Challenges to the Implementation of EHRs to Achieve MU among CAHs

Appendix A1 Survey Instrument This survey was fielded by The Health Information Management Systems Society (HIMSS) as part of their on-going data collection efforts from November 21, 2012 to April 30, 2013. Challenges to the Implementation of EHRs to Achieve MU among CAHs HIMSS Analytics would like to collect data regarding the challenges that critical access hospitals face in implementing electronic health records to achieve meaningful use. This brief 15 question survey focuses on the following topics: challenges your hospital is experiencing related to electronic health record implementation (e.g. access to capital, IT workforce, and broadband), participation in Federal and State broadband assistance programs, current and planned Health Information Technology capabilities, and internet access, speed, and monthly costs. The results of this survey will only be publically reported in aggregate. The survey results will primarily be used for Federal programs to support enhanced outreach, to better understand the needs of critical access hospitals, and to assess the effectiveness of current health IT programs and grants. As you answer this survey, please respond keeping your hospital s current IT capabilities in mind. Screening Question: Do you play any role in your hospital s broadband or electronic health record environment? (( Yes (What role?. Proceed to survey), No (If no, please provide name and contact information for the appropriate individual within your hospital and conclude survey)) A) Name of your Hospital: B) Mailing address of your hospital: C) Your: a. Name: b. Title: c. Phone: d. Email: e. Years in current position: D) Name of IT Manager/CIO (if other than respondent) E) Date of Survey Completion: ---------------------------------------------------------------------------------

1) Does your hospital use an electronic health record (EHR) or electronic medical record (EMR) system? [Read response categories] {An EHR or EMR is defined as : Electronically originated and maintained clinical health information derived from multiple sources about an individual s health status and healthcare. An EHR replaces the paper medical record as the primary source of patient information, does not include billing and scheduling systems.} a. Yes, fully electronic b. Yes, partially paper and partially electronic c. No d. Do not know 2) Is your EMR/EHR solution hosted by an outside party? (only ask if they have an EMR/EHR in question one above). a. Yes b. No c. Do not know 3) Does your hospital have plans to upgrade or install a new EHR within the next 12 months? a. Yes b. No c. Do not know 4) Which of the following best describes your hospital s plan for participation in the EHR Incentive Program for the Meaningful Use of EHRs? a. Our hospital has already attested for Meaningful Use and has received payment b. Our hospital has attested for MU and has not yet received payments c. Our hospital plans to attest for Meaningful Use by the end of 2013 d. Our hospital plans to attest for Meaningful Use in 2014 or beyond e. Our hospital has no plans to attest for Meaningful Use f. I am not familiar with the Meaningful Use EHR Incentive Program 5) Who is the primary source for your hospital s EHR implementation and technical support? a. Hospital system owner b. External management company c. Third party vendor d. No outside support

6) Does your hospital pool resources with other CAHs or small rural hospitals to acquire or implement EHRs or health information exchange? a. Yes b. No c. Do not know 7) Please indicate how your hospital currently makes EHR purchasing decisions. a. This CAH makes these decisions independently with no outside support b. Corporate hospital system owner is primarily responsible for making these decisions for this CAH c. This CAH makes decisions jointly with a group of other CAHs or rural hospitals in an HER network d. This CAH makes these decisions independently with recommendations from third party consultant e. An external management company makes these decisions for this CAH 8) Below is a list of commonly cited challenges to the effective implementation and use of an electronic health record (EHR). For each of the following items, please indicate the extent to which it is currently a challenge at your hospital. When answering this question, please use a scale of one to seven, where one is not at all a challenge and seven is a significant challenge. [Read response categories] Broadband Broadband unavailable/insufficient Workforce and Workflow Inadequate EHR training for employees Workflow changes Lack of IT personnel Clinical staff cooperation Leadership/Executive cooperation Capital Broadband implementation costs EHR implementation costs Availability of grants/loans to support EHR Security and Privacy Security and/or Privacy risks EHR Vendor Selection/EHR usability Lack of technical support from EHR vendor 1 (Not at all a challenge) 2 3 4 (A moderate challenge) 5 6 7 (A significant challenge) DK/NA

9) Please indicate whether your hospital currently has each of the following capabilities. Telehealth Services Utilizing Real-Time, Two-Way Video Consultations Telehealth Services Utilizing Real-Time Transfer of High Resolution Images (Teleradiology) Electronic exchange of key clinical information [such as a problem list, medication list, medication allergies, or diagnostic test results] with other providers Electronic generation and transmission of permissible prescriptions for some or all of your patients (E-Prescribing) Electronic submission of discharge summaries to external care facilities (care coordination) Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge from the hospital (A) Does your hospital currently have the capability for [INSERT RESPONSE CATEGORY] (B) IF (A) = NO: Does your hospital plan to obtain [INSERT RESPONSE CATEGORY] within the next year Now we would like to ask questions regarding internet and broadband access and capabilities 10) Please indicate the extent to which you perceive your upload and download speeds are currently adequate for your inpatient clinical functions (e.g. transferring diagnostic images during the daytime). When answering this question, please provide responses for upload (e.g. sending a file) and download (e.g. opening a file sent to you) speeds using a scale of one to seven, where one is not at all adequate and seven is more than adequate. Internet Speed Upload Speed Download Speed 1 (Not at all adequate) 2 3 4 (Currently Adequate) 5 6 7 (More than Adequate) DK/NA

11) What is the primary way your hospital connects to the internet for most inpatient clinical functions? Type Hospital Internet Connection A dial-up telephone line DSL-enabled phone line (ADSL and SDSL) Dedicated line (T-1, DS-3, OC-3, etc) Cable Satellite download only Satellite download and upload A fiber optic connection Mobile wireless broadband services (3G,4G, etc) Fixed wireless (i.e., Wi-Fi) broadband service No connection [Skip to Q12] Do not know (Do not read) 12) What are your hospital s typical Internet upload and download speeds? Please test your hospital s internet connection speed at www.speedtest.net. [Do not read response categories] Speed Download Speed Upload Speed 64 kbps to less than 1Mbps 1 Mbps to less than 3 Mbps 3 Mbps to less than 4 Mbps 4 Mbps to less than 6 Mbps 6 Mbps to less than 10 Mbps 10 Mbps to less than 25 Mbps 25 Mbps to less than 50 Mbps 50 Mbps to less than 100 Mbps 100 Mbps or greater Do not know (Do not read) 13) How many internet service providers (ISPs) is your hospital able to choose from in your market? Please include all available local and national internet service providers. Internet Service Providers 0 1 2 3 4 5 or more Do not know (do not read)

Now we would like to ask questions regarding broadband funding sources and costs associated with broadband or internet service 14) FCC/USAC Universal Service Fund Rural Health Care Program Telecommunications Services or Internet Access Services Support subsidies for monthly recurring costs (Primary Program) FCC/USAC Universal Service Fund Rural Health Care Program Pilot Program Support USDA Rural Utilities Service Broadband Technology Opportunities Program (BTOP) USDA Community Facilities Program Other Broadband Funding Program (A) For each of the following, please indicate if you are aware of the program [INSERT RESPONSE CATEGORY] Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No IF (A)=YES: (B) Is your hospital currently receiving assistance from [INSERT RESPONSE CATEGORY

15) What is the approximate total fee you pay per month to your service provider for internet or broadband service at your hospital (please report dollars per month)? (Skip if answer to Q10= No Connection ) (DO NOT READ RESPONSE CATEGORIES). (Add including including any subsidy if answer to Q13 (B) = Yes to any response category) Total Monthly Cost Less than $250 $250-$750 $751-$1,500 $1,501-$3,000 $3,001 - $4,500 $4,501-$6,000 $6,001-$8,500 $8,501-$10,000 $10,000+ Not applicable Do not know Approximate total net monthly internet expenses at your hospital 16) What is the amount of your monthly subsidy for internet or broadband service (please report dollars per month)? (Skip if answer to Q10= No Connection or Q13 (B)= No or Don t Know ) (DO NOT READ RESPONSE CATEGORIES). Total Monthly Subsidy Less than $250 $250-$750 $751-$1,500 $1,501-$3,000 $3,001 - $4,500 $4,501-$6,000 $6,001-$8,500 $8,501-$10,000 $10,000+ Not applicable Do not know Approximate total monthly subsidy amount given to your hospital for internet/broadband expenses

health information technology among critical-access hospitals. Health Aff (Millwood). Appendix A2. Factors associated with Significant Challenges to Health IT Implementation and Use Adjusted Predicted Probabilities Hospital and Organizational Characteristics System Ownership % Significant Financial Challenges Significant Work Flow and Staffing Challenges Significant Technical Challenges (adjusted predicted probabilities) Significant Security and Privacy Risk Challenges Owned by a System 32% 0.52 0.49 0.22 0.16 Independent 68% 0.62 0.53 0.31 0.21 Hospital Type Not for Profit 50% 0.59 0.48 0.29 0.20 Government (non-federal) 45% 0.58 0.55 0.28 0.19 For Profit 4% 0.68 0.67 0.37 0.32 Broadband and Internet Infrastructure Upload Speed Upload Speed - Do Not Know 15% 0.65 0.54 0.51* 0.24 Upload Speed - 64kbps to less than 3 Mbps 12% 0.67 0.56 0.33 0.24 Upload Speed - 3 Mbps to less than 10 Mbps 26% 0.55* 0.50 0.21* 0.17* Upload Speed - 10 Mbps or greater 47% 0.54* 0.50 0.27 0.15 Number of ISPs in Market Do Not Know 15% 0.57 0.46* 0.28 0.20 One or Less 26% 0.64 0.58 0.34 0.21 Two 31% 0.57 0.52 0.20* 0.21 Three or More 28% 0.58 0.49 0.32 0.13

health information technology among critical-access hospitals. Health Aff (Millwood). Electronic Capabilities Telehealth Yes 59% 0.61 0.56* 0.30 0.19 No 41% 0.57 0.46 0.27 0.20 Teleradiology Yes 70% 0.60 0.51 0.27 0.20 No 30% 0.57 0.54 0.32 0.20 EHR Implementation Status Full or Partial 89% 0.58 0.5* 0.31* 0.19 No EHR 11% 0.68 0.64 0.17 0.22 Health IT Support Pool Resources with Other Hospitals Yes 33% 0.59 0.52 0.26 0.16 No 67% 0.59 0.52 0.30 0.21 EHR Purchasing Decisions Independent 39% 0.67 0.55 0.31 0.23 System Owner is Responsible 31% 0.5* 0.44 0.25 0.11* CAH Consortium or Rural Hospital Joint Decision 5% 0.71 0.57 0.48 0.21 Independently, but with third party consultants 24% 0.58 0.55 0.25 0.22 External Management Company Makes Decision 2% 0.45 0.49 0.30 0.23 Sources of Technical Assistance No Outside TA 12% 0.57 0.62 0.27 0.17 System 45% 0.60 0.48* 0.30 0.22 Third Party Vendor 34% 0.56 0.53 0.29 0.17 External Management Company TA 9% 0.66 0.53 0.24 0.27

health information technology among critical-access hospitals. Health Aff (Millwood). Area Characteristics Region South 23% 0.64 0.49 0.30 0.22 West 21% 0.56 0.55 0.37 0.17 Midwest 50% 0.58 0.53 0.24 0.19 Northeast 5% 0.61 0.46 0.34 0.25 Rurality Metro Area 26% 0.65 0.53 0.31 0.23 Nonmetro - Urban Large (population > 20,000) 15% 0.55 0.49 0.26 0.13* Nonmetro - Urban Small (population < 20,000) 8% 0.62 0.60 0.33 0.19 Nonmetro- Completely Rural or Population < 2,500) 51% 0.57 0.51 0.28 0.20 Source: HIMSS CAH Survey, HIMSS 2012 End of Year Full Analytic File, Area Resource File Notes: * Value significantly different from reference category at the 0.05 level. Adjusted for hospital and organizational characteristics, broadband and internet infrastructure, health IT support, and area characteristics. Reference categories include system ownership (yes), pool resources with other hospitals (yes), not for profit hospital type, upload speed of 64 kbps-less than 3 mbps, one or less ISPs in marketplace, independent EHR purchasing decisions, no outside source of technical assistance, Southern region of the United States, and metro area. kbps = kilobytes per second; mbps = megabytes per second

health information technology among critical-access hospitals. Health Aff (Millwood). Appendix A3. Factors Associated with Adoption of Electronic Health Records and Specific Key Electronic Capabilities Adjusted Predicted Probabilities: Electronic Capabilities Hospital and Organizational Characteristics Has an EHR Teleradiology Telehealth/ Video Consult E- Prescrib ing Health Information Exchange (adjusted predicted probabilities) Electronic ally Submit Discharge Summaries to External Care Facilities View, Download, and Transmit Health Information after Discharge System Ownership Owned by a System (ref) 0.82 0.77* 0.61 0.53 0.56 0.42 0.14 Independent 0.89 0.66 0.58 0.51 0.49 0.36 0.17 Hospital Type Not for Profit (ref) 0.88 0.74 0.63 0.55 0.58 0.39 0.16 Government (non-federal) 0.88 0.64* 0.53* 0.50 0.46* 0.38 0.16 For Profit 0.67* 0.85 0.77 0.3* 0.29* 0.21 0.09 Broadband and Internet Infrastructure Upload Speed Upload Speed - Do Not Know 0.77* 0.68 0.61 0.42 0.46 0.31 0.06 Upload Speed - 64kbps to less than 3 Mbps (ref) 0.87 0.72 0.58 0.52 0.46 0.39 0.11 Upload Speed - 3 Mbps to less than 10 Mbps 0.89 0.71 0.63 0.56 0.57 0.41 0.2* Upload Speed - 10 Mbps or greater 0.91 0.65 0.48 0.45 0.48 0.35 0.16 Number of ISPs in Market Do Not Know 0.84 0.72 0.57 0.53 0.47 0.38 0.12 One or Less (ref) 0.89 0.70 0.58 0.52 0.54 0.38 0.18 Two 0.9 0.69 0.63 0.50 0.54 0.40 0.17 Three or More 0.85 0.67 0.58 0.50 0.48 0.35 0.14

health information technology among critical-access hospitals. Health Aff (Millwood). Health IT Support Pool Resources with Other Hospitals Yes (ref) 0.93* 0.71 0.63 0.56 0.60* 0.44* 0.17 No 0.84 0.69 0.58 0.50 0.47 0.35 0.15 EHR Purchasing Decisions Independent (ref) 0.88 0.72 0.58 0.50 0.51 0.39 0.10 System Owner is Responsible 0.86 0.67 0.60 0.63* 0.58 0.44 0.28* CAH Consortium or Rural Hospital Joint Decision 0.76 0.77 0.73 0.39 0.51 0.25 0.12 Independently, but with third party consultants 0.9 0.68 0.57 0.45 0.44 0.32 0.11 External Management Company Makes Decision 0.82 0.51 0.66 0.29 0.57 0.38 0.09 Sources of Technical Assistance No Outside TA (ref) 0.81 0.72 0.58 0.49 0.46 0.35 0.14 System 0.92* 0.68 0.66 0.53 0.54 0.35 0.16 Third Party Vendor 0.82 0.71 0.59 0.50 0.50 0.43 0.15 External Management Company TA 0.88 0.72 0.58 0.55 0.50 0.36 0.19 Area Characteristics Region South (ref) 0.89 0.71 0.45 0.52 0.57 0.37 0.14 West 0.8* 0.74 0.75* 0.54 0.52 0.37 0.18 Midwest 0.88 0.67 0.58* 0.51 0.48 0.39 0.16 Northeast (empty) 0.69* 0.65* 0.54 0.57 0.33 0.08

health information technology among critical-access hospitals. Health Aff (Millwood). Rurality Metro Area (ref) 0.85 0.64 0.67 0.55 0.51 0.38 0.16 Nonmetro - Urban Large (population > 20,000) 0.91 0.68 0.46* 0.54 0.47 0.35 0.17 Nonmetro - Urban Small (population < 20,000) 0.91 0.69 0.47* 0.51 0.53 0.38 0.14 Nonmetro- Completely Rural or Population < 2,500) 0.87 0.74 0.61 0.50 0.52 0.39 0.15 Source: HIMSS CAH Survey, HIMSS 2012 End of Year Full Analytic File, and the Area Resource File Notes: * Value significantly different from reference category at the 0.05 level. Adjusted for hospital and organizational characteristics, broadband and internet infrastructure, health IT support, and area characteristics. Reference categories (ref) include system ownership (yes), pool resources with other hospitals (yes), not for profit hospital type, upload speed of 64 kbps-less than 3 mbps, one or less ISPs in marketplace, independent EHR purchasing decisions, no outside source of technical assistance, Southern region of the United States, and metro area. kbps = kilobytes per second; mbps = megabytes per second