is additionally account acquainted that the allurement bulk covers alone a baby atom of the absolute bulk for hospitals to accept an EHR (10 percent, according to the American Hospital Association), 14 which suggests that the allurement was efficient. However, there were additionally incentives accessible for acceptable professionals (who are abundantly ambulant providers) that could accept added hospitals’ admiration by cross-subsidizing hospital costs and thereby could accept contributed to the after-effects that we observed. Ultimately, a absolute appraisal of the bulk of HITECH requires quantifying the assets in agreement of affection and ability of care, area the affirmation to date has been mixed. 15–17

Another important application in the bulk appraisal is that HITECH did not ambition incentives alone to hospitals that contrarily would not accept adopted an EHR. 18 Thus, at atomic some of the hospitals that accustomed incentives already had an EHR or would accept adopted one on their own during the HITECH aeon alike if the HITECH allurement affairs had not existed, which was a suboptimal use of accessible dollars. The after-effects of our robustness tests that did not accord HITECH acclaim for basal EHR acceptance amid hospitals that appear affairs to accept afore 2011 advance a 50 percent abridgement in aftereffect admeasurement (from 8 allotment credibility to 4 allotment points). However, our award that, compared to clandestine not-for-profit hospitals, clandestine for-profit institutions responded abundant added acerb to the incentives bolsters the altercation that the incentives were acknowledged at affective nonadopters. We would apprehend clandestine for-profit hospitals to behave in means that advice the institutions accomplish their banking goals. Thus, their low EHR acceptance bulk in the aeon afore the meaningful-use incentives and the ample admission in that bulk afterwards the incentives became accessible advance that the affairs was abundantly able in targeting hospitals that would not accept contrarily adopted an EHR. While a added able use of accessible dollars would accept created an allurement affairs that targeted alone nonadopters, such an admission would accept disinterestedness implications: It would unfairly amerce hospitals that took a accident in advance in a technology with acute accommodating benefits, decidedly in the assurance domain, but with an ambiguous acknowledgment on investment. Furthermore, it could accept abject hospitals’ alertness to advance in technology in the approaching because of affair about missing out on abeyant government incentives.

Our allegation accept implications for approaching action efforts that seek to activation technology adoption. They advance that banking incentives angry to technology acceptance are acceptable to essentially acceleration uptake beyond a ambit of hospital types. However, accustomed that antecedent analyses of ambulant affliction departments bootless to acquisition an aftereffect of HITECH, 5 it is not bright which mechanisms are at play. It may be that hospitals accept authoritative capabilities to accept and acknowledge to circuitous allurement programs such as meaningful-use incentives that are defective in ambulant practices. It is additionally accessible that the altered after-effects are explained by the accretion ability of the EHR market. In 2009, back HITECH was passed, the ambulant EHR bazaar was beneath complete than the hospital EHR market; there were several thousand certified ambulant EHR articles from which to choose—which could accept fabricated it added difficult for ambulant affliction providers to respond.

Added broadly, our after-effects accession the catechism of why HITECH was acknowledged in active change amid hospitals back abounding added action efforts that seek to change hospitals’ and ambulant providers’ behavior accept not succeeded. In particular, there is alloyed affirmation on the capability of pay-for-performance programs in convalescent affection of care. 19 We doubtable that a primary acumen is the faculty of inevitability: EHR acceptance was acceptable in abounding hospitals’ abiding plans, and the availability of incentives may accept artlessly confused it up on the antecedence list. In contrast, abounding hospitals ability not accept been acquainted of the consequence of issues such as hospital-acquired infections or accidental readmissions until they became the focus of civic policies. It is additionally accessible that hospitals acquainted added assured that they could be acknowledged in responding to the meaningful-use allurement program, compared to in abbreviation hospital-acquired infections or accidental readmissions, because implementing an EHR arrangement was perceived as easier than advisedly convalescent accommodating outcomes. While adopting an EHR is a circuitous undertaking, the process’s alone accomplish (for example, selecting a bell-ringer and planning for implementation) may assume added aboveboard than those accompanying to convalescent analytic outcomes.

We accustomed to actuate the admeasurement to which HITECH should be accustomed with the ample admission in EHR acceptance amid hospitals that occurred afterward its passage. We begin that HITECH collection anniversary assets in EHR acceptance of 8 allotment credibility in the bristles years afterwards accomplishing of the act’s meaningful-use allurement affairs (with 4 allotment credibility as a bourgeois lower bound). Accustomed the complication of all-embracing change in hospitals, this aftereffect is affecting and suggests that HITECH can serve as a archetypal for added countries gluttonous to admission EHR acceptance amid hospitals and for added action efforts gluttonous to advance technology acceptance added generally.

Exhibit 2 Percentages of hospitals that adopted at atomic a basal cyberbanking bloom almanac arrangement in 2008–15, by accommodation for meaningful-use incentives

SOURCE Authors’ assay of abstracts for 2008–15 from the American Hospital Association’s Anniversary Bloom Advice Technology Supplemental Survey.

Exhibit 3 Boilerplate anniversary admission in the percentages of hospitals adopting at atomic a basal cyberbanking bloom almanac system, by accommodation status, afore and afterwards accomplishing of meaningful-use incentives

This assignment was presented at the AcademyHealth Anniversary Research Meeting, Minneapolis, MN, June 16, 2015. The agnate columnist had abounding admission to the abstracts in the abstraction and takes albatross for the candor of the abstracts and the accurateness of the abstracts analysis.

To admission the Appendix, bang on the Appendix articulation in the box to the appropriate of the commodity online.

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