Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
P E
ROGRESS IN  LECTRONIC 
 
 
H R
EALTH  ECORD 
 
 
I T
MPLEMENTATION  HROUGH 
 
 
HRSA G H
  RANTS TO  EALTH 
C C
ENTER  ONTROLLED 
N  
ETWORKS 
 
 
 
 
 
 
 
 
Daniel R. Levinson   
Inspector General  
 
January 2014 
OEI-09-11-00380 
   
EXECUTIVE SUMMARY:  PROGRESS IN ELECTRONIC HEALTH RECORD 
IMPLEMENTATION THROUGH HRSA GRANTS TO HEALTH CENTER  
CONTROLLED NETWORKS, OEI-09-11-00380 
 
WHY WE DID THIS STUDY 
 
One goal of the Health Resources and Services Administration (HRSA) is to ensure that all of its 
health centers implement health information technology (HIT), including electronic health record 
(EHR) systems.  Since 2007, HRSA has awarded $176.9 million in grants to networks of health 
centers known as health center controlled networks (HCCNs) to support this goal through the 
acquisition, implementation, and meaningful use of EHR systems.  To assess the grants 
contributions toward HRSAs HIT goal, we assessed health centers progress in using HRSA 
grantsfunded by the American Recovery and Reinvestment Act (ARRA)to implement EHR 
systems that support meaningful use.  HRSA did not require demonstration of meaningful use as 
a condition of the grants, but has stated that Stage 1 meaningful use objectives, as set forth by the 
Centers for Medicare & Medicaid Services, are a reasonable baseline to assess health center 
progress in implementing EHR systems.  We also did this study to determine whether health 
centers face challenges related to the financial sustainability of their EHR systems. 
 
HOW WE DID THIS STUDY  
 
We surveyed health centers that participated in HRSAs ARRA-funded HCCN grant projects 
that supported EHR implementations and enhancements.  Using survey responses, we 
determined the extent to which health centers established the capability for the Stage 1  
meaningful use objectives.  We also determined whether health centers reported facing 
challenges related to the financial sustainability of their EHR systems.  To supplement the survey 
responses, we reviewed grantee progress reports and conducted visits at 11 health centers.   
 
WHAT WE FOUND 
 
Most health centers established the capability for meaningful objectives related to capturing data.  
However, fewer health centers established the capability for meaningful use objectives related to 
sharing data. Establishing the capability for objectives relating to sharing data often requires 
health centers to incur additional EHR-related costs.  Although 76 percent of health centers 
reported facing financial sustainability challenges, grantee progress reports contained limited 
information related to the financial sustainability of EHR systems at health centers.   
 
WHAT WE RECOMMEND   
 
We recommend that HRSA (1) use data to understand progress towards meaningful use 
objectives and to provide guidance and technical assistance to health centers, (2) ensure that 
HCCN grantees provide information on the financial sustainability of EHR systems at health 
centers, and (3) examine the feasibility of collecting information directly from health centers 
regarding the financial sustainability of their EHR systems.  HRSA concurred with all of our 
recommendations.  
 
   
 
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................9 

Most health centers established the capability for meaningful  

use objectives related to capturing data; fewer established the 

capability for objectives related to sharing data ..............................9 

Seventy-six percent of health centers reported facing  
financial sustainability challenges .................................................12 

HCCNsgrantee progress reports contained limited information  
related to the financial sustainability of EHR systems at  
health centers .................................................................................14 

Conclusion and Recommendations ............................................................17 

Agency Comments and Office of Inspector General Response .................20 

Appendixes ................................................................................................21 

A: Stage 1 Meaningful Use Objectives .........................................21 

B: Stage 1 Meaningful Use Objectives and the Percentage 
 
of Health Centers With the Capability for Each Objective ............24 

C: The Extent to Which Eligible Professionals at Health  

Centers Demonstrate the Stage 1 Meaningful Use Objectives ......25 

D: Agency Comments  ...................................................................27 

Acknowledgments......................................................................................30 

 
 
   
 
OBJECTIVES  
1. 	  To assess health centers progress toward implementing electronic 
health record (EHR) systems that support meaningful use through 
Health Resources and Services  Administration (HRSA) Health Center 
Controlled Network (HCCN) grants funded by the American Recovery 
and Reinvestment Act (ARRA). 
2. 	  To determine whether health centers face challenges related to the 
financial sustainability of their EHR systems that were implemented or 
enhanced with HRSAs  ARRA-funded HCCN grants. 
BACKGROUND 
Between 2007 and 2013, HRSA awarded $176.9 million in health 
information technology (HIT) grants, with the majority of this amount 
coming from ARRA.1   These grants support HRSAs goal to ensure that all 
of its health centers2 implement HIT, which includes the implementation 
and meaningful use of EHR systems.3  EHR systems enable users to record 
patient health information and medical history electronically instead of 
using paper records. Professionals at health centers may become  
meaningful users of EHR systems if they meet a set of meaningful use 
objectives as defined in Federal regulations.4   These objectives encompass 
capabilities that are meant to improve health care quality and efficiency by 
electronically capturing and sharing data.  Health centers must first 
establish these capabilities so that professionals can become meaningful 
users by using the capabilities.   
HRSA HIT Grants 
To support the implementation and meaningful use of EHR systems at 
health centers, HRSA awarded its HIT  grants to health center controlled 
networks (HCCN).  An HCCN is a group of health centers that use group 
purchasing power and shared resources, infrastructure, and training to 
adopt and implement HIT in a more cost-efficient manner.5   Although 
 
1 HRSA awarded  $35.3 million from 2007 through  2008; $120.5 million from 2009 
 
through  2010 (with  funds made available through ARRA  3011, amending Titles XVIII 

and XIX of the Social Security Act); and $21.1 million in fiscal year 2013 (with funds 

made available through the Patient Protection and Affordable Care Act). 
 
2 HRSA-funded health centers provide comprehensive primary  care services to medically 

underserved communities and vulnerable populations.  Public Health Service Act  330 
 
(codified at 42 U.S.C.  254b).  

3  77  Fed.  Reg. 72870 (Dec. 6, 2012). 

4  42  CFR  495.6. 
  
5 HRSA, Affordable Care ActHCCNs, HRSA-13-327, June 19, 2012, pp. 12. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   1   
 
HCCNs received the funding, the HIT grants supported projects for the 
HCCNs member health centers.  
EHR Implementation Grants. Between 2009 and 2010, HRSA awarded 
$98.9 million in ARRA-funded grants to 43 HCCNs for EHR 
implementation projects.6 (In this report, we refer to these grants as EHR 
implementation grants.)  A total of 260 health centers, varying in size and 
location (i.e., rural or urban), participated in EHR implementation grant 
projects through their respective HCCNs.7  Some of these health centers 
were already using an EHR system prior to participating in grant projects.  
The EHR implementation grants funded two types of projects to support 
meaningful use at health centers:  new EHR implementation projects 
andto expand the capabilities of existing EHR systemsEHR 
enhancement projects.8  Some HCCNs received EHR implementation 
grants to support both types of projects at one or more of their health 
centers. For example, a health center participating in both types of 
projects may have implemented an EHR system at one site and expanded 
the capabilities of its EHR system at another site.   
Financial Sustainability. Once an EHR system is implemented, there are 
ongoing operational and maintenance costs related to financially 
sustaining the system and implementing the capabilities to support 
meaningful use.  These ongoing costs can include hardware and software 
license/maintenance agreements and upgrades, ongoing staff training, and 
information technology (IT) support fees.  In addition, hiring new staff 
such as IT operations staff, clinical data analysts, or application analysts 
can add to the ongoing costs.9   The estimated average yearly costs of an 
EHR system range from $4,000 to $8,000 per professional, depending on 
the type of EHR system.10    
 
6  We  did not include $21.6 million of the $120.5 million in  grant funds made available 
through  ARRA because they  were only for  HIT innovation projects.  

7 The number of HRSA-funded  health centers that participated in  EHR implementation 
 
grant  projects is based on  Office of Inspector General  (OIG) verification with HCCN
  
grantees. 

8 Examples of enhancement projects include integrating with State-wide  Health 
 
Information Exchanges, expanding  data reporting capabilities, implementing a patient  

portal, and creating data registries.   

9 Office of the National Coordinator for Health Information Technology (ONC), How 

much is this going to cost me?  Accessed at http://www.healthit.gov/providers-
professionals/faqs/how-much-going-cost-me on September 16, 2013. 
 
10  Costs vary depending on whether centers  select  an onsite EHR  system  or Web-based 

EHR system.  Web-based EHR systems typically require providers to  pay  a fixed 

monthly subscription cost.   Onsite EHR systems typically require providers to  pay for 

ongoing costs to support and manage onsite data servers.  ONC,  How much is this going 

to cost me?  Accessed at http://www.healthit.gov/providers-professionals/faqs/how-
much-going-cost-me on September 16, 2013. 
 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   2   
 
HRSA awarded the EHR implementation grants as one-time funding; the 
grants were not intended to cover the ongoing maintenance and 
operational costs. HRSA expects HCCNs and their participating health 
centers to have a plan for how grant projects will be financially sustained 
during and after the period of Federal grant funding (grant period), 
particularly for ongoing maintenance and operational costs.11    
Grantee Progress Reports.  For EHR implementation grants, HRSA 
required HCCN grantees to submit quarterly progress reports during the 
grant period. During the September 2011 grant period, HRSA updated the 
format of the grantee progress reports.  The updated format includes (1) a 
narrative section to collect information on any challengeswhether 
related to financial sustainability or to other issuesexperienced by 
HCCNs and participating health centers to date and (2) another field to 
collect sustainability plans.  HRSA asked HCCNs to describe their 
sustainability plans because it expects HCCNs and their participating 
health centers to plan how grant projects will be sustained during and after 
the grant period.  
Meaningful Use of EHR Systems  
HRSA awarded the EHR implementation grants in 2009 and 2010 with the 
goal of implementing EHR systems to prepare health centers for 
meaningful use, without any requirement to meet  any specific meaningful 
use objectives because such objectives had not yet been established.12   
HRSA required that grant funds be used only to implement or enhance an 
EHR system certified by an organization recognized by the Secretary of 
Health and Human Services.13, 14  Such certification provides assurance that 
the EHR system offers the necessary electronic capability to help health 
center professionals become meaningful users (i.e., demonstrate 
meaningful use objectives as defined in Federal regulations).15    
CMS is defining and rolling out the meaningful use objectives in three 
stages; each stage is adding increased  capabilities to improve patient care, 
 
11 HRSA, HIT Implementation for HCCNs, HRSA-10-154, December 9, 2009, p. 28. 
12 HRSA announced the latest funding  opportunity for the ARRA-funded EHR 
implementation grants in December 2009, and applications were due in  February  2010.   
The Centers for Medicare &  Medicaid Services (CMS)  did not  finalize the definitions  
and requirements for Stage 1  meaningful  use until July 2010.  HRSA, HIT 
Implementation for HCCNs, HRSA-10-154, December 9, 2009; 42 CFR  495.6.  
13 HRSA, HIT Implementation for HCCNs, HRSA-10-154, December 9, 2009, p. 6. 
14 ONC issued the initial set of  certification criteria on January 13, 2010, which  
established the capabilities and  related standards that certified EHR systems needed to  
support the achievement of the proposed Stage 1 meaningful use rule.  ONC defined  
EHR certification requirements and the process for certification in Federal regulations.   
45 CFR  pt. 170, subparts CE.   
15 42 CFR   495.6.  
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   3   
 
enhance care coordination, and increase patient engagement.  For each 
meaningful use objective, CMS defines a specific measure that must be 
met to demonstrate the objective.  In July 2010, CMS defined the Stage 1 
meaningful use objectives and their associated measures.16   These 
objectives set the baseline for two types of capabilities:   
	   capturing data (i.e., electronically capturing health information in a 
structured format17 and using it for evidence-based clinical 
decisions) and 
 	  sharing data (i.e., electronically sharing health information for care 
coordination, patient engagement, and public health reporting).18  
In September 2012, CMS defined the Stage 2 meaningful use objectives, 
which expand on Stage 1 with a focus on sharing data for continued 
quality improvement.19  Stage 2 meaningful use objectives became  
effective on January 1, 2014 for professionals.20 CMS expects to define 
Stage 3 meaningful use objectives related to improved health outcomes in 
2016.21    
Under the Medicaid EHR incentive program, a professional who is 
eligible for the program (eligible professional)22 and demonstrates all 
three stages of meaningful use can receive incentive payments totaling 
$63,750 over 6 years.23  Eligible professionals who register for the 
Medicaid EHR incentive program have until 2017 to demonstrate Stage 1 
meaningful use to receive the maximum amount of incentive payments.   
 
16  75  Fed.  Reg. 44314 (July 28, 2010). 

17 Structured data is another way of  referring to data that are entered into  a specific 

field, as opposed to free text in a chart note.  Structured  data enable patient information 
 
to be easily retrieved and transferred.  CMS, Certified EHR Technology. Accessed at 

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/  

Certification.html on  April 4, 2013. 

18 ONC,  How to Implement EHRs  Step  5:  Achieve Meaningful Use.  Accessed at 

http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-5-
achieve-meaningful-use  on September 16, 2013. 
 
19  77  Fed.  Reg. 53968, 53970 (Sept. 4, 2012).  When  CMS finalized  Stage 2 meaningful 
 
use objectives, it included minor changes to Stage 1 that take effect outside our period of 

review. 
 
20  CMS, Stage2.  Accessed at http://www.cms.gov/Regulations-and-Guidance/Legislation 
/EHRIncentivePrograms/Stage_2.html on January  22, 2014.   

21 ONC,  Meaningful Use Definition  &  Objectives.  Accessed at 

http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives on 
 
September 16,  2013. 
 
22 42 CFR   495.304(b).  Eligible professionals include physicians, nurse practitioners, 

certified nurse midwives,  dentists, and physician assistants who may participate in the 

Medicaid EHR incentive program. 
 
23 42 CFR   495.310.  
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   4   
 
Stage 1 Meaningful Use.  After CMS finalized the Stage 1 meaningful use 
objectives, HRSA stated that the Stage 1 mandatory objectives (core 
objectives) are a reasonable baseline to assess health center progress on 
implementing EHR systems.24   The Stage 1 meaningful use core objectives 
include 15 objectives, of which 9 are related to capturing data and 5 are 
related to sharing data.25  Stage 1 also includes 10 additional objectives 
(menu objectives).  An eligible professional who is participating in the 
Medicaid EHR incentive program would need to demonstrate Stage 1 
meaningful use by meeting the measures for all 15 of the core objectives 
and 5 of the 10 menu objectives, 1 of which must be a public health 
objective.26   Although a health center may have established the capability 
for Stage 1 meaningful use, it is up to the individual eligible professional 
to meet the measures for the objectives to receive incentive payments.  See 
Appendix A for a list of the core and menu objectives for Stage 1 
meaningful use, along with the type of capability the objectives represent  
(i.e., capturing data or sharing data) and their associated measures for 
eligible professionals. 
METHODOLOGY 
Scope 
In July 2012, we surveyed health centers that fell within the scope of our 
studynamely, health centers that participated in EHR implementation 
grant projects and that are funded by HRSA through section 330 of the 
Public Health Services  Act.   These health centers are associated with the 
55 EHR implementation grants that HRSA awarded to 43 HCCNs with 
funds made available through ARRA.  To supplement survey responses, 
we reviewed grantee progress reports submitted to HRSA by HCCNs in 
2011 and 2012 and we conducted site visits at a purposive sample of 
11 health centers from May to September 2012.   
To assess health centers progress toward implementing EHR systems that 
support meaningful use, we examined  the extent to which health centers 
reported having the capability for Stage 1 meaningful use objectives, 
which set the baseline for capturing and sharing data.  We use the Stage 1 
 
24 HRSA, UDS Reporting Instructions for Section  330  Grantees, January 2011, p. 114.   
Accessed at http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/2010manual.pdf on  
August 25, 2011; HRSA, UDS  Reporting Instructions for Section 330 Grantees, 
December, 2012, p. 153.  Accessed at http://www.bphcdata.net/docs/uds_rep_instr.pdf on 
July 23, 2013. 
25 42 CFR   495.6.  The core  objectives also  include one objective related to ensuring the 
privacy of health information.   

26 Ibid.  The public health  objectives for eligible professionals include two  objectives 

related to submitting data to  public health agencies (immunization  registries data and 

syndromic surveillance data).   

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   5   
 
meaningful use objectives, as initially finalized by CMS, because HRSA  
stated that this set of Stage 1 core objectives is a reasonable baseline to 
assess health center progress in implementing EHR systems.    
We also determined whether health centers had reported facing challenges 
related to the financial sustainability of their EHR systems.   
Data Collection and Analysis 
Health Center Survey. We administered a survey to health centers to 
collect information on their progress toward implementing EHR systems 
that support meaningful use and any issues related to the financial 
sustainability of their EHR systems.  To identify our survey population, we 
obtained from HRSA a list of HCCNs that received an EHR 
implementation grant(s) and these HCCNs section 330-funded health 
centers that participated in EHR implementation grant projects.  However,  
HRSA could not confirm that the list was complete, as participating health 
centers may leave or join HCCNs.  Therefore, we contacted all 43 HCCNs  
on HRSAs list and asked them to verify their respective lists of health 
centers that were participating in grant projects.  We also asked the 
HCCNs to provide names and contact information for any participating 
health centers that were not included on these lists. 
As a result, we compiled a list of 260 section 330-funded health centers 
participating in EHR implementation grant projects.  We pretested the 
survey with six of these health centers and excluded them from the survey 
population. We administered the survey to the remaining 254 health 
centers. We received 246 responses, a 97-percent response rate.  We  
excluded 13 health centers that reported they had not yet implemented an 
EHR system, because our survey questions focused on issues that are 
relevant only for health centers that have already implemented an EHR 
system.27   Therefore, our findings are based on 233 health centers.  
For the health centers that reported using an EHR system, we analyzed 
their survey responses to examine their progress toward implementing 
EHR systems that support meaningful use.  For each Stage 1 meaningful 
use objective, the survey asked whether all, most, some, few, or 
none of the health centers eligible professionals met the measure for the 
objective for the preceding 90 days.28  If the health center reported that all, 
most, some, or few of its eligible professionals met the measure, we 
concluded that the health center had established the capability for the 
 
27 These health centers had purchased an EHR  system but had not yet implemented it at  
the time of  our review.   

28 42 CFR   495.4.  We used a 90-day reporting period  because the Medicaid EHR
  
incentive program uses a 90-day reporting  period for the first year in  which the eligible 

professional  is demonstrating meaningful use.
   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   6   
 
objective. If the health center reported that none of its eligible 
professionals met the measure, we concluded that the health center had not 
established the capability for the objective.  We asked health centers that 
did not establish the capability for the objective when they expected to 
establish it.  If we concluded that a health center had established the 
capability for 15 core objectives and 5 menu objectives (including 1 of the  
public health menu objectives), we concluded that the health center had 
established the capability for all the objectives necessary for Stage 1 
meaningful use.  Finally, we analyzed survey responses to determine the 
extent to which eligible professionals at health centers are registered for 
the Medicaid EHR incentive program.   
We analyzed survey responses from the health centers that reported using 
an EHR system to determine whether they reported facing challenges 
related to the financial sustainability of their EHR systems.  For those 
health centers that reported facing such sustainability challenges, we 
analyzed open-ended survey responses to describe their challenges and 
their efforts to offset the ongoing costs of operating and maintaining the 
systems. 
Grantee Progress Reports. We obtained from HRSA all grantee progress 
reports submitted by HCCNs as of August 2012.  We reviewed two fields 
in the narrative section of the most recent progress reports:  challenges and 
sustainability plans. We reviewed the challenges to determine whether 
HCCNs reported to HRSA that their health centers were facing financial 
sustainability challenges during the grant period and whether these 
challenges, if any, were similar to those reported by health centers through 
our survey.  We reviewed HCCNs sustainability plans to determine 
whether the plans addressed the challenges that health centers reported 
facing related to the sustainability of their EHR systems.   
Health Center Site Visits. We visited a purposive sample of 11 health 
centers chosen on the basis of their location and size.  We visited health 
centers in California, Delaware, Illinois, Maryland, Oregon, and Utah that 
varied in size (3,000 to 70,000 patient encounters per year), location 
(urban/rural), and duration of EHR system use.  At each health center, we 
conducted structured onsite interviews  with staff members (e.g., eligible 
professionals, the medical director, and executive management) who 
perform key roles in the health centers EHR implementation and progress 
toward meaningful use.  We asked the staff about their experiences in 
implementing the EHR system, including challenges they faced, and about 
the strategies they used to establish the capability for Stage 1 meaningful 
use objectives and to financially sustain the EHR system.  Staff from five 
health centers completed our survey prior to our onsite visits.  We asked 
these staff to elaborate on select responses from their survey.  We analyzed 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   7   
 
the information from health center staff interviews for additional or 
supporting information on health centers progress toward implementing 
EHR systems that support meaningful use and challenges related to 
sustaining their EHR system. 
Limitations 
This study relies on self-reported data from health center respondents.  We  
did not request documentation to verify their responses.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.     
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   8   
 
FINDINGS 
Most health centers established the capability for 
meaningful use objectives related to capturing data;
fewer established the capability for objectives related 
to sharing data 
Although the grants that HRSA awarded to HCCNs did not require 
participating health centers to demonstrate Stage 1 meaningful use, the 
health centers have made significant progress toward establishing the 
capability for objectives related to capturing data. However, they have not 
made commensurate progress with regard to the objectives related to 
sharing data, thus hindering their progress toward implementing EHR 
systems that support meaningful use. Seventy-two percent (168 of 233) of 
health centers had established the capability for all the core objectives 
related to capturing data.29 In contrast, only 24 percent (56 of 233) of 
health centers had done so for all the core objectives related to sharing 
data.30  Although most of the health centers (192 of 233) had established 
the capability for at least 5 menu objectives, only 36 percent (83 of 233) 
had done so for 1 of 2 public health menu objectives related to sharing 
data. Overall, 14 percent (32 of 233) of health centers had established the 
capability for all of the objectives necessary for Stage 1 meaningful use, 
i.e., all 15 of the core objectives plus 5 of the 10 menu objectives. 
Although only a small percentage of health centers had established the 
capability for all the objectives necessary for Stage 1 meaningful use, 
more than half of health centers had established the capability for each 
individual objective, with the exception of four objectivesone core, 
three menurelated to sharing data.  (See Appendix B for an ordered list 
of the Stage 1 meaningful use objectives by the percentage of health 
centers with the capability for each objective.) 
Although only 14 percent of health centers had established the capability 
for all the objectives necessary for Stage 1 meaningful use, at the time of 
our review, an additional 27 percent (62 of 233) of health centers reported 
that they would establish the capability for Stage 1 by mid-2013.  
Furthermore, almost all health centers (221 of 233) reported that they 
expected all of their eligible professionals to register for the Medicaid 
EHR incentive program to demonstrate Stage 1 meaningful use and 
 
29 Core objectives related to capturing  data include vital signs, active medication,  
medication allergy lists, demographics, drug  interaction checks, problem lists, smoking  
status, computerized provider order entry, and clinical  decision support.  
30 Core objectives related to sharing  data include electronic prescribing, clinical 
summaries, clinical quality objectives, electronic copy  of health information, and 
electronic exchange of clinical information.  
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   9   
 
receive incentive payments.  Eligible  professionals who register for the 
Medicaid EHR incentive program have until 2017 to demonstrate Stage 1 
meaningful use to receive the maximum amount of incentive payments.  
Therefore, participation in the Medicaid EHR incentive program indicates  
that the majority of health centers plan to establish the capability to enable 
all of their eligible professionals to demonstrate Stage 1 meaningful use by 
2017 or earlier. 
Establishing the capability for objectives related to sharing 
data often requires health centers to incur additional 
EHR-related costs 
Establishing the capability for objectives related to sharing data may be 
challenging for health centers because  these objectives can require health 
centers to incur additional EHR-related costs.  Health centers reported that 
they have to purchase separate applications or pay separate fees for 
specific software capabilities for objectives related to sharing data with 
other providers of care,31 public health agencies, and patients. Health 
centers reported that such costs can be unanticipated because they 
expected their certified EHR systems to include all the capabilities 
necessary to demonstrate meaningful use.  
Establishing the Capability To Share  Data With Other Providers of Care  
and Public Health Agencies May Create Financial Challenges. On 
average, only 27 percent (63 of 233) of health centers had established the 
capability for the 3 objectives related to sharing data with other providers 
of care and public health agencies. Establishing this capability may 
require health centers to purchase additional technology to establish an 
interface (i.e., a data connection to an external system).  In their surveys, 
health centers provided supplementary information about the financial 
challenges associated with establishing interfaces.  For example, one 
health center reported that every different connection with outside entities 
requires the purchase of a very expensive interface [along with] the cost 
of IT support and training.  Another health center reported that its health 
 
31 For the purposes of this report, provider of  care is a general term that includes not  
only professionals, but also  hospitals and other patient-authorized entities (i.e., any 
individual or organization to which the  patient  has granted access to his or her clinical 
information).  
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   10   
 
information exchange32 interface will cost $39 per professional per month, 
which will create an additional expense in excess of $10,000 per year.   
Additionally, health centers reported that establishing interfaces to share 
information can also be challenging because such sharing is dependent on  
the readiness of other entities.  Even if the health center is prepared to 
send information electronically, some organizationssuch as 
immunization registries and State health departmentsmay not have the 
ability to receive the electronic data.   
Establishing the Capability To Share Data With Patients May Create 
Financial Challenges.  Only 29 percent (68 of 233) of health centers had 
established the capability for the objective related to providing patients 
with electronic access to their health information.  A common way to 
establish this capability is to implement a patient portal, which is an online 
application that can enable patients to access their health records and 
allow them to interact and communicate with their professionals.  
However, patient portals may be costly for health centers to implement 
and financially sustain. During our site visit to one health center, staff 
reported that the centers patient portal technology cost $80,000.  Another 
health center reported that its vendor charges it $49 per month per 
professional, which increases its annual expenses by $15,000 per year.  A  
third health center reported that its vendor charges it $150 per month per 
professional. This objective was optional for Stage 1 meaningful use, but 
it will be required for Stage 2 along with additional objectives that can be 
met through the use of a patient portal.33      
   
 
32 The term health information exchange, or  HIE,  refers to the process of sharing 
health-related information among organizations according to  nationally recognized  
standards.  The term is often  used interchangeably to  refer both to a process and an entity, 
with many organizations referring to themselves as HIEs.  Search  HealthIT, Briefing:   
What is Health Information  Exchange?   Accessed at 
http://searchhealthit.techtarget.com/tutorial/FAQ-What-is-health-information-
exchange#HIEstandards on  January 29, 2013.  Health  information exchanges are  
different from health  insurance exchanges, which are entities that are meant to create a 
more organized and competitive market for health insurance.  Kaiser Family Foundation, 
Explaining  Health Care Reform: Questions About  Health Insurance Exchanges, 
April 2010.  Accessed online at 
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7908-02.pdf on  July 11, 2013. 
33  Stage 2 Core Objective 12 (send reminders  for preventive care) and Core Objective 17 
(use secure electronic messaging) can be met through the use of a patient  portal.   
77 Fed. Reg. 54031  (Sept.  4, 2012).   ONC, How to Implement EHRs   Step 5:  Achieve 
Meaningful Use, Patient Reminders.  Accessed at http://www.healthit.gov/providers-
professionals/achieve-meaningful-use/menu-objectives/patient-reminders on July 11, 
2013. 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   11   
 
The extent to which eligible professionals met the Stage 1 
meaningful use objectives related to capturing and sharing 
data varied 
We concluded that a health center had established the capability for a 
meaningful use objective if the health center reported that all, most, 
some, or few of its eligible professionals met the objective.  Although 
a health center may have established the capability for an objective, the 
extent to which its eligible professionals actually met the objective varied 
from a few to all eligible professionals.  This variation may indicate 
how difficult it is for eligible professionals to meet an objective once the 
health center has established the capability.  For example, although 
93 percent (216 of 233) of health centers established the capturing-data 
capability related to recording the smoking status for all patients 13 years 
old or older, only 37 percent (86 of 233) of health centers reported that all 
of their eligible professionals met that objective.  Health centers reported 
that this objective is difficult for their eligible professionals to meet for a 
variety of reasons, including difficulties in capturing the data in a 
structured format and resistance to requesting the information from  
patients as young as 13. Furthermore, some eligible professionals, such as 
dentists, do not normally request this information from patients. 
Although 82 percent (191 of 233) of health centers had established the 
sharing-data capability related to providing clinical summaries to patients 
following a visit, only 21 percent (50 of 233) of health centers reported 
that all of their eligible professionals met that objective.  Health centers 
reported that this objective is difficult for their eligible professionals to 
meet, because it is challenging to accurately record the health information 
in a meaningful way.  Specifically, sometimes it is challenging for eligible 
professionals to accurately record health information in plain language 
andfor patients whose native language is not Englishto provide it in a 
clinical summary in the patients native language.  Other health centers 
reported that this objective is difficult because of the logistics of having to 
print the summary before the patient leaves the health center. (See 
Appendix C for a breakdown of the Stage 1 meaningful use objectives by 
the extent to which eligible professionals at health centers met them.) 
Seventy-six percent of health centers reported facing 
financial sustainability challenges  
Seventy-six percent (177 of 233) of health centers reported that they face, 
or anticipate facing, challenges related to the financial sustainability of 
their EHR systems.  Health centers reported facing such challenges largely 
as a result of increased costs and loss of productivity and despite their 
efforts to offset the costs of sustaining an EHR system.  Health centers  
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   12   
 
use of EHR systems and ability to provide services may be negatively 
impacted when the centers face financial sustainability challenges that 
they are unable to overcome.   
Health centers face financial sustainability challenges because 
of increased costs and loss of productivity associated with 
their EHR systems 
The health centers that reported facing financial sustainability challenges 
commonly reported challenges related to increased costs and a loss of 
productivity associated with the EHR system.  Of the health centers that 
reported facing such challenges, 66 percent (116 of 177) cited increased 
costs and 25 percent (45 of 177) cited a loss of productivity.  Health 
centers generally reported facing more than one type of sustainability 
challenge at the same time.  
 
The Increased Costs Associated With Operating and Maintaining an EHR 
System Can Be Challenging for Health Centers. Of the health centers that 
reported facing financial sustainability challenges, almost a third cited 
challenges related to the costs of operating an EHR system.  These 
operational costs include ongoing staff training costs, IT support fees, 
interface costs, software licensing fees, and telecommunications fees.  At 
the same time, approximately a quarter of health centers cited challenges 
related to the costs of maintaining the EHR system.  These maintenance 
costs include hardware and software maintenance agreements and 
upgrades. Other health centers cited EHR-related costs in general that 
could not be categorized as operational or maintenance costs specifically.   
A Loss of ProductivityOr a Decline in the Number of Patient Visits 
Can Be Associated With Lower Reimbursement From Payers and 
Decreased Revenue.   Thirty-six health centers reported that loss of  
productivity was one of the most costly aspects of EHR implementation.  
These health centers reported a range of lost revenues that were due to a 
loss of productivity.  For example, one health center reported that the loss 
of productivity has resulted in $900,000 in lost revenues per year, whereas 
another health center estimated its loss at $15,000.   
A persistent loss of productivity following EHR implementation may 
occur as a result of usability issues  with the EHR system.  When a health 
centers EHR system is difficult for professionals to use, they may not be 
able to see as many patients as they were able to see prior to EHR 
implementation.  For example, on one of our site visits to a health center, 
professionals explained that it takes longer for them to navigate through 
the EHR and check all the appropriate boxes than it took for them to fill 
out the paper record. Furthermore, professionals explained that the EHR 
system and the meaningful use objectives place a larger documentation 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   13   
 
burden on them than on other staff.  The 45 health centers that reported 
facing sustainability challenges that are due to a loss of productivity 
implemented their EHR system almost 2 years prior to our review, on 
average. Eight of these health centers implemented their EHR system  
more than 3 years prior to our review.   
Health centers face financial sustainability challenges despite 
efforts to offset the costs of sustaining an EHR system 
The health centers that reported facing financial sustainability challenges 
also reported that they are trying to offset the costs of sustaining their 
EHR systems.  Their efforts to offset costs included identifying additional 
sources of funding (e.g., external funding opportunities and Medicaid 
EHR incentive payments), increasing  efficiencies with their respective 
EHR systems (e.g., enhancing collections of billable claims and 
optimizing billing), and increasing productivity through training and 
optimizing EHR systems to enable professionals to navigate them more 
quickly.   
Health centers use of their EHR systems and their ability to provide 
services could be negatively impacted if the centers are not able to 
overcome financial sustainability challenges.  Health centers provided 
supplementary information on their surveys about the difficult decisions 
they have had to make to address sustainability challenges.  Centers stated 
that because of the high costs of operating and maintaining EHR systems, 
they have had to delay purchasing and implementing interfaces, patient 
portals, and other capabilities. Other health centers reported that their 
sustainability challenges affect their ability to provide services to patients.  
One health center stated that reduced productivity compounded with 
extra [EHR-related] costs have caused the health center to be operating at 
a loss and [we are] faced with cutting positions to continue providing the 
same level of services to our patients.  Some health centers reported that 
their only option has been to charge patients more for services.  Other 
health centers reported that staff dissatisfaction with the EHR system has 
led some experienced professionals to quit.   
HCCNs grantee progress reports contained limited 
information related to the financial sustainability of 
EHR systems at health centers  
HCCNs, not health centers, wrote and submitted quarterly grantee 
progress reports to HRSA during the grant periods.  We found that as a 
result, the narratives in the grantee progress reports were generally written 
from the HCCN perspective and contained limited information about the 
financial sustainability of EHR systems at their health centers.   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   14   
 
First, some of the financial sustainability challenges reported by health 
centers were not reflected in the grantee progress reports.  Second, most 
grantee progress reports did not include the HCCNs plans to sustain EHR 
systems at health centers beyond the grant period.  As a result of these 
limitations, HRSA may lack information on the challenges that health 
centers are facing and on how HCCNs are supporting their health centers  
efforts to financially sustain their EHR systems.   
Financial sustainability challenges reported by health centers  
were generally not reflected in HCCNs grantee progress 
reports 
HRSA requested information related to challenges experienced during the 
grant period to date, but it did not specify whether these challenges should 
be those experienced by the HCCN or those experienced by the health 
center.   The grantee progress reports that we examined generally did not 
mention challenges specific to health centers ability to sustain their EHR 
systems.  As a result, financial sustainability challenges reported by health 
centers through our survey were generally not reflected in the grantee 
progress reports that HCCNs submitted to HRSA.  For example, in 
response to our survey, 45 health centers associated with 25 different 
HCCNs reported loss of productivity as a sustainability challenge.  
However, only 4 of those 25 HCCNs reported their health centers loss of 
productivity as a challenge in their grantee progress reports.  Furthermore, 
for five HCCNs, the field for challenges in the grantee progress reports 
was left blank in at least one of the two most recent submissions.  When 
HCCNs grantee progress reports do not mention the sustainability 
challenges that their health centers are facing, HRSA may not be aware of 
the extent of these challenges.  
Most sustainability plans did not include plans to sustain EHR 
systems at health centers  
HRSA requested that in their grantee progress reports, HCCNs describe 
their respective sustainability plans, including a brief description of their 
plans to sustain the grant projects beyond the grant period.  However,  
three HCCNs did not include such plans in their most recent grantee 
progress reports. Furthermore, the majority of the sustainability plans in  
progress reports did not include information specific to the HCCNs plans 
to sustain EHR systems at the health-center level beyond the grant period.  
Instead, the majority of the sustainability plans that were submitted in 
grantee progress reports included information related to how the HCCNs 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   15   
 
planned to sustain their own operations (26 of 38).34   These plans included  
strategies such as charging membership fees, leveraging funding from HIT  
regional extension centers,35  expanding HCCN membership, and relying 
on external funding opportunities. 
When sustainability plans have limited information at the health-center 
level, HRSA may lack information on how HCCNs help or hinder health 
centers efforts to financially sustain their EHR systems.  For example, the 
majority of sustainability plans that focused only on HCCNs included 
strategies related to relying on resource commitments (e.g., membership 
fees) from their current health center members for sustaining HCCN 
operations (18 of 26). Most HCCNs require such resource commitments 
from their member health centers, but the grantee progress reports 
generally do not include any information on the affordability of these 
resource commitments and how they affect health centers budgets.  For 
example, one health center reported that the fees its HCCN charged were 
not fairly divided among health centers.  (In this case, the HCCN 
charged the same fee for each health center, rather than weighting it by 
each centers number of professionals).      
 
34 In addition to the three HCCNs that did  not include sustainability plans in their most 
recent grantee progress  reports, two HCCNs were  reporting in the older format wherein 
HRSA did  not  request a sustainability plan.  There were 43 HCCN grantees.  Therefore, 
we analyzed  38 sustainability plans. 
35 Section 3012(a) of the Public Health  Service Act created the HIT extension program  
that provides grants to establish  HIT regional extension centers to provide technical 
assistance and guidance  to all  professionals.   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   16   
 
CONCLUSION AND RECOMMENDATIONS 
To improve coordination of care and to implement new models of service 
delivery and payment, it is critical that EHR systems be able not just to 
capture data, but also to share data.36   Although most health centers that 
participated in EHR implementation grant projects through their respective 
HCCNs established the capability for  meaningful use objectives related to 
capturing data, fewer established the capability for objectives related to 
sharing data. Establishing capabilities for objectives related to sharing 
data is a challenge that is not unique to health centers.  Recent research 
indicates that there are substantial barriers to the widespread sharing of 
health information across all practice settings.37    
Although HRSAs EHR implementation grants were not intended to cover 
the ongoing costs of operating and maintaining EHR systems, HRSA  
expects HCCNs and health centers to have sustainability plans to cover 
these costs. However, 76 percent of health centers using EHR systems 
reported facing challenges related to their financial sustainability.  
Additional costs incurred by health centers as they establish the capability 
to share data can contribute to financial sustainability challenges.  Health 
centers use of their EHR systems and their ability to provide services may 
be negatively impacted if health centers are not able to overcome such 
challenges. 
HRSA may not have complete information regarding financial 
sustainability at health centers because grantee progress reports submitted 
by HCCNs provided limited information.  These progress reports do not 
give HRSA enough information to determine whether health centers are 
able to financially sustain HRSAs investment in EHR systems over the 
long term in the absence of future Federal grant opportunities, incentive 
payments, and new payment models under the Affordable Care Act.   
   
 
36 78 Fed. Reg. 14793  (March  7, 2013). 

37 Michael F. Furukawa, et al., Hospital Electronic Health Information Exchange Grew 

Substantially In  200812, Health  Affairs  32 (8), August 2013. 
  
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   17   
 
To address these issues, we recommend that HRSA:  
Use data to understand progress towards meaningful use 
objectives and to provide guidance and technical assistance 
to health centers 
HRSA is updating its progress-reporting process for grantees to reflect its 
most recent fiscal year 2013 funding opportunity, which will require 
HCCNs to report on their participating health centers attainment of 
meaningful use objectives as well as emerging needs and challenges 
encountered related to meaningful use.38  HRSA also collects similar 
meaningful use information from all health centers reporting to HRSAs  
Uniform Data System, its annual reporting tool for health centers.  Moving 
forward, HRSA should use this information to determine what types of 
assistancetechnical or financialhealth centers need to implement the 
capabilities related to sharing data.   
Ensure that HCCN grantees provide information on the 
financial sustainability of EHR systems at health centers  
The goal of HRSAs HIT-related grants is to serve the interests of health 
centers through HCCNs. We found that most grantee progress reports did 
not contain information on financial sustainability of EHR systems at 
health centers. As part of its ongoing monitoring of HCCN grantees, 
HRSA could gather information from HCCNs about the financial impact 
of implementation on participating health centers, including information 
on health centers current and anticipated challenges.  HRSA could also 
gather information from HCCNs about the specific actions they are taking 
to assist health centers efforts to financially sustain their EHR systems.   
Examine the feasibility of collecting information directly from 
health centers regarding the financial sustainability of their 
EHR systems  
Grantee progress reports are submitted only by current HCCN grantees.  
To determine whether health centers are able to financially sustain HRSAs  
investment in EHR systems over the long term, HRSA should consider the 
feasibility of gathering information directly from all health centers 
regarding the financial sustainability of their EHR systems.  Specifically,  
HRSA could do so by using existing toolssuch as its Uniform Data 
Systemfor monitoring health centers.  This would enable HRSA to 
annually collect sustainability information on all of its health centers, as 
opposed to only those currently participating in HRSA HIT-related grant 
projects. 
 
38  77  Fed.  Reg. 72870 (Dec. 6, 2012). 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   18   
 
This information would be helpful for HRSA as it plans for future funding 
opportunities. HRSA could also use this information to provide guidance 
and technical assistance to health centers to help them financially sustain 
their EHR systems.  For example, HRSA could use the information to 
identify promising practices and to reach out to health centers that report 
facing financial sustainability challenges. 
   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   19   
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
HRSA concurred with all of our recommendations. 
To address our recommendation that HRSA use data to understand 
progress towards meaningful use objectives and to provide guidance and 
technical assistance to health centers, HRSA stated it will continue to 
analyze information from health center UDS reports and HCCN progress 
reports on meaningful use attainment.  HRSA will use this information to 
inform future HIT technical assistance and training webinars. 
To address our recommendation that HRSA ensure HCCN grantees 
provide information on the financial sustainability of EHR systems at 
health centers, HRSA commented that it has increased its focus on 
sustaining EHR systems as part of its recent funding opportunity 
announcements.   
To address our final recommendation that HRSA examine the feasibility of  
collecting information directly from health centers regarding the financial 
sustainability of their EHR systems, HRSA stated that it will update its 
Site Visit Protocol to ensure a portion of the visit focuses on financial 
sustainability, addresses health center concerns, and provides targeted 
guidance. HRSA commented that it uses information submitted by health 
centers in the annual UDS reports and required independent audits to 
monitor financial sustainability of health centers. 
For a full text of HRSAs comments, see Appendix D. 
 
 
 
   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   20   
 
APPENDIX A 
Stage 1 Meaningful Use Objectives  
Core objectives  
Objective   Type of Capability   Measure  
More than 30 percent of all 
1.   Use computerized  unique patients with at least  one 
provider order  entry  Capturing data   medication in their medication 
(CPOE)    list have at least one medication  
order entered using CPOE.  
The eligible professional (EP) 
2.   Implement drug   enables drug-drug and  
Capturing data  
interaction checks   drug-allergy check  functionality 
for the entire reporting  period.  
More than 80 percent of all 
unique patients have at least  one 
3.   Maintain problem   entry (or an indication that no  
Capturing data   
lists   problems are known for the 
patient) recorded as structured  
data.  
More than 40 percent of all 
permissible prescriptions  written  
4.   Use electronic  
Sharing data   by the EP are transmitted  
prescribing  
electronically using certified  
EHR systems. 
More than 80 percent of all 
unique patients have at least  one 
5.   Maintain active  entry (or an indication that the 
Capturing data  
medication lists  patient is not currently 
prescribed any  medication) 
recorded as structured data. 
More than 80 percent of all 
unique patients have at least  one 
6.   Maintain medication   entry (or an indication that the 
Capturing data  
allergy lists  patient  has no known  medication 
allergies) recorded as structured 
data.  
More than 50 percent of all 
7.   Record  unique patients have 
Capturing data  
demographics   demographics recorded  as  
structured data. 
More than 50 percent of all 
unique patients age 2 and over  
8.   Record  vital signs   Capturing data   have height, weight, and blood  
pressure recorded as structured  
data.  
More than 50 percent of all 
9.   Record smoking  unique patients 13 years old or  
Capturing data  
status  older have smoking status  
recorded as structured data. 
continued on next page  
   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   21   
 
    Stage 1 Meaningful Use Objectives 
Core objectives (continued)  
Objective   Type of Capability   Measure  
10.  Report clinical  The EP successfully reports 
quality measures  Sharing data   ambulatory CQMs selected by CMS 
(CQMs)   in the manner specified by CMS. 
11.  Implement 
The EP implements one clinical 
clinical decision  Capturing data  
decision support rule. 
support rule 
12.  Provide  More than 50  percent of all patients 
electronic copy  who request  electronic copies of their 
Sharing data  
of health   health information are provided  with  
information   copies within  3 business  days.  
For more than  50 percent of all office 
13.  Provide clinical 
Sharing data   visits, clinical summaries are provided  
summaries  
to  patients  within 3 business days.  
14.  Exchange  The EP  performs at least one test of 
clinical  the certified EHR systems capacity to 
Sharing data  
information   electronically exchange key clinical 
electronically  information.  
The EP conducts or reviews a security 
risk analysis in accordance with the 
requirements under 
15.  Protect 
45 CFR  164.308(a)(1).  The EP  
electronic health  Ensuring privacy 
implements security updates as 
information   
necessary and corrects identified 
security deficiencies as part of the 
risk-management process. 
Menu objectives  
Objective   Type of Capability   Measure  
The EP enables the functionality to  
check drug formularies and has access 
1.   Implement drug  
Capturing data   to at least one internal or external 
formulary checks  
formulary for the entire EHR 
reporting period.  
More than 40 percent of all clinical 
lab test results  ordered by the  EP 
2.   Incorporate  during the EHR reporting period  
clinical lab test  Capturing data   whose results are either in a 
results  positive/negative  or numerical format 
are incorporated in certified EHR 
system as structured  data. 
The EP  generates at least one report 
3.   Generate patient  
Capturing data   listing patients with a specific 
lists  
condition. 
More than 20  percent of all patients 65  
years old or older or  5 years  old or  
4.   Send patient  
Sharing data   younger  were sent an appropriate 
reminders  
reminder during the EHR reporting 
period.  
continued on next page 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   22   
 
Stage 1 Meaningful Use Objectives 
 
Menu objectives (continued) 
Objective  Type of Capability   Measure  
At least 10 percent of all unique 
patients are provided timely  
(available to the patient  within   
4 business  days  of being updated 
5.   Provide patients with 
Sharing data   in the certified EHR system) 
electronic access 
electronic access to their health 
information subject to the EPs 
discretion to withhold certain 
information.  
More than 10 percent of all 
6.   Provide patient-
unique patients are provided  
specific education  Sharing data  
patient-specific education 
resources 
resources. 
The EP  performs  medication 
7.   Perform medication 
Capturing data   reconciliation  for more than  
reconciliation 
50 percent of transitions of care. 
The EP  who transitions or refers a 
patient to another setting of care 
8.   Provide transition of  or  provider of care provides a  
Sharing data  
care summaries  summary of care record for  
more than 50 percent of 
transitions of care and referrals. 
The EP  performs at least one test 
of the certified  EHR systems 
9.   Submit electronic 
capacity to submit electronic data 
data to immunization   Sharing data  
to immunization  registries and a 
registries  
followup submission if the test is 
successful. 
The EP  performs at least one test 
of the certified  EHR systems 
capacity to provide electronic 
syndromic surveillance data to  
10.  Submit electronic  public health agencies and a  
syndromic  Sharing data   followup submission if the test is 
surveillance data  successful (unless none of the  
public health agencies to which 
an EP submits such information 
has the capacity to receive the  
information electronically). 
Source: OIG analysis of Federal regulations (42 CFR  495.6), 2013. 
   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   23   
 
APPENDIX B 
Stage 1 Meaningful Use Objectives and the Percentage of 
Health Centers With the Capability for Each Objective  
Percentage 
Type of  Core or Menu 
Objective   with Capability  
Capability  Objective  
(N=233)  
Record vital  signs    96%   Capturing  data   Core  
Maintain active medication lists  95%  Capturing data  Core 
Maintain medication allergy lists  95%  Capturing data  Core 
Record demographics   95%   Capturing  data   Core  
Implement drug interaction checks   93%   Capturing data   Core  
Maintain problem lists   94%  Capturing data  Core 
Record smoking status   93%   Capturing data   Core  
Use computerized provider order entry   92%   Capturing data   Core  
Use electronic prescribing   91%   Sharing data   Core  
Generate  patient lists    90%   Capturing data   Menu  
Provide patient-specific education 
87%  Sharing data   Menu  
resources 
Incorporate clinical lab test  results   85%   Capturing data   Menu  
Provide clinical summaries   82%  Sharing  data  Core 
Perform medication  reconciliation  78%  Capturing data  Menu  
Implement clinical decision support  rule   77%   Capturing data   Core  
Provide transition of care summaries  74%  Sharing  data  Menu  
Implement drug  formulary checks   73%   Capturing data   Menu  
Ensuring 
Protect electronic health information  66%   Core 
privacy 
Send patient  reminders   67%   Sharing data   Menu  
Report clinical quality measures  60%  Sharing  data  Core 
Provide electronic copy of health 
58%  Sharing data   Core  
information  
  <50%      
Exchange clinical information 
37%  Sharing data   Core  
electronically 
Submit electronic data to immunization 
33%  Sharing data   Menu*  
registries  
Provide patients with electronic access  29%   Sharing data  Menu 
Submit electronic syndromic 
10%  Sharing data   Menu*  
surveillance data 
*One of the two public health menu objectives is necessary  to demonstrate Stage 1 meaningful use.  
Source:  OIG analysis of survey  responses and Federal regulations (42 CFR  495.6), 2013. 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   24   
 
APPENDIX C 
The Extent to Which Eligible Professionals (EP) at Health Centers Met the Stage 1 Meaningful Use Objectives 
Table C-1:  Percentage of Health Centers by the Extent to Which Their EPs Met the Stage 1 Meaningful Use Core 
Objectives for At Least 90 Days 
  Core Objectives  
Implement   Provide 
Use   Implement   Maintain   Report  Provide  Exchange  Protect  
Maintain   Use   Maintain   Record   Record   Record   clinical  electronic 
computerized   drug   active   clinical  clinical  clinical  electronic 
problem  electronic  medication   demo- vital   smoking  decision   copy of 
provider order  interaction   medication   quality   summ- information  health  
lists   prescribing  allergy lists   graphics  signs   status  support   health  
  entry   checks  lists   measures   aries   electronically*  information  
rule   information  
Percentage of Health Centers (N=233)**  
All EPs 
52%  60%   53%   47%  58%  54%   72%   61%   37%   28%   37%  25%   21%  37%   35%  
met  
Most EPs 
28%  23%   31%   31%  30%  32%   18%   29%   41%   19%   24%  14%   24%   N/A   18%  
met  
Some EPs 
9%  8%   7%   9%  6%  7%   4%   4%   12%   11%   12%   10%   23%   N/A   8%  
met  
Few EPs  
3%  3%   3%   3%  2%  2%   1%   2%   3%   3%   4%  9%   14%   N/A   5%  
met  
No EPs 
5%  5%   4%   6%  3%  3%   3%   3%   5%   26%   12%   23%   15%   55%   23%  
met  
Dont 
1%  2%   3%   3%  2%  2%   2%   2%   2%   14%   11%   9%   3%  8%   12%  
know 
* Yes/no-only objective  that can be attested to at the health  center level versus the EP level. 
 
** Some column percentages do  not total 100 percent because of rounding and/or because health centers claimed an exclusion to an objective.  An exclusion may be  claimed if the meaningful use 

objective is not applicable to the  EP. 

Source: OIG analysis of survey  responses, 2012. 

 
   
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   25 
 
   
 
 
 
 
 
 
 
Table C-2:  Percentage of Health Centers by the Extent to Which Their EPs Met the Stage 1 Meaningful Use Menu 
Objectives for At Least 90 Days 
Menu Objectives 
Provide  Provide  Submit  Submit 
Implement  Provide 
Incorporate  Generate  Send  patients  patient- Perform  electronic  electronic 
  drug  clinical lab  patient  patient  with   specific  medication  transition of  data to  syndromic 
formulary  care  
test results  lists   reminders   electronic  education  reconciliation   immunization  surveillance 
checks   summaries 
access   resources  registries*  data* 
Percentage of Health Centers (N=233)**  
All EPs met  45%  61%   65%   16%   9%   31%  31%   21%  33%   10%  
Most EPs met  16%  15%   12%   18%  6%   27%   27%   26%   N/A   N/A  
Some EPs met   6%  7%   9%   19%  8%   21%   14%   17%   N/A   N/A  
Few EPs met  5%  2%   4%   13%  6%   7%   6%   10%   N/A   N/A  
No EPs met  17%  12%   7%   26%   67%   10%  14%   16%  58%   75%  
Dont know  9%  3%   3%   6%   4%   3%  7%   9%  8%   15%  
 
* Yes/no-only objectives that can be attested to  at the health center level versus the EP level.
  
** Some column percentages do  not total 100 because of rounding and/or because health centers claimed an exclusion to a objective.  An exclusion may  be claimed if the 

meaningful use objective is not applicable to the  EP. 

Source: OIG analysis of survey  responses, 2012. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)   26 
 
  APPENDIX D 
Agency Comments 
Health Resources and Services 
DEPARTMENT OF HEALTH &. HUMAN SERVICES  Administration 
Rockville MD 20857 
TO:  Deputy Inspector General 
Inspector General, HHS OIG 
FROM:  Administrator, Health Resources and Services Administration 
SUBJECT:  HRSA's comments on Progress In Electronic Health Record Imp/emenation 
through HRSA Grants to Health Center Controlled Networks, (OEI-09-11
00830) 
Thank you for the opportunity to review and provide comments on OIG's report. Attached 
please find HRSA's comments. 
If you have any questions, please contact Rebeca Sanchez-Barrett in HRSA's Office of Planning, 
Analysis and Evaluation at (301) 443-0324. 
Mary K. Wakefield, Ph.D., R.N. 
Attachments 
Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380)  27   
 
Agency Comments Continued 
 
   
Progress in EHR Implementation Through HRSA Grants to Health  Center Controlled Networks (OEI-09-11-00380)      28 
  
 
Agency Comments Continued 
 
   
Progress in EHR Implementation Through HRSA Grants to Health  Center Controlled Networks (OEI-09-11-00380)      29 
  
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry,  Deputy Regional Inspector General.  
China Tantameng served as the team leader for this study, and  
Tiffany Stanley served as the lead analyst.  Other Office of Evaluation and 
Inspections staff from the San Francisco regional office who conducted 
the study include Linda Min. Central office staff who provided support 
include Clarence Arnold, Heather Barton, Kevin Manley, Christine Moritz, 
and Sherri Weinstein.  
 
Progress in EHR Implementation Through HRSA Grants to Health  Center Controlled Networks (OEI-09-11-00380)      30   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs  and operations and providing all 
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.