EHR adoption of all physicians in the US. Source: DesRoches et al. (2008).
 ;templatestyles src="Legend/styles.css" / ;  Fully functional EHR system (4%) ;templatestyles src="Legend/styles.css" / ;  Basic EHR system (13%) ;templatestyles src="Legend/styles.css" / ;  Bought but not implemented yet (13%) ;templatestyles src="Legend/styles.css" / ;  EHR purchase planned in 2 years (22%) ;templatestyles src="Legend/styles.css" / ;  No EHR system (48%)
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records. The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use EMRs by 2015, for covered patients) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the, American Recovery and Reinvestment Act of 2009.
The 21st Century Cures Act, passed in 2016, prohibited information blocking, which had slowed interoperability. In 2018, the Trump administration announced the MyHealthEData initiative to further allow for patients to receive their health records. The federal Office of the National Coordinator for Health Information Technology leads these efforts.
One VA study estimates its electronic medical record system may improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions. Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true". A 2014 survey of the American College of Physicians member sample, however, found that family practice physicians spent 48 minutes more per day when using EMRs. 90% reported that at least 1 data management function was slower after EMRs were adopted, and 64% reported that note writing took longer. A third (34%) reported that it took longer to find and review medical record data, and 32% reported that it was slower to read other clinicians' notes.
Coverage.
In a 2008 survey by DesRoches et al. of 4484 physicians (62% response rate), 83% of all physicians, 80% of primary care physicians, and 86% of non-primary care physicians had no EHRs. "Among the 83% of respondents who did not have electronic health records, 16%" had bought, but not implemented an EHR system yet.
The 2009 National Ambulatory Medical Care Survey of 5200 physicians (70% response rate) by the National Center for Health Statistics showed that 51.7% of office-based physicians did not use any EMR/EHR system.
In the United States, the CDC reported that the EMR adoption rate had steadily risen to 48.3 percent at the end of 2009. This is an increase over 2008 when only 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008. However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical progress notes. As of 2013, 78 percent of office physicians are using basic electronic medical records. As of 2014, more than 80 percent of hospitals in the U.S.have adopted some type of EHR. Though within a hospital, the type of EHR data and mix varies significantly. Types of EHR data used in hospitals include structured data (e.g., medication information) and unstructured data (e.g., clinical notes).
The healthcare industry spends only 2% of gross revenues on Health Information Technology (HIT), which is low compared to other information intensive industries such as finance, which spend upwards of 10%.
The usage of electronic medical records can vary depending on who the user is and how they are using it. Electronic medical records can help improve the quality of medical care given to patients. Many doctors and office-based physicians refuse to get rid of traditional paper records. Harvard University has conducted an experiment in which they tested how doctors and nurses use electronic medical records to keep their patients' information up to date. The studies found that electronic medical records were very useful; a doctor or a nurse was able to find a patient's information fast and easy just by typing their name; even if it was misspelled. The usage of electronic medical records increases in some workplaces due to the ease of use of the system; whereas the president of the Canadian Family Practice Nurses Association says that using electronic medical records can be time-consuming, and it isn't very helpful due to the complexity of the system. Beth Israel Deaconess Medical Center reported that doctors and nurses prefer to use a much more friendly user software due to the difficulty and time it takes for medical staff to input the information as well as to find a patient's information. A study was done and the amount of information that was recorded in the EMRs was recorded; about 44% of the patient's information was recorded in the EMRs. This shows that EMRs are not very efficient most of the time.
The cost of implementing an EMR system for smaller practices has also been criticized; data produced by the Robert Wood Johnson Foundation demonstrates that the first-year investment for an average five-person practice is $162,000 followed by about $85,000 in maintenance fees. Despite this, tighter regulations regarding meaningful use criteria and national laws (Health Information Technology for Economic and Clinical Health Act and the Affordable Care Act) have resulted in more physicians and facilities adopting EMR systems:
Beyond financial concerns there are a number of legal and ethical dilemmas created by increasing EMR use, including the risk of medical malpractice due to user error, server glitches that result in the EMR not being accessible, and increased vulnerability to hackers.
Legal status.
Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator. Under data protection legislation, the responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. This role has been said to require changes such that the sole medico-legal record should be held elsewhere. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.
The Health Information Technology for Economic and Clinical Health Act (HITECH) (Pub. L. ,§2.A.III &amp; B.4) (a part of the 2009 stimulus package) set meaningful use of interoperable EHR adoption in the health care system as a critical national goal and incentivized EHR adoption. The "goal is not adoption alone but 'meaningful use' of EHRs—that is, their use by providers to achieve significant improvements in care."
Title IV of the act promises maximum incentive payments for Medicaid to those who adopt and use "certified EHRs" of $63,750 over 6 years beginning in 2011. Eligible professionals must begin receiving payments by 2016 to qualify for the program. For Medicare the maximum payments are $44,000 over 5 years. Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years. In order to receive the EHR stimulus money, the HITECH Act requires doctors to show "meaningful use" of an EHR system. As of June 2010, there were no penalty provisions for Medicaid.
In 2017 the government announced its first False Claims Act settlement with an electronic health records vendor for misrepresenting its ability to meet “meaningful use” standards and therefore receive incentive payments. eClinicalWorks paid $155 million to settle charges that it had failed to meet all government requirements, failed to adequately test its software, failed to fix certain bugs, failed to ensure data portability, and failed to reliably record laboratory and diagnostic imaging orders. The government also alleged that eClinicalWorks paid kickbacks to influential customers who recommended its products. The case marks the first time the government applied the federal Anti-Kickback Statute law to the promotion and sale of an electronic health records system. The False Claims Act lawsuit was brought by a whistleblower who was a New York City employee implementing eClinicalWorks’ system at Rikers Island Correctional Facility when he became aware of the software flaws. His “qui tam” case was later joined by the government. Notably, CMS has said it will not punish eClinicalWorks clients that "in good faith" attested to using the software.
Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve "meaningful use" and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level.
Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.
 Quality and safety measurement
 Clinical decision support (automated advice) for providers
 Patient registries (e.g., "a directory of patients with diabetes")
 Electronic laboratory reporting for reportable conditions (hospitals)
 Immunization reporting to immunization registries
 Syndromic surveillance (health event awareness)
Quality.
Studies call into question whether, in real life, EMRs improve the quality of care. 2009 produced several articles raising doubts about EMR benefits. A major concern is the reduction of physician-patient interaction due to formatting constraints. For example, some doctors have reported that the use of check-boxes has led to fewer open-ended questions.
Meaningful use.
The main components of meaningful use are:
In other words, providers need to show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.
The meaningful use of EHRs intended by the US government incentives is categorized as follows:
The Obama Administration's Health IT program intends to use federal investments to stimulate the market of electronic health records:
The detailed definition of "meaningful use" is to be rolled out in 3 stages over a period of time until 2017. Details of each stage are hotly debated by various groups.
Meaningful use Stage 1.
The first steps in achieving meaningful use are to have a certified electronic health record (EHR) and to be able to demonstrate that it is being used to meet the requirements. Stage 1 contains 25 objectives/measures for Eligible Providers (EPs) and 24 objectives/measures for eligible hospitals. The objectives/measures have been divided into a core set and menu set. EPs and eligible hospitals must meet all objectives/measures in the core set (15 for EPs and 14 for eligible hospitals). EPs must meet 5 of the 10 menu-set items during Stage 1, one of which must be a public health objective.
Full list of the Core Requirements and a full list of the Menu Requirements.
Core Requirements:
Menu Requirements:
To receive federal incentive money, CMS requires participants in the Medicare EHR Incentive Program to "attest" that during a 90-day reporting period, they used a certified EHR and met Stage 1 criteria for meaningful use objectives and clinical quality measures. For the Medicaid EHR Incentive Program, providers follow a similar process using their state's attestation system.
Meaningful use Stage 2.
The government released its final ruling on achieving Stage 2 of meaningful use in August 2012. Eligible providers will need to meet 17 of 20 core objectives in Stage 2, and fulfill three out of six menu objectives. The required percentage of patient encounters that meet each objective has generally increased over the Stage 1 objectives.
While Stage 2 focuses more on information exchange and patient engagement, many large EHR systems have this type of functionality built into their software, making it easier to achieve compliance. Also, for those eligible providers who have successfully attested to Stage 1, meeting Stage 2 should not be as difficult, as it builds incrementally on the requirements for the first stage.
Meaningful use Stage 3.
On March 20, 2015 CMS released its proposed rule for Stage 3 meaningful use. These new rules focus on some of the tougher aspects of Stage 2 and require healthcare providers to vastly improve their EHR adoption and care delivery by 2018.
Barriers to adoption.
Costs.
The price of EMR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment have a significant influence on EMR adoption. In a project initiated by the Office of the National Coordinator for Health Information, surveyors found that hospital administrators and