Mobile Health Apps, Family Caregivers, and Care Planning: Scoping Review.

BACKGROUND: People living with multiple chronic conditions (MCCs) face substantial challenges in planning and coordinating increasingly complex care. Family caregivers provide important assistance for people with MCCs but lack sufficient support. Caregiver apps have the potential to help by enhancing care coordination and planning among the health care team, including patients, caregivers, and clinicians. OBJECTIVE: We aim to conduct a scoping review to assess the evidence on the development and use of caregiver apps that support care planning and coordination, as well as to identify key factors (ie, needs, barriers, and facilitators) related to their use and desired caregiver app functionalities. METHODS: Papers intersecting 2 major domains, mobile health (mHealth) apps and caregivers, that were in English and published from 2015 to 2021 were included in the initial search from 6 databases and gray literature and ancestry searches. As per JBI (Joanna Briggs Institute) Scoping Review guidelines and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews), 2 authors independently screened full texts with disagreements resolved by a third author. Working in pairs, the authors extracted data using a pilot-tested JBI extraction table and compared results for consensus. RESULTS: We identified 34 papers representing 25 individual studies, including 18 (53%) pilot and feasibility studies, 13 (38%) qualitative studies, and 2 experimental or quasi-experimental studies. None of the identified studies assessed an intervention of a caregiver app for care planning and coordination for people with MCCs. We identified important caregiver needs in terms of information, support, and care coordination related to both caregiving and self-care. We compiled desired functionalities and features enabling apps to meet the care planning and care coordination needs of caregivers, in particular, the integration of caregiver roles into the electronic health record. CONCLUSIONS: Caregiver needs identified through this study can inform developers and researchers in the design and implementation of mHealth apps that integrate with the electronic health record to link caregivers, patients, and clinicians to support coordinated care for people with MCCs. In addition, this study highlights the need for more rigorous research on the use of mHealth apps to support caregivers in care planning and coordination.

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review.

BACKGROUND: Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans-which typically are difficult to share across care settings and care team members-poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions. OBJECTIVE: To review the landscape of e-care plans and care plan-related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions. METHODS: We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards. RESULTS: We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards. CONCLUSIONS: A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

A novel application of SMART on FHIR architecture for interoperable and scalable integration of patient-reported outcome data with electronic health records.

OBJECTIVE: Despite a proliferation of applications (apps) to conveniently collect patient-reported outcomes (PROs) from patients, PRO data are yet to be seamlessly integrated with electronic health records (EHRs) in a way that improves interoperability and scalability. We applied the newly created PRO standards from the Office of the National Coordinator for Health Information Technology to facilitate the collection and integration of standardized PRO data. A novel multitiered architecture was created to enable seamless integration of PRO data via Substitutable Medical Apps and Reusable Technologies on Fast Healthcare Interoperability Resources apps and scaled to different EHR platforms in multiple ambulatory settings. MATERIALS AND METHODS: We used a standards-based approach to deploy 2 apps that source and surface PRO data in real-time for provider use within the EHR and which rely on PRO assessments from an external center to streamline app and EHR integration. RESULTS: The apps were developed to enable patients to answer validated assessments (eg, a Patient-Reported Outcomes Measurement Information System including using a Computer Adaptive Test format). Both apps were developed to populate the EHR in real time using the Health Level Seven FHIR standard allowing providers to view patients' data during the clinical encounter. The process of implementing this architecture with 2 different apps across 18 ambulatory care sites and 3 different EHR platforms is described. CONCLUSION: Our approach and solution proved feasible, secure, and time- and resource-efficient. We offer actionable guidance for this technology to be scaled and adapted to promote adoption in diverse ambulatory care settings and across different EHRs.

Building the evidence-base to reduce electronic health record-related clinician burden.

Clinicians face competing pressures of being clinically productive while using imperfect electronic health record (EHR) systems and maximizing face-to-face time with patients. EHR use is increasingly associated with clinician burnout and underscores the need for interventions to improve clinicians' experiences. With an aim of addressing this need, we share evidence-based informatics approaches, pragmatic next steps, and future research directions to improve 3 of the highest contributors to EHR burden: (1) documentation, (2) chart review, and (3) inbox tasks. These approaches leverage speech recognition technologies, natural language processing, artificial intelligence, and redesign of EHR workflow and user interfaces. We also offer a perspective on how EHR vendors, healthcare system leaders, and policymakers all play an integral role while sharing responsibility in helping make evidence-based sociotechnical solutions available and easy to use.

Advancing the use of patient-reported outcomes in practice: understanding challenges, opportunities, and the potential of health information technology.

PURPOSE: The effective use of patient-reported outcomes (PROs) can play a critical role in improving health care delivery and patient experience with care. However, PROs are not widely collected and used in clinical practice. This study aims to understand current opportunities and challenges with the use of PROs and the potential for health information technology (IT) to advance their use. METHODS: The Agency for Healthcare Research and Quality held two technical expert panel (TEP) meetings to discuss the current use of PROs, challenges, and opportunities in implementation, and how health IT can be leveraged to support effective PRO use in clinical practice. Results were synthesized to identify major themes and takeaways based on different stages of PRO data utilization. RESULTS: Findings from the TEP meetings indicated varying degrees of PRO usage in ambulatory care settings. Practices often lack a business case to collect PROs. Primary care physicians face more challenges than specialists in selecting appropriate PRO measures due to extensive variation in their patient populations. Providers also need training to use PRO data for shared decision making and population health management. Potential research areas to address PRO implementation challenges include measures harmonization, implementation process and workflow, electronic data collection and integration, and user-friendly data displays. CONCLUSIONS: Opportunities exist during different stages of PRO implementation to advance the use of PROs in clinical practice. Health IT can be utilized to address challenges in data collection, integration, and visualization to make PRO data accessible and understandable to patients and providers.

A socio-technical systems approach to the use of health IT for patient reported outcomes: Patient and healthcare provider perspectives.

BACKGROUND: Patient-Reported Outcomes (PROs) can be used to inform the clinical management of individuals, including patient self-management, care planning, and goal setting. Despite a rapid proliferation of technology to collect and integrate PROs in clinical care, uptake by patients and healthcare providers remains sub optimal. A consideration of systems factors to understand these challenges is needed. OBJECTIVES: To apply the socio-technical systems (STS) model as a framework for understanding the usability and functional requirements of patients collecting PRO data using applications (apps), and of healthcare providers using these data at the point of care in ambulatory settings. METHODS: With questions guided by the STS model, semi-structured interviews were conducted with eighteen patients and nine healthcare providers to elicit feedback about facilitators and barriers to successful use of PRO apps and PRO data in ambulatory settings. Patient participants were selected to fit into two categories: older, low utilizers of technology with less than a bachelor's degree, and younger higher utilizers of technology with at least a bachelor's degree. Participants were from primary and specialty care practices. Data were analyzed inductively to identify emergent themes. RESULTS: Younger patients were only interested in using a PRO app if they had an active health issue to track. The nine older patients preferred passive means of data collection if they were to track a health issue, and preferred direct contact with their healthcare provider and using office visits to share information. All patients desired optimal usability and emphasized bidirectional communication in an app that is transparent about privacy. All nine healthcare providers agreed that PRO data would be most useful and relevant if key patient populations were targeted based on the specific measure. In this case the healthcare providers noted potentially optimal utility of collecting physical function PRO data for patients 65 and older. Access to the data was highlighted by each healthcare provider stating that these data would be most useful if they were seamlessly integrated into the electronic health record. DISCUSSION: Several emergent themes were identified under the five selected dimensions of the STS model (clinical content, human computer interface, hardware and software computing infrastructure, people, and workflow and communication). Findings highlighted the continued need for innovative methods to obtain more rapid cycle, continuous feedback to identify system factors impacting use of these technologies. CONCLUSION: The STS model provides a comprehensive framework that can be applied to collect patient and healthcare provider feedback to better guide the design and implementation of new health information technology.

In which states are physician assistants or nurse practitioners more likely to work in primary care?

OBJECTIVE: Examine availability of physician assistants (PAs) or nurse practitioners (NPs) in primary care physician practices by state and by state PA and NP scope-of-practice laws. METHODS: Availability of PAs and NPs in primary care practices was examined in multivariate analysis using a 2012 state-based, nationally representative survey of office-based physicians. Covariates included practice characteristics, state, and in a separate model, PA and NP scope-of-practice variables. RESULTS: After controlling for practice characteristics, higher use of PAs and NPs was found in three states (Minnesota, Montana, and South Dakota). In a separate model, higher use of PAs or NPs was associated with favorable PA scope-of-practice laws, but not with NP scope-of-practice laws. CONCLUSIONS: Higher availability of PAs or NPs was associated with favorable PA scope-of-practice laws. Lack of association between PA or NP availability and NP scope-of-practice laws requires further investigation.

The role of health information technology in care coordination in the United States.

OBJECTIVES: Examine the extent to which office-based physicians in the United States receive patient health information necessary to coordinate care across settings and determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT) (defined by presence or absence of electronic health record system and electronic sharing of information). RESEARCH DESIGN: Cross-sectional study using the 2012 National Electronic Health Records Survey (65% weighted response rate). SUBJECTS: Office-based physicians. MEASURES: Use of HIT and 3 types of patient health information needed to coordinate care. RESULTS: In 2012, 64% of physicians routinely received the results of a patient's consultation with a provider outside of their practice, whereas 46% routinely received a patient's history and reason for a referred consultation from a provider outside of their practice. About 54% of physicians reported routinely receiving a patient's hospital discharge information. In adjusted analysis, significant differences in receiving necessary information were observed by use of HIT. Compared with those not using HIT, a lower percentage of physicians who used an electronic health record system and shared patient health information electronically failed to receive the results of outside consultations or patient's history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. Among physicians routinely receiving information needed for care coordination, at least 54% of them did not receive the information electronically. CONCLUSIONS: Although a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one third did not routinely receive the needed patient information at all.

Despite substantial progress In EHR adoption, health information exchange and patient engagement remain low in office settings.

The United States is making substantial investments to accelerate the adoption and use of interoperable electronic health record (EHR) systems. Using data from the 2009-13 Electronic Health Records Survey, we found that EHR adoption continues to grow: In 2013, 78 percent of office-based physicians had adopted some type of EHR, and 48 percent had the capabilities required for a basic EHR system. However, we also found persistent gaps in EHR adoption, with physicians in solo practices and non-primary care specialties lagging behind others. Physicians' electronic health information exchange with other providers was limited, with only 14 percent sharing data with providers outside their organization. Finally, we found that 30 percent of physicians routinely used capabilities for secure messaging with patients, and 24 percent routinely provided patients with the ability to view online, download, or transmit their health record. These findings suggest that although EHR adoption continues to grow, policies to support health information exchange and patient engagement will require ongoing attention.

State variability in supply of office-based primary care providers: United States, 2012.

KEY FINDINGS: Data from the National Ambulatory Medical Care Survey (NAMCS) and the NAMCS Electronic Health Records Survey In 2012, 46.1 primary care physicians and 65.5 specialists were available per 100,000 population. From 2002 through 2012, the supply of specialists consistently exceeded the supply of primary care physicians. Compared with the national average, the supply of primary care physicians was higher in Massachusetts, Rhode Island, Vermont, and Washington; it was lower in Arkansas, Georgia, Mississippi, Nevada, New Mexico, and Texas. In 2012, 53.0% of office-based primary care physicians worked with physician assistants or nurse practitioners. Compared with the national average, the percentage of physicians working with physician assistants or nurse practitioners was higher in 19 states and lower in Georgia. Primary care providers include primary care physicians, physician assistants, and nurse practitioners. Primary care physicians are those in family and general practice, internal medicine, geriatrics, and pediatrics (1). Physician assistants are state-licensed health professionals practicing medicine under a physician's supervision. Nurse practitioners are registered nurses (RNs) with advanced clinical training (2-6). The ability to obtain primary care depends on the availability of primary care providers (3). This report presents state estimates of the supply of primary care physicians per capita, as well as the availability of physician assistants or nurse practitioners in primary care physicians' practices. Estimates are based on data from the National Ambulatory Medical Care Survey (NAMCS), Electronic Health Records (EHR) Survey, a nationally representative survey of office-based physicians.

Trends in electronic health record system use among office-based physicians: United States, 2007-2012.

OBJECTIVES: This report presents trends in the adoption of electronic health records (EHRs) by office-based physicians during 2007-2012. Rates of adoption are compared by selected physician and practice characteristics. METHODS: The National Ambulatory Medical Care Survey (NAMCS) is based on a national probability sample of nonfederal office-based physicians who see patients in an office setting. Prior to 2008, data on physician characteristics were collected through in-person interviews with physicians. To increase the sample for analyzing physician adoption of EHR systems, starting in 2008, NAMCS physician interview data were supplemented with data from an EHR mail survey. This report presents estimates from the 2007 in-person interviews, combined 2008-2010 data from both the in-person interviews and the EHR mail surveys, and 2011-2012 data from the EHR mail surveys. Sample data were weighted to produce national estimates of office-based physician characteristics and their practices. RESULTS: In 2012, 71.8% of office-based physicians reported using any type of EHR system, up from 34.8% in 2007. In 2012, 39.6% of physicians had an EHR system with features meeting the criteria of a basic system, up from 11.8% in 2007; 23.5% of office-based physicians had an EHR system with features meeting the criteria of a fully functional system in 2012, up from 3.8% in 2007. In 2007, a wide gap existed in use of any type of EHR system between physicians in practices with 11 or more physicians (74.3%) compared with physicians in smaller practices (20.6% among solo practitioners); the gap, however, narrowed during 2007-2012. In 2007, no significant gap was observed in adoption of a fully functional system between primary care (4.7%) and nonprimary care physicians (2.8%); the gap, however, widened over time (27.9% compared with 19.4% in 2012). The difference in adoption of a fully functional system between physicians in practices with 11 or more physicians compared with solo practitioners was 10.4 percentage points in 2007; the gap widened to 30.6 percentage points in 2012.

Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013.

KEY FINDINGS: In 2013, 78% of office-based physicians used any type of electronic health record (EHR) system, up from 18% in 2001. In 2013, 48% of office-based physicians reported having a system that met the criteria for a basic system, up from 11% in 2006. The percentage of physicians with basic systems by state ranged from 21% in New Jersey to 83% in North Dakota. In 2013, 69% of office-based physicians reported that they intended to participate (i.e., they planned to apply or already had applied) in "meaningful use" incentives. About 13% of all office-based physicians reported that they both intended to participate in meaningful use incentives and had EHR systems with the capabilities to support 14 of the Stage 2 Core Set objectives for meaningful use. From 2010 (the earliest year that trend data are available) to 2013, physician adoption of EHRs able to support various Stage 2 meaningful use objectives increased significantly. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized incentive payments to increase physician adoption of electronic health record (EHR) systems (1,2). The Medicare and Medicaid EHR Incentive Programs are staged in three steps, with increasing requirements for participation. To receive an EHR incentive payment, physicians must show that they are "meaningfully using" certified EHRs by meeting certain objectives (3,4). This report describes trends in the adoption of EHR systems from 2001 through 2013, as well as physicians' intent to participate in the EHR Incentive Programs and their readiness to meet 14 of the Stage 2 Core Set objectives for meaningful use in 2013.

Electronic medical record features and seven quality of care measures in physician offices.

The effect of electronic medical records (EMRs) on quality of care in physicians' offices is uncertain. This study used the 2008-2009 National Ambulatory Medical Care Survey to examine the relationship between EMRs features and quality in physician offices. The relationship between selected EMRs features and 7 quality measures was evaluated by testing 25 associations in multivariate models. Significant relationships include reminders for guideline-based interventions or screening tests associated with lower odds of inappropriate urinalysis and prescription of antibiotics for upper respiratory infection (URI), prescription order entry associated with lower odds of prescription of antibiotics for URI, and patient problem list associated with higher odds of inappropriate prescribing for elderly patients. EMRs system level was associated with lower odds of blood pressure check, inappropriate urinalysis, and prescription of antibiotics for URI compared with no EMRs. The results show both positive and inverse relationships between EMRs features and quality of care.

Emergency department visits and resulting hospitalizations by elderly nursing home residents, 2001-2008.

This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001-2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.

Office-based physicians are responding to incentives and assistance by adopting and using electronic health records.

Expanding the use of interoperable electronic health record (EHR) systems to improve health care delivery is a national policy priority. We used the 2010-12 National Ambulatory Medical Care Survey--Electronic Health Records Survey to examine which physicians in what types of practices are implementing the systems, and how they are using them. We found that 72 percent of physicians had adopted some type of system and that 40 percent had adopted capabilities required for a basic EHR system. The highest relative increases in adoption were among physicians with historically low adoption levels, including older physicians and those working in solo practices or community health centers. As of 2012, physicians in rural areas had higher rates of adoption than those in large urban areas, and physicians in counties with high rates of poverty had rates of adoption comparable to those in areas with less poverty. However, small practices continued to lag behind larger practices. Finally, the majority of physicians who adopted the EHR capabilities required to obtain federal financial incentives used the capabilities routinely, with few differences across physician groups.

Variation in electronic health record adoption and readiness for meaningful use: 2008-2011.

BACKGROUND: Federal initiatives are underway that provide physicians with financial incentives for meaningful use (MU) of electronic health records (EHRs) and assistance to purchase and implement EHRs. OBJECTIVE: We sought to examine readiness and interest in MU among primary care physicians and specialists, and identify factors that may affect their readiness to obtain MU incentives. DESIGN/PARTICIPANTS: We analyzed 4 years of data (2008-2011) from the National Ambulatory Medical Care Survey (NAMCS) Electronic Medical Record (EMR) Supplement, an annual cross-sectional nationally representative survey of non-federally employed office-based physicians. MAIN MEASURES: Survey-weighted EHR adoption rates, potential to meet selected MU criteria, and self-reported intention to apply for MU incentives. We also examined the association between physician and practice characteristics and readiness for MU. KEY RESULTS: The overall sample consisted of 10,889 respondents, with weighted response rates of 62 % (2008); 74 % (2009); 66 % (2010); and 61 % (2011). Primary care physicians' adoption of EHRs with the potential to meet MU nearly doubled from 2009 to 2011 (18 % to 38 %, p<0.01), and was significantly higher than specialists (19 %) in 2011 (p<0.01). In 2011, half of physicians (52 %) expressed their intention to apply for MU incentives; this did not vary by specialty. Multivariate analyses report that EHR adoption was significantly higher in both 2010 and 2011 compared to 2009, and primary care physicians and physicians working in larger or multi-specialty practices or for HMOs were more likely to adopt EHRs with the potential to meet MU. CONCLUSIONS: Physician EHR adoption rates increased in advance of MU incentive payments. Although interest in MU incentives did not vary by specialty, primary care physicians had significantly higher rates of adopting EHRs with the potential to meet MU. Addressing barriers to EHR adoption, which may vary by specialty, will be important to enhancing coordination of care.

The rise of electronic health record adoption among family physicians.

PURPOSE: Realizing the benefits of adopting electronic health records (EHRs) in large measure depends heavily on clinicians and providers' uptake and meaningful use of the technology. This study examines EHR adoption among family physicians using 2 different data sources, compares family physicians with other office-based medical specialists, assesses variation in EHR adoption among family physicians across states, and shows the possibility for data sharing among various medical boards and federal agencies in monitoring and guiding EHR adoption. METHOD: We undertook a secondary analysis of American Board of Family Medicine (ABFM) administrative data (2005-2011) and data from the National Ambulatory Medical Care Survey (NAMCS) (2001-2011). RESULTS: The EHR adoption rate by family physicians reached 68% nationally in 2011. NAMCS family physician adoption rates and ABFM adoption rates (2005-2011) were similar. Family physicians are adopting EHRs at a higher rate than other office-based physicians as a group; however, significant state-level variation exists, indicating geographical gaps in EHR adoption. CONCLUSION: Two independent data sets yielded convergent results, showing that adoption of EHRs by family physicians has doubled since 2005, exceeds other office-based physicians as a group, and is likely to surpass 80% by 2013. Adoption varies at a state level. Further monitoring of trends in EHR adoption and characterizing their capacities are important to achieve comprehensive data exchange necessary for better, affordable health care.

A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*.

OBJECTIVES: To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit. DESIGN: We conducted a multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006. SETTING: Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems. INTERVENTIONS: A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication. MEASUREMENTS AND RESULTS: We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates <1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to <1/1,000 central line days (a 69% reduction) at 12 months. CONCLUSIONS: This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.

Most physicians were eligible for federal incentives in 2011, but few had EHR systems that met meaningful-use criteria.

As more physicians adopt electronic health record systems in their practices, policy interest is focusing on whether physicians are ready to meet the federal "meaningful use" criteria--a vital threshold to qualify for financial incentives. In our analysis of a 2011 nationally representative survey of office-based physicians, we found that 91 percent of physicians were eligible for Medicare or Medicaid meaningful-use incentives. About half of all physicians intended to apply. However, only 11 percent both intended to apply for the incentives and had electronic health record systems with the capabilities to support even two-thirds of the stage 1 core objectives required for meaningful use. Although the federal Medicare incentives will be available through 2016, and Medicaid incentives through 2021, widespread gaps in readiness throughout the states illustrate the challenges physicians face in meeting the federal schedule for the incentive programs.