Number 22 n April 30, 2010

Use of Electronic Medical Records by Ambulatory

Care Providers: United States, 2006

by Esther Hing, M.P.H.; Margaret J. Hall, Ph.D.; and Jill J. Ashman, Ph.D.

Division of Health Care Statistics

Abstract

Objectives—This report presents 2006 information on adoption of electronic

medical records (EMRs) in five ambulatory care settings. Use of EMR systems

within these settings is presented by selected provider characteristics.

Methods—Nationally representative estimates are from 2006 provider-based

surveys, including the National Ambulatory Medical Care Survey (NAMCS), the

National Hospital Ambulatory Medical Care Survey (NHAMCS), and the

National Survey of Ambulatory Surgery (NSAS).

Results—In 2006, 62.4 percent of hospital-based ambulatory surgery centers

(ASCs) reported using EMR systems, almost triple the percentage reported by

freestanding ASCs (22.3 percent). EMR use by hospital emergency departments

(EDs) was 46.2 percent, followed by hospital outpatient departments (OPDs)

(29.4 percent) and office-based physicians (29.2 percent). Based on items

collected in the 2006 NAMCS, NHAMCS, and NSAS, 18.6 percent of hospitalbased ASCs, 14.0 percent of hospital EDs, and 10.5 percent of office-based

physicians had systems with similar features of a basic system, but only

1.7 percent of hospital EDs and 3.1 percent of office-based physicians had

systems with similar features of a fully functional system. Fully functional

systems are a subset of basic systems. Physicians in practices with 11 or more

physicians were most likely to use EMRs (46.5 percent), whereas physicians in

solo practices were least likely to use EMRs (24.0 percent). Use of EMR systems

was higher among physicians located in the West (42.3 percent) than in other

regions of the country (23.5 percent to 29.3 percent). EMR use did not vary by

neighborhood poverty level for any of the ambulatory providers studied. From

2001 through 2005, EMR systems in hospital EDs increased by 47.2 percent. Use

of EMRs among office-based physicians increased by 60.4 percent from 2001

through 2006. If those without EMR systems in 2006 with definite plans to

install a system actually do so, 85.4 percent of hospital-based ASCs, 72.2 percent

of EDs, 62.6 percent of OPDs, 47.3 percent of freestanding ASCs, and

47.0 percent of physicians will be using EMR systems in 2009.

Keywords: physicians c emergency departments c outpatient departments c

ambulatory surgery centers

Introduction

Policymakers’ interest in the

progress of health information

technology (HIT) adoption by health

care providers has increased since 2004,

when the federal government set the

goal that most Americans would have

electronic health records (EHRs) by

2014 (1). The American Recovery and

Reinvestment Act (ARRA) of 2009 may

accelerate the pace of EHR adoption by

health care providers, because it

includes funding to promote the

adoption and use of EHR systems (2).

Starting in 2011, physicians who can

demonstrate meaningful use of

interoperable systems may receive extra

Medicare payments over 5 years (2).

This report presents data on the use

of electronic medical record (EMR)

systems in 2006 from five types of

ambulatory health care providers:

office-based physicians, hospital

outpatient departments (OPDs), hospital

emergency departments (EDs), and for

the first time, hospital-based and

freestanding ambulatory surgery centers

(ASCs). The report includes data on the

number and characteristics of providers

that used any EMR (all or partially

electronic) system and the features

contained within those systems. The

National Ambulatory Medical Care

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
Page 2 National Health Statistics Reports n Number 22 n April 30, 2010

Survey (NAMCS) and the National

Hospital Ambulatory Medical Care

Survey (NHAMCS) have collected data

on EMR systems since 2001 (3–6). The

report includes trend data on EMR

systems in these settings. The report

also provides estimates of providers

with plans to adopt EMR systems within

the next 3 years.

EMR system features were also

examined. This report presents two

concepts of EMR systems defined by

experts: basic and fully functional

electronic systems (7,8). Based on items

collected in the 2006 NAMCS,

NHAMCS, and the National Survey of

Ambulatory Surgery (NSAS), systems

defined as basic include computerized

systems with the following features:

patient demographic information,

clinical notes, orders for prescriptions,

and viewing laboratory and imaging

results. Fully functional systems, a

subset of basic systems, include all

features of basic systems plus the

following additional features: medical

history and follow-up, orders for tests,

prescription and test orders sent

electronically, warnings of drug

interactions or contraindications,

highlighting out-of-range test levels,

electronic images returned, and

reminders for guidelinebased interventions (Table A). These

definitions provide information on the

extent to which current EMR systems

have the features of systems that the

federal government hopes will be

adopted by most health care providers

by 2014 (1,2). Although more recent

estimates of physician use of basic and

fully functional systems have been

published (9), 2006 is the only year

these systems can be compared across

the five types of ambulatory care

providers.

Methods

Data sources

Data were gathered in 2006 from

office-based physicians (NAMCS),

hospital emergency and outpatient

departments (NHAMCS), and

ambulatory surgery centers (NSAS). The

surveys are probability surveys

representative of the 50 states and the

District of Columbia. NAMCS and

NHAMCS include multistage designs of

geographic primary sampling units

(PSUs), samples of providers within

PSUs, and samples of visits within

provider-reporting units (10–12). In

contrast, NSAS includes a national

probability sample of hospital-based and

freestanding ASCs and samples of visits

within ASCs (13). More information

about the sample design and content of

these surveys is available (10–13). The

U.S. Census Bureau collected the data

for all three surveys. Data processing

and medical coding for the surveys were

performed by the Constella Group Inc.,

Durham, North Carolina (now SRA

International).

NAMCS, NHAMCS, and NSAS

include questions about practice or

facility characteristics, including EMR

availability and use. In 2006, the

(unweighted) response rate was

61.9 percent for NAMCS physicians,

87.4 percent for EDs and 85.6 percent

for OPDs in NHAMCS, and

75.1 percent for hospital-based and

74.1 percent for freestanding ASCs in

NSAS. The corresponding weighted

response rates were 63.6 percent for

NAMCS physicians, 89.1 percent for

EDs and 85.2 percent for OPDs in

NHAMCS, and 85.9 percent for

hospital-based and 81.5 percent for

freestanding ASCs in NSAS. Annual

national estimates presented in this

report are based on responses from

1,311 physicians, 362 hospital EDs, 223

Table A. Survey items defining minimally functional, basic, and fully functional electronic medical record systems

Minimally Fully

functional Basic functional

Features of electronic medical record systems system1 system2 system2

Patient demographics ................................ X X 
 

Physician clinical notes ............................... X X X 
 

Medical history and follow-up notes ...................... X
 

Guideline-based interventions or screening test reminders ........ X
 

Test results (lab or imaging) ............................ X 
 

Lab results ..................................... X X 
 

Out-of-range values highlighted ....................... X
 

Imaging results ................................... X X
 

Electronic images returned .......................... X
 

Computerized orders for prescriptions ...................... X X X 
 

Drug interaction or contraindication warning provided ........... X
 

Prescription sent to pharmacy electronically ................. X
 

Computerized orders for tests . . . . . . . . . . . . . . . . . . . . . . . . . . . X X 
 

Test orders sent electronically.......................... X
 

Public health reporting................................ 
 

Notifiable diseases sent electronically ..................... 
 

1

Based on definition presented in Blumenthal D, DesRoches C, Donelan K, et al. Health Information Technology in the United States: The Information Base for Progress. Robert Wood Johnson

Foundation. 2006. 2

Based on items collected in the 2006 National Ambulatory Medical Care Survey (NAMCS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and National Survey of Ambulatory

Surgery (NSAS) and features identified in Health Information Technology in the United States: Where We Stand, 2008. Robert Wood Johnson Foundation. 2008. Fully functional sytems are a

subset of basic systems.

NOTES: Survey items are from 2006 NAMCS, NHAMCS, and NSAS. Features were asked of respondents reporting use of electronic medical records. EMR feature, ‘‘Patient problem list’’ is not

available in the 2006 surveys.
National Health Statistics Reports n Number 22 n April 30, 2010 Page 3

hospital OPDs, and 143 hospital-based

and 295 freestanding ASCs.

This report includes several

measures of EMR use or availability

based on 2006 induction interview

responses by NAMCS, NHAMCS, and

NSAS respondents. This report covers

use of any EMR system, future plans to

install an EMR system within the next 3

years, and availability of EMR systems

that include the features of basic and

fully functional EHR systems among

ambulatory care providers (7,8,14,15).

Any EMR use for NAMCS,

NHAMCS, and NSAS is based on the

question, ‘‘Does your [practice/ED/OPD/

this facility/hospital] use electronic

medical records (not including billing

records)?’’

In this report, a ‘‘yes’’ response to

either all electronic or partially

electronic (part paper and part

electronic) medical records by

ambulatory providers is described as

using any EMR system (see Figures

I–III in the ‘‘Technical Notes’’ section

for the actual questions used in the 2006

surveys). Note that in 2001, 2002, and

2005, the NHAMCS EMR question

asked about EMR availability rather

than use: ‘‘Does your [ED/OPD] have

electronic medical records (EMR)?’’ In

2006, the NHAMCS question was

changed (‘‘Does your [ED/OPD] use

electronic medical records?’’) in order to

match the question asked of NAMCS

physicians since 2001. The change in

NHAMCS question wording affects

2006 EMR estimates for EDs and OPDs

when compared with those from earlier

years, because potentially more EDs and

OPDs could have EMRs available, but

not actually use them (see Figure IV in

the ‘‘Technical Notes’’ section for 2005

NHAMCS questions).

Respondents in 2006 who reported

using any EMR system were asked

additional questions about whether their

EMR systems included specific features,

such as computerized orders for tests or

prescriptions (see the ‘‘Technical Notes’’

section for the actual questions used in

the 2006 and 2005 surveys). Using

similar definitions developed by HIT

experts, these detailed questions make it

possible to categorize EMR systems as

basic or fully functional (7,8,14,15).

Basic and fully functional systems are

subsets of EMR systems; fully

functional systems are a subset of basic

systems. The categories of basic and

fully functional have superseded the

category of minimally functional

(Table A). Minimally functional systems

are not discussed in this report, but for

comparison with previous reports,

estimates of these systems for EDs,

OPDs, and ASCs are included in the

table in the ‘‘Technical Notes’’ section.

This report presents estimates of any

EMR use, as well as use of basic and

fully functional systems.

This report discusses basic and fully

functional EMR systems in terms of

availability to providers in 2006 rather

than actual use by these providers.

Based on the question wording, ‘‘Does

your [practice’s/ED’s/OPD’s/facility’s/

hospital’s] electronic medical record

include’’ specific features, it is not

known whether the features defining

basic and fully functional systems were

actually used, although they were

available. Estimates of basic and fully

functional systems also assume that any

feature reported as available but turned

off was a feature of the facility’s EMR

system, because a feature was there and

available for use. In 2006, one or more

features were turned off for 2.3 percent

of physicians, 9.4 percent of hospital

EDs, 5.2 percent of hospital OPDs, and

12.1 percent of freestanding and

9.7 percent of hospital-based ASCs.

Data on EMR system use were

missing for fewer than 2 percent of each

provider type (1.8 percent of physicians,

0.7 percent of hospital EDs, 1.2 percent

of hospital OPDs, 1.3 percent of

freestanding ASCs, 1.0 percent of

hospital-based ASCs). For this analysis,

providers that had missing data on EMR

use were assumed to not have an EMR

system. If missing cases were randomly

distributed, this approach might

underestimate the incidence of EMR

adoption.

The report also presents projections

of EMR availability in 3 years, based on

questions about future plans to upgrade

or install a new EMR system within 3

years. For this projection, estimates of

future use include current EMR users

and providers without an EMR system

in 2006 who reported having plans to

install a new EMR system.

In this report, EMR measures are

examined by characteristics of providers.

Physician practice size was defined for

the location where the physician saw

most patients during the sampled week

of practice. For the 0.9 percent of

physicians missing this information,

practice size was imputed by randomly

assigning a value from a physician with

similar characteristics (employment

setting, physician specialty, and

geographic region). Neighborhood

poverty level, defined as the percentage

of the county population with income

below the poverty level, was obtained

from the Area Resource File (16) and

matched to the counties of providers

participating in NSAS, NAMCS, and

NHAMCS. The county percentages were

then divided into tertiles. The first tertile

included counties with the lowest level

of poverty, that is, those in which under

10 percent of the population was below

the poverty level. The second tertile

included those with 10 percent–

13.4 percent of the population below the

poverty level and the last one included

those counties having more than

13.4 percent of the population below the

poverty level.

For NAMCS, NHAMCS, and

NSAS, the sampling weights used to

derive national estimates (10–13) and to

calculate the corresponding sampling

errors (17) take into account the

complex sampling design. Statements of

differences in estimates are based on

statistical tests (e.g., chi-square tests of

independence, students-t, or weighted

linear regression) with significance at

the p < 0.05 level for NAMCS and

NHAMCS and the p < 0.01 level for

NSAS.

In this report, estimates that do not

meet standards of reliability or precision

are flagged. The relative standard error

(RSE) of an estimate is obtained by

dividing the standard error by the

estimate itself. The result is then

expressed as a percentage of the

estimate. Estimates based on 30 or more

cases include an asterisk if the RSE of

the estimate exceeds 30 percent.

Estimates are not presented if they are

based on fewer than 20 cases in the
70 

60 

Hospital 

outpatient 

departments 

22.3 

29.2 29.4 

46.2 

62.4 

50

Percent of providers

40 

30 

20 

10 

0 

Freestanding 

ambulatory 

surgery centers 

Physicians’ 

offices 

Hospital 

emergency 

departments 

Hospital-based 

ambulatory 

surgery centers 

Setting 

NOTE: Any EMR is a medical record system that is either all or partially electronic (excluding systems solely for billing). 

Basic and fully functional systems are subsets of EMR systems.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, 


and National Survey of Ambulatory Surgery.
 

0 

4 

8 

16 

20 

Basic system Fully functional system 

Freestanding Physicians’ Hospital Hospital-based 

ambulatory offices emergency ambulatory 

surgery centers departments surgery centers 

Hospital 

outpatient 

departments 

*3.2 

10.5 

*6.0 

14.0 

18.6 

*0.5 

3.1 

*0.8 

1.7 

*3.9 

Setting 

* Figure does not meet standards of reliability or precision. 


NOTES: Basic and fully functional systems are subsets of EMR systems. The components of a basic and fully 


functional system are listed in Table A.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, 


and National Survey of Ambulatory Surgery.
 Percent of providers 12 

Page 4 National Health Statistics Reports n Number 22 n April 30, 2010

sample data; only an asterisk (*) appears

in the tables. Estimates based on 20–29

regardless of the RSE level.

cases are presented with asterisks,

Results

EMR use and availability of

basic and fully functional

systems

In 2006, there were an estimated

300,700 office-based physicians, 2,700

hospital OPDs, 4,700 hospital EDs, and

3,700 hospital-based ASCs and 3,800

freestanding ASCs in the United States

(Table 1). The percentage of hospitalbased ASCs that reported using any

EMR system (62.4 percent) was almost

triple the percentage reported by

freestanding ASCs (22.3 percent)

(Figure 1). Hospital EDs had the second

largest proportion of EMR use

(46.2 percent), followed by hospital

OPDs (29.4 percent) and office-based

physicians (29.2 percent).

Figure 2 presents percentages of

ambulatory care providers who have

EMR systems that meet the criteria of

basic systems (patient demographic

Figure 1. Percentage of ambulatory providers using any EMR system, by setting:

United States, 2006

Figure 2. Percentage of ambulatory providers with basic and fully functional electronic

medical record (EMR) systems, by setting: United States, 2006

information, clinical notes, orders for

prescriptions, and viewing laboratory

and imaging results). In 2006,

18.6 percent of hospital-based ASCs,

14.0 percent of EDs, and 10.5 percent of

office-based physicians used EMR

systems that could be classified as basic

systems (Figure 2). These percentages

did not differ significantly across

settings. Although percentages of

freestanding ASCs and hospital OPDs

that used systems meeting the criteria of

basic systems are presented in Figure 2,

both sets of estimates were unreliable

due to high sampling variability.

Systems defined as fully functional,

a subset of basic systems, include all the

features of basic systems plus the

following additional features: medical

history and follow-up, orders for tests,

prescription and test orders sent

electronically, warnings of drug

interactions or contraindications,

highlighting out-of-range test levels,

electronic images returned, and
80 

90 

Office-based physicians Hospital emergency departments 

Percent of physicians

Percent of emergency departments 

0 

10 

20 

30 

40 

50 

60 

70 

80 

24.0 

28.0 30.0 30.9 

46.5 

0 

10 

20 

30 

40 

50 

27.7 

59.2 

68.8 

Solo 2 3–5 6–10 11 or more Under 100 100–199 200 or more


Number of physicians Number of hospital beds
 

80 

26.9 

77.8 

33.1 

44.7 

26.1 

74.3 

Nonprofit Government Proprietary
 

Hospital ownership
 

Percent of emergency departments 70 

60 

50 

40 

30 

20 

10 

70 

60 

50 

40 

30 

20 

10 

0 

Percent of physicians 

0 

Physician or Health maintenance Other ownership 

physician group organization 

Practice ownership 

NOTES: Any EMR is a medical record system that is either all or partially electronic (excluding systems solely for billing). Office-based physicians include nonfederal, office-based 


physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.
 

National Health Statistics Reports n Number 22 n April 30, 2010 Page 5

Figure 3. Percentage of office-based physicians and hospital emergency departments using any EMR system, by size and ownership:

United States, 2006

reminders for guideline-based

interventions (Table A). In 2006, only a

small percentage of ambulatory care

providers had an EMR system with

features of a fully functional system;

3.1 percent of office-based physicians

and 1.7 percent of hospital EDs had

such a system (Figure 2). National

estimates of hospital OPDs and ASCs

(both hospital-based and freestanding)

using EMR systems meeting these

criteria were unreliable due to small cell

sizes.

Variation in use of EMR

systems

Consistent with findings from

previous studies, the larger the practice

size, the more likely physicians were to

use any EMR (4–6). Physicians in

practices with 11 or more physicians

were most likely to use EMRs

(46.5 percent), whereas physicians in

solo practices were least likely to use

EMRs (24.0 percent) (Figure 3).

Similarly, EMR use by EDs in large

hospitals with 200 or more beds

(68.8 percent) was more likely than in

small hospitals with fewer than 100
Page 6 National Health Statistics Reports n Number 22 n April 30, 2010

beds (27.7 percent). However, in

hospital-based ASCs and OPDs, EMR

use did not vary by hospital size

(Table 2). Comparable information on

the size of freestanding ASCs was not

collected, so it was not possible to

examine EMR use by size for these

providers.

EMR use varied by ownership

status. Among office-based physicians,

EMR use was highest in HMO-owned

practices (Figure 3). EMR use in

hospital EDs varied by hospital

ownership. EDs in government-owned

hospitals were less likely to use EMR

systems than EDs in both proprietary

and nonprofit hospitals. Use of EMR

systems was unrelated to hospital

ownership among hospital OPDs and

hospital-based ASCs. Information on

ownership of freestanding ASCs was not

collected.

EMR use also varied by geographic

region. Use of EMR systems was higher

among physicians located in the West

(42.3 percent) than in other regions of

the country (23.5 percent–29.3 percent)

(Table 2). Office-based physicians and

EDs located in metropolitan statistical

areas (MSAs) had significantly more

EMR usage. The relationship between

MSA status and EMR usage appears to

follow a similar pattern for hospital

OPDs and ASCs (freestanding and

hospital-based), but differences were not

statistically significant because estimates

were either unreliable or had high

sampling variability. EMR use did not

vary by neighborhood poverty level for

any of the ambulatory providers studied.

Variation in use of basic

systems

Table 3 presents characteristics of

office-based physicians, hospital EDs,

and hospital-based ASCs whose EMR

systems had features meeting the criteria

of a basic system. The observed

associations between office-based

physicians’ characteristics and their use

of basic systems were the same as the

previously discussed associations found

between physicians’ characteristics and

any EMR use. That is, their use of basic

systems was positively associated with

practice size, highest among HMOowned practices compared with other

practices, and higher among physicians

located in MSAs than physicians

practicing outside of MSAs. Physicians

in multi-specialty practices were more

likely than physicians in solo or

single-specialty practices to use basic

systems, and physicians in the West

were more likely to use basic systems

than physicians in the Northeast. EDs in

proprietary hospitals were more likely to

use basic EMR systems than EDs in

nonprofit hospitals. The high variability

of this measure among the remaining

provider settings limited other

comparisons.

Variation in use of fully

functional systems

Nationally, 3.1 percent of officebased physicians and 1.7 percent of

hospital EDs used EMR systems with

the features of fully functional systems,

while the percentages of hospital OPDs

and ASCs (both hospital-based and

freestanding) using such systems were

unreliable (Figure 2). Due to small cell

sizes of physicians and EDs using fully

functional systems, few physician

estimates by practice characteristics and

few ED estimates by hospital

characteristics were reliable. In 2006,

7.3 percent of physicians in the West

used systems that met the criteria of

fully functional systems, but estimates

of physicians using such systems in the

remaining geographic regions were

unreliable (data not shown).

Features of EMR systems

Table 4 presents EMR system

features by type of ambulatory provider.

Among these settings, computerized

prescription order entry was more likely

to be available in EMR systems used by

hospital-based ASCs (23.4 percent), EDs

(22.6 percent), and physicians’ offices

(19.5 percent), compared with OPDs

(9.9 percent). Computerized test order

entry was more likely to be available in

hospital-based ASCs (43.6 percent) and

hospital EDs (37.9 percent) than in

OPDs (15.3 percent) or physicians’

offices (16.2 percent). Ability to view

test results (lab or imaging) was also

more likely in hospital-based ASCs

(57.9 percent) and hospital EDs

(42.5 percent) than in the remaining

ambulatory settings. A number of

estimates for EMR system features in

freestanding ASCs were unreliable and

could not be compared with those of the

other settings.

Similar to other studies, the data

show that many EMR systems lack

important features such as warnings for

drug interactions or contraindications

and sending prescriptions to the

pharmacy electronically (18,19). Overall,

19.5 percent of office-based physicians

reported that their EMR systems

included computerized prescription order

entry, but only 14.6 percent reported that

their EMR systems provided warnings

for drug interactions or

contraindications, and 11.9 percent

reported that their systems sent

prescriptions to the pharmacy

electronically (Table 4). No ASC

reported that its EMR system provided

warnings for drug interactions or

contraindications. Because few

freestanding ambulatory surgery centers

had EMR systems, many of the

estimates of EMR system features from

this setting were unreliable.

EMR trends

NHAMCS has monitored

availability of EMR systems in hospital

EDs and OPDS from 2001 through 2005

using the question, ‘‘Does your

[ED/OPD] have electronic medical

records (EMR)?’’ From 2001 to 2005,

availability of EMRs in hospital EDs

increased by 47.2 percent, from

30.5 percent to 44.9 percent, while

availability of EMRs among hospital

OPDs was unchanged. Figure 4 does not

include 2006 data for EDs and OPDs

because the 2006 question on ‘‘use’’ of

EMR systems is not comparable (see the

‘‘Methods’’ section for details).

In contrast, NAMCS has monitored

use of EMR systems in physicians’

offices since 2001 using the question,

‘‘Does your [practice] use electronic
50 

18.2 

29.3 

33.1 

30.8 

30.5 

17.3 

34.8 

44.9 

17.3 

20.8 

23.9 

29.2 

Emergency 

departments 

Outpatient departments 

Physicians’ offices 

40 

Percent of providers

30 

20 

10 

0 

2001 2002 2003 2004 2005 2006 

Year 

NOTES: EMR is electronic medical record. Any EMR is a medical record system that is either all or partially electronic 

(excluding systems solely for billing). Dashed lines for 2003–2004 indicate the items were not collected. Basic and fully 

functional systems are subsets of EMR systems; fully functional systems are a subset of basic systems. Physician, 

2006 emergency department (ED), and 2006 outpatient department (OPD) estimates are based on the question 

indicating the provider “uses” EMR. Prior to 2006, ED and OPD estimates are based on the question indicating the 

provider “has” EMR. 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care 

Survey. 

100 

87.7 

85.4 

80.1 

47.0 

59.5 

29.2 

22.3 

47.3 

63.6 62.6 

29.4 

71.2 

46.2 

72.2 

62.4 

Maximum projected use by 2009
 

Minimum projected use by 2009
 

Use in 2006

Percent of providers 

80 

60 

40 

20 

0 

Physicians’ Freestanding Hospital Hospital Hospital-based 

offices ambulatory outpatient emergency ambulatory 

surgery centers departments departments surgery centers 

Setting 

NOTES: Estimates to the right of the bars show use in 2006 and minimum and maximum projections of use in 2009 if providers without EMR systems in 2006 actually install EMRs. 


Minimum estimate of use by 2009 includes 2006 EMR users plus respondents with “Yes” responses to plans for installing new EMR systems by 2009. Maximum estimate of use by 2009 


includes 2006 EMR users plus respondents with “Yes” and “Maybe” responses to plans for installing new EMR systems by 2009. Any EMR is a medical record system that is either all or 


partially electronic (excluding systems solely for billing). 


SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
 

National Health Statistics Reports n Number 22 n April 30, 2010 Page 7

system within the next 3 years. Among

hospital-based ASCs without EMR

systems, 61.1 percent reported that they

planned to install a new system within

the next 3 years (Table 5). This did not

differ significantly from hospital EDs

(48.4 percent) and OPDs (47.1 percent)

without EMR systems. Office-based

physicians (25.3 percent) and

freestanding ASCs (32.3 percent)

without EMR systems were less likely

Figure 4. Percentage of ambulatory care providers that have or use any EMR system, by

setting: United States, 2001–2006

medical records?’’ (3). From 2001 to EMR system plans for the

2006, EMR use among office-based future

physicians increased by 60.4 percent;

Ambulatory care providers were from 18.2 percent to 29.2 percent

(Figure 4). asked about plans to install an EMR

than other ambulatory providers to

report plans to install them within the

next 3 years.

Figure 5 presents percentages of

providers who may have EMR systems

in 2009 based on their reported future

plans. These calculations were obtained

by adding the number of facilities with

plans to install systems within 3 years to

the number of existing 2006 EMR users.

If all providers without EMR systems in

2006 who reported that they have plans

to install an EMR system by 2009

actually do install a system, then

47.0 percent of office-based physicians,

47.3 percent of freestanding ASCs,

62.6 percent of hospital OPDs,

72.2 percent of hospital EDs, and

85.4 percent of hospital-based ASCs will

Figure 5. Projected 2009 percentage of ambulatory providers using any EMR system, by setting: United States
Page 8	 National Health Statistics Reports n Number 22 n April 30, 2010

be using EMR systems (minimum

estimates). In addition, if providers who

reported that they might install new

EMR systems by 2009 actually do so,

then 87.7 percent of hospital-based

ASCs, 80.1 percent of EDs, 71.2 percent

of OPDs, 63.6 percent of freestanding

ASCs, and 59.5 percent of office-based

physicians will be using EMR systems

by 2009 (maximum estimates).

Discussion

This report is the first to examine

use of EMR systems across five

ambulatory care settings: physicians’

offices, hospital OPDs and EDs, and

hospital-based and freestanding ASCs.

In 2006, higher percentages of hospitalbased ASCs (62.4 percent) and hospital

EDs (46.2 percent) reported using any

EMR system compared with officebased physicians’ offices (29.2 percent),

hospital OPDs (29.4 percent), and

freestanding ASCs (22.3 percent).

Features of EMR systems varied

considerably by provider setting

(Table 4). Consistent with previous

research, this study found much higher

EMR system use in hospital EDs than

other parts of the hospital (20,21).

From 2001 through 2005,

availability of EMR systems in hospital

EDs increased by 47.2 percent, but was

stable in OPDs. Starting in 2006,

NHAMCS began collecting information

on use of EMR systems in hospital EDs

and OPDs. Since 2001, use of EMR

systems among office-based physicians

increased by 60.4 percent.

Estimates presented in this report of

2006 EMR use by hospital-based ASCs

provide a first look at adoption of

EMRs by these providers, and may also

serve as a baseline against which data

on future use can be compared.

Hospital-based ASCs were added to the

2009 NHAMCS, and freestanding ASCs

were added to the 2010 NHAMCS (22).

This report also presents minimum

and maximum calculations of future

EMR use in 2009, based on providers’

plans in 2006 to definitely (‘‘Yes’’) or

possibly (‘‘Maybe’’) install EMR

systems within the next 3 years. If these

providers’ plans come to fruition, at a

maximum, use of any EMR system will

have increased to 59.5 percent of

physicians, 63.6 percent of freestanding

ASCs, 71.2 percent of hospital OPDs,

80.1 percent of hospital EDs, and

87.7 percent of hospital-based ASCs by

the end of 2009.

This report presents NAMCS,

NHAMCS, and NSAS estimates of

EMR systems with similar criteria to

basic and fully functional systems (7,8).

In 2006, only 18.6 percent of hospitalbased ASCs, 14.0 percent of EDs, and

10.5 percent of office-based physicians

used EMR systems that met the criteria

of basic systems. The subset of

providers with basic systems that also

met the criteria of fully functional

systems was much smaller; 3.1 percent

of office-based physicians and

1.7 percent of hospital EDs used

systems with these criteria. Estimates of

fully functional systems used by hospital

OPDs, hospital-based ASCs, and

freestanding ASCs were all unreliable;

their characteristics were not examined

due to small sample sizes.

The 2006 estimates of hospitalbased ASCs (18.6 percent) and hospital

EDs (14.0 percent) with basic system

features are somewhat higher than a

previous estimate that 9.1 percent of

acute care hospitals in 2007 had a basic

system in at least one clinical unit (23).

The survey estimates vary primarily

because the definition of a basic system

in the other study (demographic

characteristics of patients, physician

notes, nursing assessments, problem

lists, medication lists, discharge

summaries, laboratory reports, radiologic

reports, diagnostic-test results, and

computerized provider-order entry for

medications) is more stringent than the

criteria for basic systems used in this

study (23). That study’s definition of a

comprehensive system (all of the

features listed above and advance

directives; radiologic images; diagnostictest images; consultant reports;

computerized provider-order entry for

laboratory tests, radiologic tests,

consultant requests, and nursing orders;

and decision support for clinical

guidelines, clinical reminders, drugallergy alerts, drug-drug interaction

alerts, and drug-dose support) includes

more features than included in this

study’s definition of a fully functional

system (a subset of basic systems). In

spite of this, the 2006 estimate of

hospital EDs with systems meeting the

criteria of a fully functional system

(1.7 percent) is similar to the other

study’s estimate (1.5 percent) of

hospitals with a comprehensive system

present in all clinical units (23).

Based on estimates of providers

using EMR systems that meet the

criteria of basic systems, it appears

likely that widespread adoption of EMR

systems with these features by

ambulatory care providers will take

many years. However, the financial

incentives for ‘‘meaningful use’’ of

‘‘interoperable’’ EHR systems included

in the 2009 ARRA may accelerate the

growth of electronic systems. The

definition of ‘‘meaningful’’ is not yet

finalized, but may include a number of

the EMR features examined here.

Interoperable systems are those that

communicate or exchange health

information across provider settings

(24). Although it is presently believed

that few systems now include

interoperability (14), all EHR systems

certified by the Certification

Commission for Healthcare Information

Technology (CCHIT) are interoperable

(2). Starting in 2009, NAMCS and

NHAMCS began to collect information

on whether EMR/EHR systems in use

are certified by CCHIT. Adoption of

interoperable systems is expected to

improve coordination of patient care

services across health care settings, as

well as improve overall health care

quality and efficiency (14,15,25). Given

the sizable public investment to expand

EHR use, tracking EMR/EHR adoption

by health care providers will continue to

be an important research topic.

References

1.	 White House. Executive Order:

Incentives for the use of health

information technology and

establishing the position of the

National Health Information

Technology Coordinator. Available

from: http://nodis3.gsfc.nasa.gov/

displayEO.cfm?id=EO_13335_. 2004.

2.	 Blumenthal D. Stimulating the

adoption of health information
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technology. N Engl J Med
 

360(15):1477–9. 2009.
 

3.	 Burt CW, Hing E. Use of

computerized clinical support

systems in medical settings: United

States, 2001–03. Advance data from

vital and health statistics; no 353.

Hyattsville, Maryland: National

Center for Health Statistics. 2005.

4.	 Burt CW, Sisk JE. Which physicians

and practices are using electronic

medical records? Health Aff

24(5):1334–43, 2005.

5.	 Burt CW, Hing E, Woodwell DA.

Electronic medical record use by

office-based physicians: United

States, 2005. Available from:

http://www.cdc.gov/nchs/data/hestat/

electronic/electronic.htm [Accessed

08/29/06]. 2006.

6.	 Hing E, Burt CW, Woodwell DA.

Electronic medical record use by

office-based physicians and their

practices: United States, 2006.

Advance data from vital and health

statistics; no 393. Hyattsville,

Maryland: National Center for Health

Statistics. 2007.

7.	 Robert Wood Johnson Foundation.

Health information technology in the

United States: Where we stand, 2008.

Available from: http://www.rwjf.org/

files/research/062508.hit.exsummary.

pdf. 2008.

8.	 DesRoches CM, Campbell EG, Rao

SR, Donelan K, Ferris TG, Jha A, et

al. Electronic health records in

ambulatory care–A national survey of

physicians. N Eng J Med 359(1):50–

60. 2008.

9.	 Hsiao CJ, Beatty PC, Hing E.

Electronic Medical Record/Electronic

Health Record Use by Office-based

Physicians: United States, 2008 and

Preliminary 2009. National Center

for Health Statistics. Health E-Stat.

Available from: http://www.cdc.gov/

nchs/data/hestat/emr_ehr/emr_ehr.

htm. 2009.

10. Cherry DK, Hing E, Woodwell DA,

Rechtsteiner EA. National

Ambulatory Medical Care Survey:

2006 summary. National health

statistics reports; no 3. Hyattsville,

MD: National Center for Health

Statistics. 2008.

11. Hing E, Hall MJ, Xu J. National

Hospital Ambulatory Medical Care

Survey: 2006 outpatient department

summary. National health statistics

reports; no 4. Hyattsville, MD:

National Center for Health Statistics.

2008.

12. Pitts SR, Niska RW, Xu J, Burt CW.

National Hospital Ambulatory

Medical Care Survey: 2006

emergency department summary.

National health statistics reports; no

7. Hyattsville, MD: National Center

for Health Statistics. 2008.

13. Cullen KA, Hall MJ, Golosinskiy A.

Ambulatory surgery in the United

States, 2006. National health

statistics reports; no 11. Revised.

Hyattsville, MD: National Center for

Health Statistics. 2009.

14. Blumenthal D, DesRoches C,

Donelan K, et al. Health information

technology in the United States: The

information base for progress. Robert

Wood Johnson Foundation. Available

from: http://www.rwjf.org/files/

publications/other/EHRReport

0609.pdf. 2006.

15. Jha AK, Ferris TG, Donelan K,

DesRoches C, Shields A, Rosenbaum

S, Blumenthal D. How common are

electronic health records in the

United States? A summary of the

evidence. Health Aff 25(6):w496–

507. 2006.

16. HRSA. User documentation for the

area resource file (ARF): February

2005 release.

17. Research Triangle Institute.

SUDAAN user’s manual, release 9.0.

Research Triangle Park, NC:

Research Triangle Institute. 2004.

18. Simon SR, Kaushal R, Cleary P,

Jenter CA, Volk LA, Orav EJ, et al.

Physicians and electronic health

records: A statewide survey. Arch

Intern Med 167(5):507–12. 2007.

19. Grossman JM, Gerland A, Reed MC,

Fahlman C. Physicians’ experiences

using commercial e-prescribing

systems. Health Aff 26(3):w393–404.

2007.

20. American Hospital Association.

Forward momentum: Hospital use of

information technology. Washington,

DC: American Hospital Association.

Available from: http://www.aha.org/

aha/content/2005/pdf/FINALNon

EmbITSurvey105.pdf. 2005.

21. Grossman JM, Bodenheimer TS,

McKenzie K. Hospital-physician

portals: The role of competition in

driving clinical data exchange.

Health Aff 25(6):1629–36. 2006.

22. Hing E, McCaig LF, Hall MJ. New

information for policymakers:

National Ambulatory Medical Care

Survey and National Hospital

Ambulatory Medical Care Survey. In:

2009 proceedings of the section on

survey research methods, American

Statistical Association. Alexandria,

VA: American Statistical Association.

23. Jha AK, DesRoches CM, Campbell

EG, Donelan K, Rao SR, Ferris TG,

et al. Use of electronic health records

in U.S. hospitals. N Engl J Med

360(16):1628–38. 2009.

24. The National Alliance for Health

Information Technology. Report to

the Office of the National

Coordinator for Health Information

Technology on defining key health

information technology terms.

Available from: http://healthit.

hhs.gov/portal/server.pt/gateway/

PTARGS_0_10741_848133_0_0_18/

10_2_hit_terms.pdf [Accessed

02/26/10]. 2008.

25. Chaudhry B, Wang J, Wu S,

Maglione M, Mojica W, Roth E, et

al. Systematic review: Impact of

health information technology on

quality, efficiency, and costs of

medical care. Ann Intern Med

144(10):742–52. 2006.
Page 10 National Health Statistics Reports n Number 22 n April 30, 2010

Table 1. Number of ambulatory providers and percent distribution of ambulatory providers, by selected provider characteristics

according to ambulatory setting: United States, 2006

Office- Hospital Hospital Hospital-based Freestanding

based outpatient emergency ambulatory ambulatory

Selected provider characteristics physicians1 departments departments surgery centers surgery centers

Number of providers (N) ....................... 300,700 2,700 4,700 3,700 3,800

Percent distribution

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0

Provider size

Physician practice2

Solo .................................. 34.1 . . . . . . . . . . . .

2 physicians ............................. 12.3 . . . . . . . . . . . .

3–5 physicians ............................ 29.8 . . . . . . . . . . . .

6–10 physicians ........................... 15.3 . . . . . . . . . . . .

11 or more physicians ....................... 8.4 . . . . . . . . . . . .

Hospital size

Under 100 beds ........................... . . . 37.5 48.4 41.5 . . .

100–199 beds ............................ . . . 17.4 19.9 30.2 . . .

200 or more beds .......................... . . . 36.0 30.2 28.2 . . .

Unknown number of beds ..................... . . . *9.1 * – . . .

Type

Physician practice

Solo and single-specialty practice ................ 78.6 . . . . . . . . . . . .

Multi-specialty practice ....................... 20.9 . . . . . . . . . . . .

Unknown type of practice ..................... 0.5 . . . . . . . . . . . .

Hospital

Affiliated with medical school ................... . . . 39.5 30.5 19.0 . . .

Not affiliated with medical school................. . . . 60.5 69.5 81.0 . . .

Ownership

Ownership of physician practice

Physician or physician group ................... 81.6 . . . . . . . . . . . .

Health maintenance organization (HMO) ............ 2.7 . . . . . . . . . . . .

Other ownership of physician practice ............. 15.7 . . . . . . . . . . . .

Ownership of hospital

Nonprofit ............................... . . . 75.2 73.1 71.9 . . .

Government ............................. . . . 12.2 13.6 16.0 . . .

Proprietary .............................. . . . 12.6 13.3 12.1 . . .

Percentiles of county population below poverty level

Under 10% ............................... 26.9 19.9 33.2 26.9 33.0

10%–13.4% ............................... 33.9 32.8 35.6 36.3 35.2

More than 13.4%............................ 39.2 47.3 31.1 36.8 31.8

Geographic region

Northeast ................................ 20.6 20.8 13.9 13.1 9.6

Midwest ................................. 20.0 28.0 28.7 33.1 19.4

South ................................... 36.5 36.0 38.9 35.6 39.0

West ................................... 22.8 15.2 18.5 18.2 32.1

Metropolitan status

Metropolitan statistical area ..................... 89.0 63.9 66.4 65.2 89.7

Not a metropolitan statistical area ................. 11.0 36.1 33.6 34.8 *10.3

. . . Category not applicable.

* Figure does not meet standards of reliability or precision.

– Quantity zero.
 1

Includes nonfederal, office-based physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.
 2

Practice size reported for location where most patients were seen. Includes imputed data for 0.9% missing practice size; see the ‘‘Methods’’ section for details.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
 
National Health Statistics Reports n Number 22 n April 30, 2010 Page 11

Table 2. Percentage of ambulatory providers using any EMR system with corresponding standard errors, by selected practice and

hospital characteristics according to ambulatory setting: United States, 2006

Uses any EMR1

Hospital Hospital Hospital-based Freestanding

Office-based outpatient emergency ambulatory surgery ambulatory

physicians2 departments departments centers surgery centers

Selected provider characteristic (standard error) (standard error) (standard error) (standard error) (standard error)

All providers ............................... 29.2 (1.7) 29.4 (4.7) 46.2 (4.3) 62.4 (5.5) 22.3 (4.6)

Provider size

Physician practice3,4

Solo .................................. 24.0 (2.8) . . . . . . . . . . . .

2 physicians ............................. 28.0 (4.3) . . . . . . . . . . . .

3–5 physicians ............................ 30.0 (3.0) . . . . . . . . . . . .

6–10 physicians ........................... 30.9 (4.2) . . . . . . . . . . . .

11 or more physicians ....................... 46.5 (6.4) . . . . . . . . . . . .

Hospital size5

Under 100 beds ........................... . . . *19.5 (8.8) 27.7 (6.3) 67.5 (9.2) . . .

100–199 beds ............................ . . . *31.0 (9.4) 59.2 (7.8) 54.9 (10.2) . . .

200 or more beds .......................... . . . 44.6 (7.4) 68.8 (3.6) 62.8 (7.6) . . .

Unknown number of beds ..................... . . . * (. . .) * (. . .) . . . . . .

Type

Physician practice

Solo and single-specialty practice ................ 28.0 (2.0) . . . . . . . . . . . .

Multi-specialty practice ....................... 34.5 (3.5) . . . . . . . . . . . .

Unknown type of practice ..................... - . . . . . . . . . . . .

Hospital

Affiliated with medical school ................... . . . 34.4 (7.1) 54.7 (5.2) 70.5 (7.9) . . .

Not affiliated with medical school................. . . . 26.2 (6.4) 42.4 (5.7) 60.5 (6.5) . . .

Ownership

Ownership of physician practice6

Physician or physician group ................... 26.9 (1.7) . . . . . . . . . . . .

Health maintenance organization (HMO) ............ 77.8 (8.4) . . . . . . . . . . . .

Other ownership of physician practice ............. 33.1 (4.7) . . . . . . . . . . . .

Ownership of hospital7

Nonprofit ............................... . . . 28.8 (5.3) 44.7 (5.0) 57.0 (6.5) . . .

Government ............................. . . . *40.9 (14.1) 26.1 (7.6) 83.8 (14.3) . . .

Proprietary .............................. . . . *22.4 (9.4) 74.3 (6.1) 66.0 (13.8) . . .

Percentiles of county population below poverty level

Under 10% ............................... 29.2 (3.6) 37.4 (9.3) 49.5 (9.6) 52.2 (11.3) *24.2 (8.9)

10%–13.4% ............................... 29.8 (2.8) 35.2 (9.4) 48.3 (8.9) 59.2 (9.0) 31.5 (8.7)

More than 13.4%............................ 28.9 (3.4) 22.1 (5.9) 43.0 (5.5) *72.9 (9.0) *10.1 (3.1)

Geographic region6

Northeast ................................ 23.5 (2.7) 34.5 (8.9) 59.0 (4.7) *46.7 (17.6) *28.5 (14.2)

Midwest ................................. 29.3 (3.2) *40.0 (12.2) 38.0 (9.2) 49.0 (9.9) *24.4 (9.6)

South ................................... 24.2 (3.0) 16.0 (4.8) 39.1 (6.3) 77.0 (7.3) *20.3 (7.5)

West ................................... 42.3 (4.3) 35.1 (10.0) 64.0 (11.1) 69.4 (12.8) 21.6 (8.3)

Metropolitan status6,7

Metropolitan statistical area ..................... 30.3 (1.9) 36.0 (5.4) 57.0 (4.0) 63.9 (6.2) 23.7 (5.0)

Not a metropolitan statistical area ................. 20.2 (3.0) *17.9 (7.9) 24.8 (7.6) 59.4 (10.8) *9.9 (5.4)

. . . Category not applicable.

* Figure does not meet standards of reliability or precision.
 

–Quantity zero.
 1

EMR is electronic medical record. Any EMR system refers to providers reporting that their medical records are either all or partially electronic; excludes electronic billing records. Basic and fully
 

functional systems are subsets of EMR systems in use; fully functional systems are a subset of basic systems.
 2

Includes nonfederal, office-based physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.
 3

Practice size reported for location where most patients were seen. Includes imputed data for 0.9% missing practice size; see the ‘‘Methods’’ section for details.
 4

Trend by physician practice size is statistically significant.
 5

Trend for hospital emergency departments by hospital size is statistically significant.
 6

Significant relationship between use of any EMR system and physican practice characteristic.
 7

Significant relationship between use of any EMR system by emergency department and hospital characteristic.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
Page 12 National Health Statistics Reports n Number 22 n April 30, 2010

Table 3. Percentage of ambulatory providers with basic electronic record system with corresponding standard errors, by selected

physician practice and hospital characteristics according to ambulatory setting: United States, 2006

Has basic system1

Hospital Hospital-based

Office-based emergency ambulatory

physicians2 departments surgery centers

Selected provider characteristics (standard error) (standard error) (standard error)

All providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5 (1.1) 14.0 (2.0) 18.6 (4.6) 
 

Provider size

Physician practice3,4

Solo .................................. 5.3 (1.4) ... ...

2 physicians ............................. 8.0 (2.2) ... ...

3–5 physicians ............................ 13.1 (2.2) ... ...

6–10 physicians ........................... 12.9 (3.5) ... ...

11 or more physicians ....................... 22.2 (4.9) ... ...

Hospital size5

Under 100 beds ........................... ... 4.5 (1.3) *21.4 (8.5)

100–199 beds ............................ ... 25.5 (6.3) *6.6 (4.4)

200 or more beds .......................... ... 21.7 (3.3) 27.2 (8.2)

Unknown number of beds ..................... ... * (. . .) –

Type

Physician practice6

........................... 
 

Solo and single-specialty practice ................ 8.3 (1.2) ... ... 
 

Multi-specialty practice ....................... 19.3 (3.0) ... ... 
 

Unknown type of practice ..................... – ... ... 
 

Hospital

Affiliated with medical school ................... ... 19.6 (3.5) *24.2 (8.4)

Not affiliated with medical school................. ... 11.5 (2.5) *17.3 (5.3)

Ownership

Ownership of physician practice6

Physician or physician group ................... 8.1 (0.9) ... ...

Health maintenance organization (HMO) ............ 56.0 (10.7) . . . . . .

Other ownership of physician practice ............. 15.5 (3.8) ... ...

Ownership of hospital

Nonprofit ............................... ... 15.5 (2.6) 17.8 (4.9)

Government ............................. ... *3.5 (1.6) *16.7 (14.3)

Proprietary .............................. ... 16.3 (4.4) *25.4 (14.3)

Percentiles of county population below poverty level

Under 10% ............................... 11.8 (2.1) 21.8 (5.6) *11.2 (8.2)

10%–13.4% ............................... 9.9 (1.9) *9.1 (3.5) *10.5 (6.0)

More than 13.4% . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2 (2.5) 12.6 (3.0) 31.9 (8.8)

Geographic region6
 

Northeast ................................ 5.4 (1.4) 20.4 (4.7) *7.8 (6.8) 
 

Midwest ................................. 12.4 (2.5) *7.4 (2.5) *9.2 (4.9) 
 

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2 (1.9) 12.5 (3.0) *29.1 (8.9) 
 

West ................................... 17.2 (3.0) *22.5 (7.1) *22.8 (13.3) 
 

Metropolitan status

Metropolitan statistical area ..................... 11.4 (1.2) 20.1 (2.6) 18.5 (5.2)

Not a metropolitan statistical area ................. *3.3 (1.8) *1.9 (1.7) *18.6 (8.8)

. . . Category not applicable.

* Figure does not meet standards of reliability or precision.

– Quantity zero. 1

Includes patient demographics, clinical notes, computerized order entry for prescriptions, viewing laboratory results, and viewing imaging results. Basic systems are a subset of electronic medical
 

record systems in use.
 2

Includes nonfederal, office-based physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.
 3

Practice size reported for location where most patients were seen. Includes imputed data for 0.9% missing practice size; see the ‘‘Methods’’ section for details.
 4

Trend by physician practice size is statistically significant.
 5

Trend for hospital emergency departments by hospital size is statistically significant.
 6

Significant relationship between physician practice characteristic and having a basic system.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
National Health Statistics Reports n Number 22 n April 30, 2010 Page 13

Table 4. Percentage of ambulatory providers with any EMR, by selected features of their systems: United States, 2006

Hospital Hospital Hospital-based Freestanding

Office-based outpatient emergency ambulatory ambulatory

physicians1 departments department surgery centers surgery centers

Electronic medical record system feature (standard error) (standard error) (standard error) (standard error) (standard error)

Patient demographic information ....................... 26.2 (1.6) 26.9 (4.7) 43.9 (4.3) 56.5 (5.5) 20.4 (4.2) 
 

Clinical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.9 (1.5) 16.3 (3.7) 29.7 (3.4) 39.5 (5.7) 14.4 (3.8) 
 

Medical history and follow-up notes .................... 19.2 (1.4) 14.3 (3.5) 22.9 (2.5) 33.6 (5.6) 13.6 (3.8) 
 

Guideline-based interventions or screening test reminders ...... 13.1 (1.2) *7.7 (2.9) 14.7 (2.1) . . . . . . 
 

Viewing test results (lab or imaging) ..................... 20.4 (1.5) 27.5 (4.5) 42.5 (4.2) 57.9 (5.6) 14.5 (4.2) 
 

Lab results ................................... 19.3 (1.5) 27.2 (4.5) 41.3 (4.2) 57.9 (5.6) *10.7 (3.8) 
 

Out-of-range values highlighted ..................... 13.3 (1.2) 21.1 (4.2) 30.6 (3.7) 47.3 (5.7) *7.8 (3.1) 
 

Imaging results ................................ 15.0 (1.3) 23.1 (4.5) 33.9 (3.4) 54.8 (5.6) *11.2 (3.7) 
 

Electronic images returned ........................ 7.4 (0.8) 7.4 (1.6) 19.4 (2.5) 28.9 (5.1) *4.1 (2.5) 
 

Computerized orders for prescriptions.................... 19.5 (1.4) 9.9 (2.5) 22.6 (2.6) 23.4 (4.9) 5.3 (1.9) 
 

Drug interaction or contraindication warning provided ......... 14.6 (1.3) *7.2 (2.2) 15.2 (2.2) – – 
 

Prescription sent to pharmacy electronically............... 11.9 (1.3) *3.9 (1.7) 7.0 (1.4) *12.8 (3.9) *1.1 (0.5) 
 

Computerized orders for tests. . . . . . . . . . . . . . . . . . . . . . . . . 16.2 (1.4) 15.3 (3.4) 37.9 (3.9) 43.6 (5.7) *6.1 (2.5) 
 

Test orders sent electronically ....................... 9.5 (1.1) 9.4 (2.2) 27.8 (2.8) 31.9 (5.4) *1.1 (0.6) 
 

Public health reporting ............................. 6.6 (0.8) *3.6 (1.7) 11.8 (2.3) ... ... 
 

Notifiable diseases sent electronically .................. 3.5 (0.6) *0.5 (0.2) 4.7 (0.9) . . . . . . 
 

* Figure does not meet standards of reliability or precision.
 

. . . Category not applicable.
 

– Quantity zero.
 1

Includes nonfederal, office-based physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.
 

NOTE: Features are included even if they are turned off.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
 
Page 14 National Health Statistics Reports n Number 22 n April 30, 2010

Table 5. Number of ambulatory providers without electronic medical record (EMR) systems and percent distribution, by whether they

plan to install EMR systems within 3 years, with corresponding standard errors, according to ambulatory setting: United States, 2006

Hospital Hospital Hospital-based Freestanding

Number of providers without EMR systems and Office-based outpatient emergency ambulatory ambulatory

percent with and without plans to install physicians1 departments departments surgery centers surgery centers

an EMR system within 3 years (standard error) (standard error) (standard error) (standard error) (standard error)

Number of providers without EMR systems............ 212,700 (8,200) 1,900 (200) 2,500 (300) 1,400 (200) 3,000 (300)

Percent distribution of providers................... 100.0 100.0 100.0 100.0 100.0

Yes, plan to install EMR system ................. 25.3 (2.0) 47.1 (6.6) 48.4 (5.4) 61.1 (9.1) 32.3 (5.7)

May install EMR system ...................... 17.7 (1.7) 12.2 (3.1) 14.8 (3.7) *6.2 (3.8) 20.9 (4.7)

No, do not plan to install EMR system ............. 44.1 (2.2) 18.6 (4.4) 20.4 (4.7) 1.9 (1.7) 26.4 (4.7)

Unknown ............................... 12.9 (1.4) 22.1 (4.6) 16.4 (3.8) 30.8 (8.7) 20.4 (5.4)

1

Includes nonfederal, office-based physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.

NOTE: Providers without EMR systems are those reporting not using an EMR. Respondents missing information on EMR use were excluded. Data on EMR system use were missing for fewer

than 2 percent of each provider type (1.8 percent of physicians, 0.7 percent of hospital EDs, 1.2 percent of hospital OPDs, 1.3 percent of freestanding ASCs, and 1.0 percent of hospital-based

ASCs). EMR systems are all or partially electronic systems, and exclude electronic billing records.

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
National Health Statistics Reports n Number 22 n April 30, 2010 Page 15

Technical Notes

Table. Percentage of ambulatory providers with minimally functional systems with corresponding standard errors, by selected physician

practice and hospital characteristics according to ambulatory setting: United States, 2006

Has minimally functional system1

Hospital Hospital Hospital-based Freestanding

Office-based outpatient emergency ambulatory ambulatory

physicians2 departments departments surgery centers surgery centers

Selected provider characteristics (standard error) (standard error) (standard error) (standard error) (standard error)

All providers ............................... 12.4 (1.3) 6.7 (2.0) 15.7 (2.3) 18.9 (4.6) *3.2 (1.7)

Provider size

Physician practice3

Solo .................................. 7.1 (1.7) . . . . . . . . . . . .

2 physicians ............................. 9.7 (2.6) . . . . . . . . . . . .

3–5 physicians ............................ 13.4 (2.1) . . . . . . . . . . . .

6–10 physicians ........................... 16.6 (3.6) . . . . . . . . . . . .

11 or more physicians ....................... 26.6 (5.3) . . . . . . . . . . . .

Hospital size

Under 100 beds ........................... . . . *0.6 (0.6) *5.7 (1.8) 21.4 (8.5) . . .

100–199 beds ............................ . . . 8.8 (4.1) *24.7 (7.5) 6.6 (4.4) . . .

200 or more beds .......................... . . . *13.8 (4.8) 26.0 (3.7) 28.4 (8.2) . . .

Unknown number of beds ..................... . . . – * (. . .) – . . .

Type

Physician practice

Solo and single-specialty practice ................ 10.4 (1.4) . . . . . . . . . . . .

Multi-specialty practice ....................... 20.5 (3.3) . . . . . . . . . . . .

Unknown type of practice ..................... – . . . . . . . . . . . .

Hospital ................................

Affiliated with medical school ................... . . . 7.9 (2.7) 22.1 (3.9) 24.2 (8.4) . . .

Not affiliated with medical school................. . . . 6.0 (2.9) 13.1 (2.8) 17.7 (5.3) . . .

Ownership

Ownership of physician practice

Physician or physician group ................... 9.9 (1.1) . . . . . . . . . . . .

Health maintenance organization (HMO) ............ 60.4 (10.3) . . . . . . . . . . . .

Other ownership of physician practice ............. *20.1 (12.2) . . . . . . . . . . . .

Ownership of hospital

Nonprofit ............................... . . . 7.1 (2.6) 16.6 (2.8) 18.3 (4.9) . . .

Government ............................. . . . *5.2 (3.3) *4.6 (2.0) 16.7 (14.3) . . .

Proprietary .............................. . . . *6.0 (3.9) 22.5 (5.6) 25.4 (14.3) . . .

Percentiles of population below poverty level

Under 10% ............................... 13.6 (2.4) 11.3 (5.1) 18.2 (4.0) 12.4 (8.2) 0.2 (0.2)

10%–13.4% ............................... 12.1 (2.3) 5.4 (4.4) 16.0 (4.4) 10.5 (6.0) 5.1 (4.4)

More than 13.4%............................ 11.9 (2.5) 5.7 (2.1) 13.1 (3.0) 31.9 (8.8) 4.3 (2.1)

Geographic region

Northeast ................................ 7.6 (1.6) *6.1 (3.3) 20.5 (4.7) 89.8 (7.4) 16.4 (14.3)

Midwest ................................. 14.1 (2.7) *2.0 (1.7) *8.9 (2.9) 9.2 (4.9) 1.1 (0.9)

South ................................... 8.7 (1.9) *5.2 (2.6) 16.0 (3.6) 29.1 (8.9) 2.4 (1.3)

West ................................... 21.1 (3.5) *15.8 (9.5) *22.3 (7.6) 22.8 (13.3) 1.6 (1.2)

Metropolitan status

Metropolitan statistical area ..................... 13.0 (1.3) *9.6 (3.0) 22.8 (3.0) 19.0 (5.3) 3.6 (1.9)

Not a metropolitan statistical area ................. *7.7 (2.5) – *1.9 (1.7) 18.6 (8.8) –

* Figure does not meet standards of reliability or precision.
 

. . . Category not applicable.
 

– Quantity zero.
 1

Minimally functional sytems are subsets of electronic medical record systems in use. Minimally functional sytems include computerized prescription order entry, computerized test order entry, test
 

results (lab or imaging), and clinical notes.
 2

Includes nonfederal, office-based physicians who see patients in an office setting. Excludes radiologists, anesthesiologists, and pathologists.
 3

Practice size reported for location where most patients were seen. Includes imputed data for 0.9% missing practice size; see the ‘‘Methods’’ section for details.
 

SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Survey of Ambulatory Surgery.
– 

Page 16 National Health Statistics Reports n Number 22 n April 30, 2010

Section II INDUCTION INTERVIEW – Continued 

Does your practice use electronic MEDICAL

RECORDS (not including billing records)? 

22a. 1 

2 

3 

4 

Yes, all electronic 

No 

Don’t know 

� 

� 

� 

SKIP to item 24 

Yes, part paper and part electronic 

b. Does your practice’s electronic medical

record system include – 

(1) Patient demographic information? . . . ............. 

Yes No Unknown Turned off 

1 2 3 4 

(2) Computerized orders for prescriptions? . . . . . . . . . . . . 

(a) Are there warnings of drug interactions or 

(b) Are prescriptions sent electronically 

to the pharmacy? 

If Yes, ask – 

 contraindications provided? 

1 2 3 4 

1 2 3 4 

1 2 3 4 

(3) Computerized orders for tests? . . . . . ............. 

If Yes, ask – Are orders sent electronically?

1 2 3 4 

1 2 3 4 

(4) Lab results? . . . . . . . . . ....................... 

If Yes, ask – Are out of range levels highlighted?

1 2 3 4 

1 2 3 4 

(5) Imaging results? . . . . . . . . . . . . . . . . . . . .......... 

If Yes, ask – Are electronic images returned?

1 2 3 4 

1 2 3 4 

(6) Clini l . . . . . . . ....................... 

(a) Do they include medical history and 

(b) Do they include reminders for 

and/or screening tests? 

If Yes, ask – 

ca notes? 

 follow-up notes? 

 guideline-based interventions 

1 2 3 4 

1 2 3 4 

1 2 3 4 

(7) 

If Yes, ask – Are notifiable diseases sent electronically?

Public health reporting? . . . . . . . . . . . ............. 1 2 3 4 

1 2 3 4 

23. Are there any of the above features of your system

that you do NOT use or have turned off? 

1 Yes – Please specify 

FR NOTE – Indicate in item 22b, last 

column, any component(s) turned off. 

No 

Unknown 

2 

3 

24. Are there plans for installing a new EMR system or

replacing the current system within the next 3

years? 

Yes 

No 

Maybe 

Unknown 

1 

2 

3 

4 

Figure I. Selected questions from the National Ambulatory Medical Care Survey, 2006
National Health Statistics Reports n Number 22 n April 30, 2010 Page 17

Section VI – MEDICAL RECORD INFORMATION 

Does this facility (hospital) use electronic

medical records (not including billing

records) for ambulatory (outpatient)

surgical care? 

27a. Yes, all electronic 

Yes, part paper and part electronic 

No 

Don’t know 

1 

2 

3 

4 

} 

} 

Ask item 27b 

Skip to item 27e on next page 

b. Does your facility’s (hospital’s) electronic

medical record system include — 

(1) Patient demographic information? ......... 

(2a) Computerized orders for prescriptions? .....

(b) Are warnings of drug interactions or

contraindications provided? ............... 

(c) Are prescriptions sent electronically to the

pharmacy? .............................. 

(3a) Computerized orders for tests? ............ 

(b) Are orders sent electronically? ............. 

(4a) Lab results? ............................. 

(b) Are out of range levels highlighted? ........ 

Imaging or radiology results? .............. 

Are electronic images returned? ........... 

(5a) 

Clinical notes? ........................... 

Do they include medical history and

follow-up notes? .......................... 

(6a) 

(b) 

(b) 

Yes No Unknown Turned 

off 

1 2 3 4 

1 –Ask (2b) 

and (2c) 

2 –Ask (3a) 3 –Ask (3a) 4 

1 2 3 4 

1 2 3 4 

1 –Ask (3b) 2 –Ask (4a) 3 –Ask (4a) 4 

1 2 3 4 

1 –Ask (4b) 2 –Ask (5a) 3 –Ask (5a) 4 

1 2 3 4 

1 –Ask (5b) 2 –Ask (6a) 3 –Ask (6a) 4 

1 2 3 4 

1 –Ask (6b) 2 –Ask (27c) 3 –Ask (27c) 4 

1 2 3 4 

c. Are there any of the above features of your

system that you do NOT use or have turned

off? 

1 Yes – Please specify 

No 

Unknown 

2 

3 

FR NOTE: Mark (X) in item 27b, last column, any 

component(s) turned off. 

d. Are there plans for upgrading your current

electronic medical record system within

the next 3 years? 

Yes 

No 

Maybe 

Unknown 

1 

2 

3 

4 } Ask item 28 

e. Are there plans for installing an electronic

medical record system within the next 3

years? 

Yes 

No 

Maybe 

Unknown 

1 

2 

3 

4 } END interview. 

Figure II. Selected questions from the National Survey of Ambulatory Surgery, 2006
Section III – EMERGENCY DEPARTMEN

Now I would like to ask you some

questions about your ED. 

T DESCRIPTION – Continued 

14a. Does your ED use electronic MEDICAL 1 

RECORDS (not including billing records)? 2 

Yes, all electronic 

Yes, part paper and part electronic 

3 No } SKIP to 1item 4d 

4 Unknown 

b. Does your ED’s electronic medical record Yes No Unknown Turned off

system include – 

(1) Patient demographic information? 1 2 3 4 

1 2 3 4 (2) Computerized orders for prescriptions? 

If Yes, ask – (a) Are there warnings of drug 

interactions or 

contraindications provided? 1 2 3 4

(b) Are prescriptions sent 

electronically to 

the pharmacy? 1 2 3 4

1 2 3 4 (3) Computerized orders for tests? 

If Yes, ask – Are orders sent electronically? 1 2 3 4

1 2 3 4 (4) Lab results? 

If Yes, ask – Are out of range levels 

highlighted? 1 2 3 4

1 2 3 4 (5) Imaging results? 

If Yes, ask – Are electronic images returned? 1 2 3 4

1 2 (6) Clinical notes? 3 4

If Yes, ask – (a) Do they include medical 

history and follow-up notes? 1 2 3 4 

(b) Do they include reminders 

for guideline-based 

interventions and/or 

screening tests? 1 2 3 4

1 2 3 4 (7) Public health reporting? 

If Yes, ask – Are notifiable diseases sent 

electronically? 1 2 3 4

c. Are there any of the above features of your 1 Yes – Please specify system that your ED does NOT use or has

turned off? 

FR NOTE – Indicate in item 14b, last column, any 

components turned off. 

2 No 

3 

d. Are there plans for installing a new EMR 1 

system or replacing the current system 2 within the next 3 years? 3 

Unknown 

Yes 

No 

Maybe 

4 Unknown 

Page 18 National Health Statistics Reports n Number 22 n April 30, 2010

Figure III. Selected questions from the National Hospital Ambulatory Medical Care Survey, 2006
 
Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued

Now I would like to ask you some

questions about your OPD. 

14n. Does your OPD use electronic MEDICAL 1 Yes, all electronic RECORDS (not including billing records)? 2 Yes, part paper and part electronic 

3 No, } SKIP to item 14q 4 Unknown 

o. Yes No Unknown Turned off Does your OPD’s electronic medical record

system include – 

(1) Patient demographic information? 1 2 3 4 

1 2 3 4 (2) Computerized orders for prescriptions? 

If Yes, ask – (a) Are there warnings of drug 

interactions or 

contraindications provided? 1 2 3 4 

(b) Are prescriptions sent 

electronically to 

the pharmacy? 1 2 3 4 

1 2 3 4 (3) Computerized orders for tests? 

If Yes, ask – Are orders sent electronically? 1 2 3 4

1 2 3 4 (4) Lab results? 

If Yes, ask – Are out of range levels 

highlighted? 1 2 3 4 

1 2 3 4 (5) Imaging results? 

If Yes, ask – Are electronic images returned? 1 2 3 4

1 2 3 4 (6) Clinical notes? 

If Yes, ask – (a) Do they include medical 

history and follow-up notes? 1 2 3 4

(b) Do they include reminders 

for guideline-based 

interventions and/or 

screening tests? 1 2 3 4 

1 2 3 4 (7) Public health reporting? 

If Yes, ask – Are notifiable diseases sent 

electronically? 1 2 3 3 

p. Are there any of the above features of your 1 Yes – Please specify system that your OPD does NOT use or has

turned off? 

FR NOTE – Indicate in item 14o, last column, any 

components turned off. 

2 No 

3 Unknown 

q. Are there plans for installing a new EMR 1 Yes 

system or replacing the current system 2 No within the next 3 years? 3 Maybe 

4 Unknown 

National Health Statistics Reports n Number 22 n April 30, 2010 Page 19
Page 20 National Health Statistics Reports n Number 22 n April 30, 2010

Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued 

Now I would like to ask you some

questions about your ED. 

14a. Does your ED have electronic patient

medical records? 1 

2 

3 

4 

Yes, all electronic 

Yes, part paper and part electronic 

No } SKIP to 14c Unknown 

b. Does your ED’s electronic medical record

system include – 

Y es No Unknown

(1) patient demographic information? 1 2 3 

(2) computerized orders for prescriptions? 1 2 3 

(3) computerized orders for tests? 1 2 3 

(4) test results? 1 2 3 

(5) nurses’ notes? 1 2 3 

(6) physicians’ notes? 1 2 3 

(7) reminders for guideline-based 

interventions and/or screening tests? 1 2 3 

(8) public health reporting? 1 2 3 

NOTES 

Figure IV. Selected questions from the National Hospital Ambulatory Medical Care Survey, 2005
 
National Health Statistics Reports n Number 22 n April 30, 2010 Page 21

Section IV – OUTPATIENT DEPARTMENT

14l. Does your OPD have electronic patient

medical records? 1 

2 

3 

4 

m. Does your OPD’s electronic medical record

system include – 

 DESCRIPTION – Continued 

Yes, all electronic

Yes, part paper and part electronic 

No } SKIP to Section V, DISPOSITION 

Unknown AND SUMMARY on page 18 

Yes No Unknown

(1) patient demographic information? 

(2) computerized orders for prescriptions? 

(3) computerized orders for tests? 

(4) test results? 

(5) nurses’ notes? 

(6) physicians’ notes? 

(7) reminders for guideline-based 

interventions and/or screening tests? 

(8) public health reporting? 

1 2 3 

1 2 3 

1 2 3 

1 2 3 

1 2 3 

1 2 3 

1 2 3 

1 2 3 

NOTES 
Page 24 National Health Statistics Reports n Number 22 n April 30, 2010

Suggested citation

Hing E, Hall MJ, Ashman JJ. Use of electronic

medical records by ambulatory care providers:

United States, 2006. National health statistics

reports; no 22. Hyattsville, MD: National

Center for Health Statistics. 2010.

Copyright information

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public domain and may be reproduced or

copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

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Jennifer H. Madans, Ph.D., Associate Director
 

for Science
 

Division of Health Care Statistics

Jane E. Sisk, Ph.D., Director

U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

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