Page 1 GAO-12-778R Electronic Health Records

United States Government Accountability Office

Washington, DC 20548

July 26, 2012

Congressional Committees

Subject: Electronic Health Records: Number and Characteristics of Providers 

Awarded Medicare Incentive Payments for 2011

Widespread use of health information technology, such as electronic health records 

(EHR), has the potential to improve the quality of care patients receive and reduce 

health care costs. However, studies have estimated that as of 2009, 78 percent of 

office-based physicians and 91 percent of hospitals had not adopted EHRs.1 Among 

other things, the Health Information Technology for Economic and Clinical Health 

(HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 

2009 (Recovery Act)2 provided funding for various activities intended to promote the 

adoption and meaningful use of certified EHR technology.3 The largest of these 

activities, in terms of potential federal expenditures, are the Medicare and Medicaid 

EHR programs.4

 

1

See C. J. Hsiao, E. Hing, T. C. Socey, and B. Cai, “Electronic Medical Record/Electronic Health 

Record Systems of Office-Based Physicians: United States, 2009 and Preliminary 2010 State 

Estimates,” National Center for Health Statistics Health E-stat (2010); and A. K. Jha, C. M. 

DesRoches, P. D. Kralovec, and M. S. Joshi, “A Progress Report on Electronic Health Records In 

U.S. Hospitals,” Health Affairs, no.10 (2010):1951-1957.

Starting in 2011, these programs have provided incentive payments 

for certain providers, including both hospitals and health care professionals such as 

physicians and dentists, that demonstrate meaningful use of certified EHR 

technology and meet other program requirements established by the Centers for 

Medicare & Medicaid Services (CMS). Beginning in 2015, the Medicare EHR 

2

The HITECH Act was enacted as title XIII of division A and title IV of division B of the Recovery Act. 

Pub. L. No. 111-5, div. A, tit. XIII, 123 Stat. 115, 226-279 and div. B, tit. IV, 123 Stat. 115, 467-496 

(2009). 

3

Congress defined “meaningful use” in this context to reflect that the user of health information 

technology demonstrates to the satisfaction of the Secretary of the Department of Health and Human 

Services (HHS) that the technology is certified and being used in a meaningful manner, that the 

technology is connected in a manner that provides for the electronic exchange of health information 

to improve the quality of health care, and that such information is submitted in a form and manner 

specified by the Secretary. See Pub. L. No. 111-5, § 4101(a) 123 Stat. 467-472. To be certified, EHR 

technology must meet certain criteria established by HHS’s Office of the National Coordinator for 

Health Information Technology that describe minimum related performance standards and 

implementation specifications. 

4

See Pub. L. No. 111-5, §§ 4101-4201, 123 Stat. 467-494. Medicare is a federal program financing 

health care for individuals aged 65 and older, certain disabled individuals, and individuals with endstage renal disease. In 2010, Medicare covered 47 million beneficiaries. Medicaid is a federal-state 

program financing health care for certain low-income individuals. In fiscal year 2009, Medicaid 

covered over 65 million beneficiaries.
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program is generally required to begin applying a payment adjustment—that is, a 

payment reduction—for Medicare providers that do not demonstrate meaningful use. 

The Congressional Budget Office estimated total spending for the Medicare and 

Medicaid EHR programs to be $30 billion from 2011 through 2019, of which 

spending for the Medicare EHR program accounts for more than half—$17.7 billion. 

This report focuses on the Medicare EHR program.

Provisions in the HITECH Act defined the types of hospitals and professionals that

may be eligible to receive Medicare EHR incentive payments.5 Eligible hospitals 

include acute care hospitals and critical access hospitals.6 Eligible professionals 

include doctors of medicine, dental medicine or surgery, optometry, osteopathy, and 

podiatric medicine, and chiropractors.7 During 2011, the first year of the program, 

2,802 hospitals and 141,649 professionals registered for the Medicare EHR 

program, which is a necessary first step to participate in the program.8 Hospitals can 

receive Medicare EHR incentive payments for up to 4 years, and professionals can 

receive such payments for up to 5 years.9 The incentive payment amounts are 

determined as follows:

• For acute care hospitals, the incentive payment amount for any given year is 

generally based on the hospital’s annual discharges and Medicare share, which 

is the percentage of the hospital’s inpatient bed days that were attributable to 

Medicare patients. Theoretically, $6,370,400 is the maximum possible Medicare 

EHR incentive payment for an acute care hospital for 2011. This assumes that all 

patients served were Medicare patients and that the hospital had at least 23,001 

discharges, which is the highest number of discharges CMS includes in the 

calculation of Medicare EHR incentive payments.

 

5

The HITECH Act created incentive programs for Medicare fee-for-service, Medicare Advantage, and 

Medicaid. Under the Medicare Advantage EHR program, Medicare Advantage Organizations 

(MAO)—private companies that provide Medicare health insurance coverage to beneficiaries for 

hospital, physician, and other services—receive incentive payments for certain affiliated professionals 

and hospitals that meet program requirements. Pub. L. No. 111-5, §§ 4101(c), 4102(c) 123 Stat. 473- 476, 484-486. CMS requires MAOs to receive payment through their affiliated hospitals, which we 

include as hospital payments in this report. MAOs directly receive Medicare EHR incentive payments 

for their affiliated professionals that are based on services provided to Medicare Advantage plan 

enrollees. In this report, we refer to the incentive programs for Medicare fee-for-service and Medicare 

Advantage collectively as the Medicare EHR program.

6

Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are 

paid under the inpatient prospective payment system in the 50 states and the District of Columbia, including those affiliated with a qualifying MAO. 

7

Professionals must practice in the 50 states, the District of Columbia, or a U.S. insular area to be 

eligible for the Medicare EHR program. 

8

For hospitals, see CMS, “Medicare and Medicaid EHR Incentive Program Payment and Registration 

Report, November 2011.” For professionals, see CMS, “Medicare and Medicaid EHR Incentive 

Program Payment and Registration Report, February 2012.” 

9

In order to maximize the total amount of Medicare EHR incentive payments that could be awarded, 

acute care hospitals must begin participating in the program by the 2013 program year, and critical 

access hospitals and professionals must begin participating by the 2012 program year.
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• For critical access hospitals, the incentive payment amount is generally based on 

the hospital’s Medicare share as well as reasonable costs incurred for the 

purchase of depreciable assets necessary to administer certified EHR 

technology, such as computers and associated hardware and software. CMS has 

not established a maximum incentive payment amount for these hospitals.

• For professionals, the amount of incentive payment in any given year is generally 

based on the professional’s (1) Medicare Part B charges or (2) revenue for 

services provided to Medicare Advantage plan enrollees of a qualifying Medicare 

Advantage Organization (MAO), subject to an annual limit.10 For most 

professionals, the amount of the incentive payment for 2011 could not exceed 

$18,000. For professionals who predominately furnish services in geographic 

areas designated as a health professional shortage area, the amount of the 

incentive payment for 2011 generally could not exceed $19,800.11

The HITECH Act requires us to report on, among other things, the impact of its 

provisions on adoption of EHRs by providers.12 In response to this requirement, in 

April 2012 we reported on CMS’s efforts to oversee the Medicare EHR program 

during its first year as well as challenges encountered by providers and strategies 

they used to participate in the program.13 We recommended that CMS take steps to 

enhance its processes to verify that providers met the requirements to receive 

incentive payments. On behalf of CMS, the Department of Health and Human 

Services agreed with most of our recommendations.

Concerns have been raised that various factors, such as location in urban or rural 

areas or the size of hospitals and professional practices, may affect the extent to 

which different providers will respond to the provisions of the HITECH Act that aim to 

encourage the meaningful use of EHR technology. Identifying the number and 

characteristics of providers that participated during the first year of the Medicare 

EHR program can provide important information on whether certain types of 

providers were more likely than others to participate. This information could also 

provide an early indication of the types of providers that may be more likely to 

receive payment reductions in future years of the program. As discussed with the 

committees of jurisdiction, in this report we provide information on providers that 

were awarded Medicare EHR incentive payments for 2011, the first year of the 

program. We have ongoing work on the Medicaid EHR program and will issue a 

future report that will provide information on providers awarded incentive payments 

for the first year of that program, such as the number of award recipients and their 

characteristics. 

 

10Medicare Part B covers hospital outpatient, physician, and other services for persons aged 65 and 

over, certain individuals with disabilities, and individuals with end-stage renal disease. 

11The maximum incentive payment that could be awarded to an MAO on behalf of an eligible 

professional was $18,000.

12Pub. L. No. 111-5, § 13424(e), 123 Stat. 278-279.

13See GAO, Electronic Health Records: First Year of CMS’s Incentive Programs Shows Opportunities 

to Improve Processes to Verify Providers Met Requirements, GAO-12-481 (Washington, D.C.: 

Apr. 30, 2012). In our April 2012 report, we analyzed partial-year data that Medicare providers 

reported to CMS to demonstrate that they meaningfully used their certified EHR technology.
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To provide information on providers—that is, hospitals and professionals—awarded 

Medicare EHR incentive payments for 2011, we analyzed data related to the 2011 

program year that CMS collected from January 3, 2011, through April 2, 2012, as 

well as data from CMS and other government and private sources on provider 

characteristics.14 We used these data to

• determine the number of providers that were awarded a Medicare EHR incentive 

payment;

• estimate the percentage of eligible providers that were awarded a Medicare EHR 

incentive payment;

• determine the amount of Medicare EHR incentive payments awarded to 

providers; and

• examine the characteristics of providers that were awarded Medicare EHR 

incentive payments.

To determine the number of providers that were awarded a Medicare EHR incentive 

payment for 2011, we counted the number of providers that had an incentive 

payment disbursed to them or had an incentive payment that was approved and 

being processed by CMS, but had not yet been disbursed. To estimate the 

percentage of eligible providers awarded a Medicare EHR incentive payment for 

2011, we divided the number of providers awarded an incentive payment by the total 

number of eligible providers, that is, providers that were eligible for the Medicare 

EHR program, regardless of whether they were awarded an incentive payment. To 

determine the total amount of Medicare EHR incentive payments awarded to 

providers, we summed the Medicare EHR incentive payments awarded to providers. 

We also examined the distribution of the Medicare incentive payments across 

providers. Specifically, for hospitals, we determined the minimum, maximum, and 

median Medicare EHR incentive payment amount. For professionals, we determined 

the percentage who were awarded an incentive payment of various amounts.

To examine the characteristics of providers awarded Medicare EHR incentive 

payments for 2011, we analyzed data from CMS, the Health Resources and 

Services Administration, the Office of the National Coordinator for Health Information 

Technology (ONC), and Surescripts.15

 

14Our analysis includes participating hospitals that were affiliated with MAOs, but does not, in general, 

include data on participating professionals who were affiliated with MAOs. We included professionals 

who were affiliated with an MAO if they qualified to receive the maximum incentive payment amount 

based on Medicare Part B charges, which are outside the Medicare Advantage plan. At the time of 

our analysis, CMS had not yet determined which professionals would receive incentive payments 

through an MAO.

As part of our analysis, we compared the 

characteristics of providers that were awarded Medicare EHR incentive payments for 

2011 to those of other providers that were eligible for the Medicare EHR program but 

were not awarded a payment for that year. For hospitals, these characteristics 

15Surescripts operates the nation’s largest electronic prescription network and collects data on, 

among other things, the number of electronic prescriptions sent to pharmacies in its network. 
Page 5 GAO-12-778R Electronic Health Records

included, for example, whether the hospital was classified as an acute care hospital 

or critical access hospital and whether the hospital was a member of a chain. For 

professionals, these characteristics included whether the professional had previously 

participated in CMS’s electronic prescribing program16 or signed an agreement to 

receive technical assistance from a Regional Extension Center.17 To ensure the 

reliability of the various data we analyzed, we interviewed officials from CMS, ONC, 

and Surescripts; reviewed relevant documentation; and conducted electronic testing 

to identify missing data and obvious errors. On the basis of these activities, we 

determined that the data we analyzed were sufficiently reliable for our analysis. 

Enclosure I provides additional information on our scope and methodology.

We conducted this performance audit from January 2012 to July 2012 in accordance 

with generally accepted government auditing standards. Those standards require 

that we plan and perform the audit to obtain sufficient, appropriate evidence to 

provide a reasonable basis for our findings and conclusions based on our audit 

objectives. We believe that the evidence obtained provides a reasonable basis for 

our findings and conclusions based on our audit objectives.

In summary, 761 hospitals and 56,585 professionals were awarded a total of 

approximately $2.3 billion in Medicare EHR incentive payments for 2011. These 

761 hospitals represented 16 percent of the estimated 4,855 eligible hospitals, and 

were awarded $1.3 billion in Medicare EHR incentive payments for 2011. While the 

amount of EHR incentive payments awarded to each hospital ranged from $22,300 

to $4.4 million, the median payment amount was $1.7 million. About 61 percent of 

hospitals accounted for about 80 percent of the total amount of incentive payments 

awarded to hospitals. Among hospitals awarded an incentive payment for 2011, we 

found that

• the largest proportion (44 percent) were located in the South, and the lowest 

proportion (12 percent) were located in the Northeast;

• about two-thirds (67 percent) were in urban areas;

• more than four-fifths (86 percent) were acute care hospitals; and

• almost half (46 percent) were in the top third of hospitals in terms of number of 

beds.

 

16The electronic prescribing program, which was established by the Medicare Improvements for 

Patients and Providers Act of 2008, provides incentive payments from 2009 through 2013 to 

physicians and certain other Medicare professionals, such as physician assistants and nurse 

practitioners, who have prescribing authority and who adopt and use systems that meet CMS’s 

definition of a qualified electronic prescribing system. Pub. L. No. 110-275, § 132(a), 122 Stat. 2492, 

2527. From 2012 through 2014, the program may apply a payment adjustment, or penalty, on the 

program’s eligible providers that do not adopt and use such systems. See GAO, Electronic 

Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the 

Use of Health Information Technology, GAO-11-159 (Washington, D.C.: Feb. 17, 2011). 

17The regional extension center program was established by the HITECH Act and is administered by 

ONC to help some types of providers, such as those located in rural areas, to participate in CMS’s 

EHR programs. 
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Hospitals with certain characteristics were more likely to have been awarded a 

Medicare EHR incentive payment for 2011. For example, acute care hospitals were 

more than 2 times more likely than critical access hospitals to have been awarded 

an incentive payment. Hospitals in the top third in terms of numbers of beds were 

2.4 times more likely than hospitals in the bottom third to have been awarded an 

incentive payment. Further, nonprofit and for-profit hospitals were 1.1 and 1.5 times 

more likely than government-owned hospitals, respectively, to have been awarded 

an incentive payment.

The 56,585 professionals who were awarded a Medicare EHR incentive payment for 

2011 represented about 9 percent of the estimated 600,172 professionals eligible for 

the program, and were awarded a total of about $967 million in incentive payments. 

Among professionals awarded an incentive payment for 2011, we found that

• the largest proportion (32 percent) were located in the South, and the lowest 

proportion (17 percent) were located in the West;

• a significant majority (89 percent) were in urban areas;

• half (50 percent) were specialty practice physicians and over one-third 

(38 percent) were general practice physicians;

• nearly three-quarters (71 percent) did not previously participate in CMS’s 

incentive program for electronic prescribing; and

• about half were in the top third in terms of 2010 Medicare Part B charges 

(46 percent) and 2010 Medicare Part B patient encounters (51 percent).

Professionals with certain characteristics were more likely to have been awarded a 

Medicare EHR incentive payment for 2011. For example, general practice 

physicians were 1.8 times more likely than specialty practice physicians to have 

been awarded an incentive payment. Professionals who had previously participated 

in CMS’s electronic prescribing program were almost 4 times more likely to have 

been awarded an incentive payment than those who had not participated in the 

electronic prescribing program, and professionals who had signed an agreement to 

receive technical assistance from a Regional Extension Center were more than 

twice as likely to have been awarded an incentive payment. Professionals in the top 

third in terms of 2010 Medicare Part B charges or number of 2010 Medicare Part B 

encounters were more than 3 times more likely to have been awarded an incentive 

payment compared to those in the bottom third for charges or number of encounters.

See enclosure II for more information on the characteristics of hospitals that were 

awarded a Medicare EHR incentive payment for 2011. See enclosure III for more 

information on the characteristics of professionals who were awarded a Medicare 

EHR incentive payment for 2011.
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We provided a draft of this report to the Department of Health and Human Services 

for comment. In its written comments, reproduced in enclosure IV, the department 

stated that our analysis was informative and that it will use the information to 

enhance its outreach and education efforts related to the EHR programs. The 

department also suggested that GAO’s future work in this area consider the impact 

of other federal programs on providers’ participation in the EHR programs.

– – – – – 

We are sending copies of this report to the Secretary of Health and Human Services, 

the Administrator of CMS, the National Coordinator for Health Information 

Technology, and other interested parties. In addition, the report will be available at 

no charge on GAO’s website at http://www.gao.gov. If you or your staffs have any 

questions about this report, please contact me at (202) 512-7114 or at 

kohnl@gao.gov. Contact points for our Office of Congressional Relations and Office 

of Public Affairs can be found on the last page of this report. Major contributors to 

this report were E. Anne Laffoon, Assistant Director; Julianne Flowers; Krister 

Friday; Melanie Krause; Shannon Legeer; Monica Perez-Nelson; and Eric Peterson.

Linda T. Kohn

Director, Health Care

Enclosures – 4 
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List of Committees

The Honorable Max Baucus

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Tom Harkin

Chairman

The Honorable Michael B. Enzi

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry A. Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Dave Camp

Chairman

The Honorable Sander M. Levin

Ranking Member

Committee on Ways and Means

House of Representatives
Enclosure I

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Scope and Methodology

This enclosure provides additional details regarding our analysis of data from the 

Centers for Medicare & Medicaid Services (CMS) and other government and private 

sources to (a) determine the number of providers that were awarded a Medicare 

electronic health record (EHR) incentive payment; (b) estimate the percentage of 

eligible providers1 that were awarded a Medicare EHR incentive payment; 

(c) determine the amount of Medicare EHR incentive payments awarded to 

providers; and (d) examine the characteristics of providers that were awarded 

Medicare EHR incentive payments.

Number of providers that were awarded a Medicare EHR incentive payment. To 

determine the number of providers that were awarded an incentive payment, we 

analyzed data on providers that were awarded Medicare EHR incentive payments 

for 2011 from CMS’s National Level Repository.2 We analyzed data related to the 

2011 program year that CMS collected from January 3, 2011, through April 2, 2012. 

As a result, we generally included full-year information in our analysis, since the first 

program year for hospitals ended on November 30, 2011, and the first program year 

for professionals ended on February 29, 2012.3 Specifically, we counted the number 

of providers that had an incentive payment disbursed to them or whose payment 

was approved and being processed by CMS.4

Estimate of the percentage of eligible providers that were awarded a Medicare 

EHR incentive payment. To estimate the percentage of providers that were 

awarded an incentive payment, we divided the number of providers that were 

awarded an incentive payment by the total number of eligible providers, that is, 

providers that were eligible for the Medicare EHR program, regardless of whether 

they were awarded an incentive payment. We identified eligible hospitals as those 

that fit the following three criteria: (a) were acute care hospitals, including those that 

were affiliated with a Medicare Advantage Organization (MAO), or critical access 

 

1

We use the term eligible providers to refer to hospitals and professionals that were generally eligible 

for the Medicare EHR program, regardless of whether they were awarded a Medicare EHR incentive 

payment for 2011, as described in greater detail later in this enclosure.

2

The National Level Repository is a database that contains information on providers pertaining to the 

Medicare EHR program, including information on providers that are registered for the incentive 

program, whether those providers have met program requirements to receive an incentive payment, and the amount of incentive payments, if applicable. The National Level Repository also contains 

some information on providers pertaining to the Medicaid EHR program, which we generally did not 

include in our analysis. 

3

Due to various reasons, including the time needed to process providers’ payments, the total number 

of providers that received Medicare EHR incentive payments for 2011 and the total amount of 

incentive payments awarded may increase.

4

Our analysis includes participating hospitals that were affiliated with Medicare Advantage 

Organizations (MAO), but does not, in general, include data on participating professionals who were 

affiliated with MAOs. We included professionals who were affiliated with an MAO only if they qualified 

to receive the maximum incentive payment amount based on Medicare Part B charges, which are 

outside the Medicare Advantage plan. At the time of our analysis, CMS had not yet determined which 

professionals would receive incentive payments through an MAO. 
Enclosure I

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hospitals; (b) were located in one of the 50 states or the District of Columbia; and 

(c) were not terminated from participating in the Medicare program on or before 

January 2, 2011.5 We identified eligible professionals as those that fit the following 

three criteria: (a) have specialty types that are eligible for the Medicare EHR 

program, which include all medical doctor/doctor of osteopathic medicine specialties, 

chiropractors, doctors of dental medicine or surgery, podiatrists, and optometrists; 

(b) were not hospital-based professionals;6 and (c) had greater than $0 in Medicare 

Part B charges in 2010.7

Amount of Medicare EHR incentive payments awarded to providers. We 

determined the total amount of the incentive payments that were awarded to 

providers by summing the Medicare EHR incentive payments that had been 

disbursed or were approved and being processed by CMS. We also examined the 

distribution of the Medicare incentive payments across providers. Specifically, for 

hospitals, we determined the minimum, 25th percentile, median, 75th percentile, and 

maximum Medicare EHR incentive payment amount. For professionals, we 

determined the percentage who were awarded an incentive payment amount of 

(a) $18,000, which was the maximum Medicare EHR incentive payment amount for 

most professionals, (b) greater than $18,000, but less than or equal to $19,800, and 

(c) less than $18,000.8

Characteristics of providers that were awarded Medicare EHR incentive 

payments. To examine the characteristics of providers that were awarded Medicare 

EHR incentive payments for 2011, we analyzed data on provider characteristics from 

CMS, the Health Resources and Services Administration, the Office of the National 

Coordinator for Health Information Technology (ONC), and Surescripts.9

 

5

Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are 

paid under the inpatient prospective payment system. Hospitals that are affiliated with an MAO are 

hospitals described in Section 1886(d) of the Social Security Act, which are under common corporate 

governance with a qualifying MAO and for which at least two-thirds of their discharges are of 

individuals enrolled under Medicare Advantage plans. 42 C.F.R. § 495.200.

(See 

table 1.) Each characteristic is divided into two or more categories. For example, the 

characteristic “geographic region” is divided into four categories—Midwest, 

Northeast, South, and West regions. As part of this analysis, we also compared the 

6

CMS defines hospital-based professionals as those who furnish 90 percent or more of their services 

in either an inpatient or an emergency department of a hospital. We determined whether 

professionals were hospital-based by using an electronic data file provided by CMS that indicated for 

specific professionals whether 90 percent or more of their Medicare services in 2010 were provided in 

an inpatient or emergency department of a hospital. 

7

Medicare Part B charges refers to “allowed charges” set by Medicare that determine the amount of 

payments received by professionals for physician, outpatient hospital, home health care, and certain 

other services. 

8

The maximum incentive payment for 2011 that could be awarded to professionals practicing in a 

health professional shortage area was generally $19,800. Health professional shortage areas are 

areas designated by the Health Resources and Services Administration as having shortages of 

primary medical care, dental, or mental health providers.

9

Surescripts operates the nation’s largest electronic prescription network and collects data on, among 

other things, the number of electronic prescriptions sent to pharmacies in its network. 
Enclosure I

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characteristics of providers that were awarded a Medicare EHR incentive payment to 

those of eligible providers that were not awarded such payments. To do so, we 

calculated relative risk ratios that indicate how much more likely a provider in each 

category was to have been awarded an EHR incentive payment than a provider in 

the category that was least likely to have been awarded a payment.

Table 1: Data Sources Analyzed to Examine Characteristics of Eligible Providers

Agency or entity Data source

Date of extract, 

download, or release

CMS National Level Repository April 2012

2010 Medicare Part B claims January – December 2010

National Plan and Provider Enumeration System Data 

Dissemination Filea February 2012

Provider Enrollment, Chain, and Ownership Systema February 2012

Provider of Services File April 2012

Online Survey, Certification, and Reporting System May 2011

Fiscal Intermediary Standard System December 2011

Integrated Data Repository December 2010

2011 primary care health professional shortage areas November 2010

2010 recipients of incentive payments from CMS’s 

electronic prescribing program

July 2011

Health Resources and 

Services Administration

Area Resource Fileb August 2010

Office of the National 

Coordinator for Health 

Information Technology

Regional Extension Center Customer Relationship 

Management System extract filec March 2012

List of zip codes serviced by a Beacon Communityd March 2012

Surescripts Extract file containing county-level information on 

electronic prescription transactions and prescribers 

January – December 2011

Source: GAO.

a

Data contained in this data source are generally self-reported by providers to CMS.

b

Although the Area Resource File is typically released annually, at the time of our analysis, the 2010-2011 Area Resource File 

had not yet been made publicly available.

c

The Regional Extension Center program was established by the Health Information Technology for Economic and Clinical 

Health Act and is administered by the Office of the National Coordinator for Health Information Technology to help some types

of providers, such as those located in rural areas, to participate in CMS’s EHR programs.

d

The Office of the National Coordinator for Health Information Technology provided funding to support 17 Beacon Communities 

to build and strengthen their health information technology infrastructure and exchange capabilities. These communities were 

selected for various reasons, including the progress they had already made in adopting EHRs. The 17 Beacon Communities 

focus on specific and measurable improvement goals in three areas for health systems improvement—quality, cost-efficiency, 

and population health—to demonstrate the ability of health information technology to affect local health care systems.
Enclosure I

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Using the data obtained from the sources listed in table 1, we examined the 

following provider characteristics:

• Regional characteristics. We analyzed data on the following regional 

characteristics:10

• Geographic region. We used the Health Resources and Services 

Administration’s Area Resource File to identify the U.S. census region—

Midwest, Northeast, South, or West—where providers were located or 

practiced.11

• Location. We used the Health Resources and Services Administration’s Area 

Resource File to determine whether providers were located in a metropolitan 

area—an area that has at least one urbanized area of 50,000 people. We 

then categorized providers located in metropolitan areas as being located in 

urban areas and providers that were not as being located in rural areas.12

• Average county volume of electronic prescribing based on transactions per 

professional who submits electronic prescriptions. We used data from 

Surescripts to calculate, for each county during 2011, the average number of 

electronic prescriptions submitted per month from an ambulatory care setting 

by each professional who submitted electronic prescriptions. Using these 

aggregated data, we created three categories: (a) low—less than or equal to 

the 33.3rd percentile, (b) middle—greater than the 33.3rd percentile but less 

than the 66.7th percentile, and (c) high—greater than the 66.7th percentile.

 

10In most cases, in order to link the information from these files to individual providers, we obtained 

zip codes for hospital locations from CMS’s Provider of Services file and zip codes for professional 

practice locations from CMS’s National Plan and Provider Enumeration System and CMS’s Provider 

Enrollment, Chain, and Ownership System. Then, with the assistance of a zip code to Federal 

Information Processing Standard code crosswalk file we obtained from CMS, we were able to 

determine the counties in which hospitals were located and professionals practiced. We were able to 

match hospital zip codes to the crosswalk for all hospitals in our analysis. However, we were unable 

to match professional practice zip codes to the crosswalk for 207 professionals (less than 1 percent). 

Consequently, we generally excluded these 207 professionals from our analysis of regional 

characteristics, except for our analysis of geographic region. To analyze information on geographic 

region, we were able to use state information rather than zip code information.

11Information on U.S. census region was available for all eligible hospitals. We excluded four 

professionals (less than 1 percent) from our analysis of geographic region due to missing data for the 

practice state.

12Information on whether providers were located in urban or rural areas was missing for two hospitals 

(less than 1 percent). In addition to the 207 professionals for whom we could not match zip codes 

which are, therefore, excluded from our analysis of all regional characteristics (except geographic 

region), we excluded an additional 8 professionals (less than 1 percent) from our analysis of location 

due to missing data. 
Enclosure I

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• Whether a provider is located in a county with a Beacon Community. We 

used data from ONC to categorize providers as either being located in a 

Beacon Community or not.13

• Whether a professional practices in a health professional shortage area. We 

used the list from CMS that identifies the zip codes that were designated as 

primary care health professional shortage areas for bonus payments in 2011 

to categorize providers as either being located in a health professional 

shortage area or not.14

• Hospital type. We analyzed data on the following categorizations of hospital type:

• Hospital classification. We determined whether hospitals were classified as 

acute care hospitals, including hospitals that were affiliated with a MAO, or 

critical access hospitals by using data from CMS’s Provider of Services file.15

• Major teaching hospital. We determined whether or not hospitals were listed 

as having a major affiliation with a medical school in CMS’s Provider of 

Services file.16

• Ownership type. We primarily used data on ownership type from CMS’s 

Provider of Services file to create three categories of ownership: (a) for-profit 

by combining private for-profit and physician ownership, (b) nonprofit by 

combining church and private not-for-profit, and (c) government-owned by 

combining four government designations (federal, state, local, and hospital 

district or authority) and tribal. In instances in which ownership type was listed 

as “other” in the Provider of Services file, we obtained information needed to 

classify hospitals as for-profit, nonprofit, or government-owned from another 

CMS data source—the Online Survey, Certification, and Reporting System.17

• Chain membership. We categorized hospitals as being a member of a chain if 

the hospital has a chain home office listed in CMS’s Provider Enrollment, 

Chain, and Ownership System. All other hospitals with a record in CMS’s 

 

13ONC provided funding to support 17 Beacon Communities to build and strengthen their health 

information technology infrastructure and exchange capabilities. These communities were selected 

for various reasons, including the progress they had already made in adopting EHRs. The 17 Beacon 

Communities focus on specific and measurable improvement goals in three areas for health systems 

improvement—quality, cost-efficiency, and population health—to demonstrate the ability of health 

information technology to affect local health care systems. 

14CMS’s list of zip codes for health professional shortage areas does not contain zip codes that were 

only partially in a shortage area. 

15Information on hospital classification was available for all eligible hospitals. 

16Information on hospital affiliation with a medical school was available for all hospitals. 

17Information on hospital ownership type was available for all eligible hospitals. 
Enclosure I

Page 14 GAO-12-778R Electronic Health Records

Provider Enrollment, Chain, and Ownership System were designated as not 

being a member of a chain.18

• Hospital size. We analyzed data on the following measures of hospital size from 

CMS’s Provider of Services file and Fiscal Intermediary Standard System:19

• Total beds. Using data from CMS’s Provider of Services file on the total 

number of hospital beds, we created three categories: (a) low—less than or 

equal to the 33.3rd percentile, (b) middle—greater than the 33.3rd percentile 

but less than the 66.7th percentile, and (c) high—greater than the 

66.7th percentile.20

• Medicare inpatient bed days. Using data from CMS’s Fiscal Intermediary 

Standard System, for each hospital we counted the number of Medicare 

inpatient bed days. Using these aggregated data, we created three 

categories: (a) low—less than or equal to the 33.3rd percentile, (b) middle—

greater than the 33.3rd percentile but less than the 66.7th percentile, and 

(c) high—greater than the 66.7th percentile.21

• Total discharges. Using data from CMS’s Fiscal Intermediary Standard 

System on the total number of discharges for each hospital, we created three 

categories: (a) low—less than or equal to the 33.3rd percentile, (b) middle—

greater than the 33.3rd percentile but less than the 66.7th percentile, and 

(c) high—greater than the 66.7th percentile.

• Hospital charges. We analyzed data on the following measures of hospital 

charges from CMS’s Fiscal Intermediary Standard System:22

• Total charges. Using data on the total amount of charges, we created three 

categories: (a) low—less than or equal to the 33.3rd percentile, (b) middle—

 

18Information on chain membership was missing for 247 hospitals (about 5 percent) because those 

hospitals did not have a record in our extract from CMS’s Provider Enrollment, Chain, and Ownership 

System. 

19Data from CMS’s Fiscal Intermediary Standard System were missing for 453 acute care hospitals 

(about 13 percent) and 988 critical access hospitals (about 74 percent) because, at the time of our 

data extract, CMS had not yet populated the system with information on those hospitals. 

Consequently, we excluded these 1,441 hospitals from our analysis of Medicare inpatient bed days 

and total discharges.

20Information on total beds was available for all eligible hospitals. 

21In addition to the 1,441 hospitals for which we were missing data on Medicare inpatient bed days, 

we excluded an additional 6 hospitals from our analysis of Medicare inpatient bed days after 

determining that the hospitals’ data were unreliable because the number of Medicare inpatient bed 

days exceeded the total number of inpatient bed days.

22Data from CMS’s Fiscal Intermediary Standard System were missing for 453 acute care hospitals 

(about 13 percent) and 988 critical access hospitals (about 74 percent) because, at the time of our 

data extract, CMS had not yet populated the system with information on those hospitals. 

Consequently, we excluded these 1,441 hospitals from our analysis of hospital charges.
Enclosure I

Page 15 GAO-12-778R Electronic Health Records

greater than the 33.3rd percentile but less than the 66.7th percentile, and 

(c) high—greater than the 66.7th percentile.23

• Charity charges. Using data on charity charges, we created three categories: 

(a) low—less than or equal to the 33.3rd percentile, (b) middle—greater than 

the 33.3rd percentile, but less than the 66.7th percentile, and (c) high—

greater than the 66.7th percentile.24

• Professional characteristics. We included in our analysis the following five types 

of professional characteristics:

• Professional specialty. We primarily obtained data on professionals’ primary 

specialty from CMS’s National Plan and Provider Enumeration System 

Downloadable File. Then, with the assistance of a crosswalk we obtained 

from CMS that aggregates specialty taxonomy codes into a smaller number of 

specialties, we created the following six categories: (a) general practice 

physician, (b) specialty practice physician, (c) chiropractor, (d) dentist, 

(e) optometrist, and (f) podiatrist.25 In instances in which the professional 

specialty information was missing from the National Plan and Provider 

Enumeration System, we obtained information on professionals’ specialty 

from another CMS data source—the Provider Enrollment, Chain, and 

Ownership System. To examine variation among different types of specialty 

practice physicians, we used information from the CMS crosswalk to assign 

specialty practice physicians to one of 27 specialty categories, such as 

cardiology, surgery, and psychiatry. Professionals who had missing 

information on professional specialty in both data sources and had not been 

awarded a Medicare EHR incentive payment for 2011 were dropped from our 

analysis, since we were unable to determine whether they were eligible to 

receive an incentive payment.26 Information on professional specialty was 

 

23In addition to the 1,441 hospitals for which we were missing data on hospital charges, we excluded 

an additional 3 hospitals from our analysis of total charges after determining that the hospitals’ data 

were unreliable because the amount of charity charges exceeded the total amount of charges. 

24Charity charges reflect the cost of providing inpatient and outpatient hospital services for which the 

hospital is not compensated. In addition to the 1,441 hospitals for which we were missing data on 

hospital charges, we excluded an additional 3 hospitals from our analysis of charity charges after 

determining that the hospitals’ data were unreliable because the amount of charity charges exceeded 

the total amount of charges. 

25We classified doctors of medicine and osteopathic medicine that specialize in family practice, 

general practice, or internal medicine as general practice physicians; all other doctors of medicine 

and osteopathic medicine were classified as specialty practice physicians. 

26Information on professional specialty was missing for 72,107 professionals who were not awarded a 

Medicare EHR incentive payment.
Enclosure I

Page 16 GAO-12-778R Electronic Health Records

missing for 35 professionals who had been awarded a Medicare EHR 

incentive payment (less than 1 percent).27

• Number of professionals in the practice. We estimated the number of 

professionals in each practice by counting the number of professionals who 

were listed as members of each professional practice in CMS’s Provider 

Enrollment, Chain, and Ownership System. We subsequently created four 

practice size categories: (a) solo practice, (b) practice of 2 to 10 

professionals, (c) practice of 11 to 50 professionals, and (d) practice of 51 or 

more professionals. We also created a fifth category for professionals who 

were associated with more than one group practice.28

• Whether the professional had signed an agreement to receive technical 

assistance from a Regional Extension Center. We obtained data on whether 

professionals (identified by National Provider Identifier) had signed an 

agreement to receive technical assistance from a Regional Extension Center 

from ONC’s Regional Extension Center Customer Relationship Management 

System.29 We then categorized professionals as either having signed an 

agreement to receive technical assistance or not.

• Whether the professional had received an incentive payment from CMS’s 

electronic prescribing incentive program in 2010. We obtained data from CMS 

on whether professionals received an incentive payment from CMS’s 

electronic prescribing program in 2010.30 We then categorized professionals 

as either having received such an incentive payment or not.

• Years since the professional’s degree was awarded. Using data on when 

professionals had received their degree from CMS’s Provider Enrollment, 

Chain, and Ownership System, we determined the number of years since 

 

27CMS provided documentation to support the statement that the 21 professionals for whom we were 

missing information on professional specialty had permissible professional specialties. We excluded

an additional 14 professionals (less than 1 percent) from our analysis of professional specialties 

because, although they had specialty information, the information needed to classify those 

professionals into one of our professional specialty categories was not available in either CMS 

system.

28Information on the number of professionals in the practice was missing for 86,850 professionals 

(about 14.5 percent).

29The regional extension center program was established by the Health Information Technology for 

Economic and Clinical Health Act and is administered by ONC to help some types of providers, such 

as those located in rural areas, to participate in CMS’s EHR programs. 

30The electronic prescribing program, which was established by the Medicare Improvements for 

Patients and Providers Act of 2008, provides incentive payments from 2009 through 2013 to 

physicians and certain other Medicare professionals, such as physician assistants and nurse 

practitioners, who have prescribing authority and who adopt and use systems that meet CMS’s 

definition of a qualified electronic prescribing system. Pub. L. No. 110-275, § 132(a), 122 Stat. 2492, 

2527. From 2012 through 2014, the program may apply a payment adjustment, or penalty, on the 

program’s eligible providers that do not adopt and use such systems. See GAO, Electronic 

Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the 

Use of Health Information Technology, GAO-11-159 (Washington, D.C.: Feb. 17, 2011).
Enclosure I

Page 17 GAO-12-778R Electronic Health Records

each professional’s degree was awarded. We dropped data on years since 

the professional’s degree was awarded if the data were potentially 

unreliable—that is, if the number of years exceeded 75. We subsequently 

created three categories: (a) low—less than or equal to the 33.3rd percentile, 

(b) middle—greater than the 33.3rd percentile but less than the 

66.7th percentile, and (c) high—greater than the 66.7th percentile.31

• Professional practice size. We analyzed data on the following two measures of 

practice size from CMS’s calendar year 2010 Medicare Part B claims:32

• Total amount of 2010 Medicare Part B charges. For each professional 

(identified by National Provider Identifier), we summed the amount of 

Medicare Part B charges over the year. Subsequently, we created three 

categories by aggregating total charges by professional: (a) low—less than or 

equal to the 33.3rd percentile, (b) middle—greater than the 33.3rd percentile 

but less than the 66.7th percentile, and (c) high—greater than the 

66.7th percentile.33

• Total number of 2010 Medicare Part B encounters. For each professional 

(identified by National Provider Identifier), we counted the number of 

Medicare Part B encounters—that is, distinct Medicare patient visits. 

Subsequently, we created three categories by aggregating total encounters 

by professional: (a) low—less than or equal to the 33.3rd percentile, 

(b) middle—greater than the 33.3rd percentile but less than the 

66.7th percentile, and (c) high—greater than the 66.7th percentile.34

To ensure the reliability of the various data we analyzed, we interviewed officials 

from CMS, ONC, and Surescripts; reviewed relevant documentation; and conducted 

electronic testing to identify missing data and obvious errors. On the basis of these 

activities, we determined that the data we analyzed were sufficiently reliable for our 

analysis. Although the amount of missing data was generally low, in instances in 

which data were missing for 6 percent of providers or more, we noted this explicitly.

 

31Information on the number of years since the professional’s degree was awarded was missing for 

27,661 professionals (about 4.6 percent).

32Information on 2010 Medicare Part B claims was missing for 1,195 professionals who were 

awarded a Medicare EHR incentive payment (less than 1 percent).

33Percentiles were created using information on 2010 Medicare Part B charges for all professionals 

who had greater than $0 in charges. 

34Percentiles were created using information on 2010 Medicare Part B encounters for all 

professionals who had at least one encounter. 
Enclosure I

Page 18 GAO-12-778R Electronic Health Records

We conducted this performance audit from January 2012 to July 2012 in accordance 

with generally accepted government auditing standards. Those standards require 

that we plan and perform the audit to obtain sufficient, appropriate evidence to 

provide a reasonable basis for our findings and conclusions based on our audit 

objectives. We believe that the evidence obtained provides a reasonable basis for 

our findings and conclusions based on our audit objectives.
Enclosure II

Page 19 GAO-12-778R Electronic Health Records

Information on Hospitals That Were Awarded Medicare 

EHR Incentive Payments for 2011

This enclosure provides information on the number and percentage of hospitals that 

were awarded Medicare EHR incentive payments for 2011, the amount of incentive 

payments awarded to hospitals, and the characteristics of hospitals that were 

awarded incentive payments. This enclosure also compares different categories of 

eligible hospitals to determine which were more likely and which were less likely to 

have been awarded an incentive payment.

Of the estimated 4,855 eligible hospitals, 16 percent or 761 hospitals were awarded 

a Medicare EHR incentive payment for 2011.1 The percentage of eligible hospitals 

that were awarded a Medicare EHR incentive payment varied across states. For 

example, more than 20 percent of eligible hospitals in New Hampshire were 

awarded a Medicare EHR incentive payment for 2011, whereas less than 5 percent 

of eligible hospitals in New Mexico were awarded an incentive payment. (See fig. 1.)

 

1

In contrast to professionals, certain hospitals may receive an incentive payment from both the 

Medicare and Medicaid EHR programs in the same year. Through April 2, 2012, 485 hospitals were 

awarded an incentive payment from both programs for 2011.
Enclosure II

Page 20 GAO-12-778R Electronic Health Records

Figure 1: Percentage of Eligible Hospitals That Were Awarded a Medicare EHR Incentive Payment for 

2011, by State

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the 

number of hospitals that were awarded a Medicare EHR incentive payment includes hospitals that had a Medicare EHR 

incentive payment for 2011 disbursed to them or had an incentive payment that was approved and being processed by CMS 

but had not yet been disbursed. Our analysis also includes hospitals that were affiliated with Medicare Advantage 

Organizations.

Of the approximately $2.3 billion in Medicare EHR incentive payments that were 

awarded to providers for 2011, a total of $1.3 billion was awarded to hospitals. The 

amount of Medicare EHR incentive payments awarded to hospitals ranged from 

$22,300 to $4.4 million, with the median amount being $1.7 million. About 61 percent 

of hospitals that were awarded an incentive payment accounted for about 80 percent 

of the total amount of incentive payments awarded to hospitals. Acute care hospitals 

tended to receive larger incentive payments than critical access hospitals. (See 

fig. 2.)
Enclosure II

Page 21 GAO-12-778R Electronic Health Records

Figure 2: Distribution of Medicare EHR Incentive Payment Amounts Awarded to Hospitals for 2011, by 

Selected Hospital Characteristics

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. This analysis includes 

incentive payments that were awarded to hospitals for 2011, including those that had not yet been disbursed, but were 

approved and being processed by CMS.

a

Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient 

prospective payment system.

As illustrated in table 2, among hospitals that were awarded a Medicare EHR 

incentive payment for 2011:

• the largest proportion (44 percent) were located in the South and the lowest 

proportion (12 percent) were located in the Northeast; 

• about two-thirds (67 percent) were in urban areas;

• more than four-fifths (86 percent) were acute care hospitals;

• more than half (57 percent) were nonprofit hospitals;

• more than half (54 percent) were not members of a chain; and

• almost half (46 percent) were relatively large in terms of number of beds.
Enclosure II

Page 22 GAO-12-778R Electronic Health Records

Table 2: Selected Characteristics of Hospitals That Were Awarded a Medicare EHR Incentive Payment for 

2011

Characteristics Categories Number (percentage) 

Geographic region Midwest 218 (28.7)

Northeast 91 (12.0)

South 333 (43.8)

West 119 (15.6)

Location Rural 252 (33.1)

Urban 509 (66.9)

Hospital classification Acute care hospitala 652 (85.7)

Critical access hospital 109 (14.3)

Ownership type For-profit 172 (22.6)

Government-owned 163 (21.4)

Nonprofit 426 (56.0)

Chain membership Chain 343 (45.1)

Nonchain 409 (53.8)

Total beds Low (39 beds or fewer) 142 (18.7)

Middle (40-175 beds) 271 (35.6)

High (176 or more beds) 348 (45.7)

Total 761 (100)

Source: GAO analysis of CMS and Health Resources and Services Administration data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the 

number of hospitals that were awarded a Medicare EHR incentive payment includes hospitals that had a Medicare EHR 

incentive payment for 2011 disbursed to them or had an incentive payment that was approved and being processed by CMS 

but had not yet been disbursed. The sum of the number of hospitals listed by chain membership does not equal the total 

number of hospitals due to missing data. The sum of the percentage of hospitals listed by geographic region does not equal 

100 percent due to rounding.

a

Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient 

prospective payment system.

Among eligible hospitals, the percentage of hospitals that were awarded a Medicare 

EHR incentive payment for 2011 varied substantially by certain characteristics, such 

as total beds and location in an urban or rural setting. (See fig. 3.)
Enclosure II

Page 23 GAO-12-778R Electronic Health Records

Figure 3: Percentage of Eligible Hospitals That Were Awarded a Medicare EHR Incentive Payment for 

2011, by Selected Hospital Characteristics

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the 

number of hospitals that were awarded a Medicare EHR incentive payment includes hospitals that had a Medicare EHR 

incentive payment for 2011 disbursed to them or had an incentive payment that was approved and being processed by CMS 

but had not yet been disbursed.

a

Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient 

prospective payment system.

Tables 3 through 6 below compare the characteristics of hospitals that were 

awarded Medicare EHR incentive payments for 2011 to those of other eligible 

Medicare hospitals that did not receive a payment for that year. Each characteristic 

is divided into two or more categories. For example, the characteristic “geographic 

region” is divided into four categories—Midwest, Northeast, South, and West 

regions. As part of this analysis, we calculated relative risk ratios that indicate how 

much more likely a hospital in each category was to have been awarded an EHR 

incentive payment than a hospital in the category that was least likely to have been 

awarded a payment. Hospitals least likely to receive an incentive payment are 

labeled “ – ”. For example, as table 3 shows, under the characteristic “location,” the 

relative risk ratio of 1.5 for the category “urban” indicates that hospitals in urban 

areas were 1.5 times more likely to have been awarded an incentive payment for 

2011 than hospitals in rural areas. A relative risk ratio of 1.0 indicates no difference 

in the likelihood of having been awarded an incentive payment between the two 

categories, and, as relative risk ratios approach 1.0, there is less and less difference 

in the likelihood of having been awarded an incentive payment between the two 

categories.
Enclosure II

Page 24 GAO-12-778R Electronic Health Records

Table 3 examines the relationship between hospitals receiving Medicare EHR 

incentive payments for 2011 and characteristics of the regions in which the hospitals 

are located. We found that

• geographic location had a modest effect on the likelihood that hospitals were 

awarded an EHR incentive payment for 2011. For instance, hospitals in the 

South—the region with the highest level of program participation—were 1.4 times 

more likely to have been awarded a payment than hospitals in the West—the 

region with the lowest level of program participation; and

• there was little association between the likelihood of having been awarded an 

EHR incentive payment for 2011 and whether the hospital was located in a 

county with a Beacon Community or in a county with high levels of electronic 

prescribing transactions per professionals who submit electronic prescriptions.
Enclosure II

Page 25 GAO-12-778R Electronic Health Records

Table 3: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for 

2011, by Regional Characteristics

Number (percentage)

Characteristics Categories

Number 

of eligible 

hospitalsa

Awarded a 

Medicare EHR 

incentive 

payment 

Not awarded a 

Medicare EHR 

incentive 

payment 

Relative 

risk ratiob

Overall 4,855 761 (15.7) 4,094 (84.3)

Geographic location

Geographic region Midwest 1,435 218 (15.2) 1,217 (84.8) 1.2

Northeast 610 91 (14.9) 519 (85.1) 1.2

South 1,866 333 (17.8) 1,533 (82.2) 1.4

West 944 119 (12.6) 825 (87.4) — 

Location Rural 2,070 252 (12.2) 1,818 (87.8) —

Urban 2,783 509 (18.3) 2,274 (81.7) 1.5

County level of 

participation in selected 

health information 

technology initiativesc 

Average county 

volume of electronic 

prescribing based on 

transactions per 

professional who 

submits electronic 

prescriptions

Low (130.99 or 

fewer transactions)

1,489 243 (16.3) 1,246 (83.7) 1.0

Middle (131-182.58 

transactions)

1,489 248 (16.7) 1,241 (83.3) 1.1

High (182.59 or 

more transactions)

1,487 232 (15.6) 1,255 (84.4) — 

Located in a county 

with a Beacon 

Community

Yes 296 44 (14.9) 252 (85.1) — 

No 4,559 717 (15.7) 3,842 (84.3) 1.1

Source: GAO analysis of CMS, Office of the National Coordinator for Health Information Technology, Health Resources and Services Administration, and Surescripts 

data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the 

characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose 

incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other 

eligible hospitals that were not awarded a payment for that year. The sum of the number of hospitals listed by category may not 

equal the overall number of hospitals due to missing data.

a

We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of 

whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were 

(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access 

hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the 

Medicare program on or before January 2, 2011.

b

The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive 

payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative 

risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two 

categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded 

an incentive payment between the two categories.

c

These characteristics describe the level of participation in selected health information technology initiatives across all the 

providers in a given county, rather than the level of participation associated with any particular hospital.
Enclosure II

Page 26 GAO-12-778R Electronic Health Records

Table 4 examines the relationship between receiving a Medicare EHR incentive 

payment for 2011 and hospital type. We found that hospital classification and chain 

membership had a greater impact on the likelihood of receiving a Medicare EHR 

incentive payment for 2011 than being a major teaching hospital or ownership type. 

In particular,

• among the two hospital classifications, critical access hospitals were 2.3 times 

less likely to have been awarded a Medicare EHR incentive payment for 2011 

than acute care hospitals; and

• hospitals that were members of chains were 1.6 times more likely to have been 

awarded a Medicare EHR incentive payment for 2011 than hospitals that were 

not members of chains.
Enclosure II

Page 27 GAO-12-778R Electronic Health Records

Table 4: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for 

2011, by Hospital Type

Number (percentage)

Characteristics Categories

Number of 

eligible 

hospitalsa

Awarded a 

Medicare EHR 

incentive payment 

Not awarded a 

Medicare EHR 

incentive payment 

Relative 

risk ratiob

Overall 4,855 761 (15.7) 4,094 (84.3)

Hospital 

classification

Acute care hospitalc 3,524 652 (18.5) 2,872 (81.5) 2.3

Critical access 

hospital

1,331 109 (8.2) 1,222 (91.8) — 

Major teaching 

hospital

Yes 441 92 (20.9) 349 (79.1) 1.4

No 4,414 669 (15.2) 3,745 (84.8) — 

Ownership type For-profit 833 172 (20.6) 661 (79.4) 1.5

Government-owned 1,217 163 (13.4) 1,054 (86.6) —

Nonprofit 2,805 426 (15.2) 2,379 (84.8) 1.1

Chain 

membership

Chain 1,581 343 (21.7) 1,238 (78.3) 1.6

Nonchain 3,027 409 (13.5) 2,618 (86.5) — 

Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the 

characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose 

incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other 

eligible hospitals that were not awarded a payment for that year. The sum of the number of hospitals listed by chain 

membership does not equal the total number of hospitals due to missing data.

a

We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of 

whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were 

(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access 

hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the 

Medicare program on or before January 2, 2011.

b

The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive 

payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative 

risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two 

categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded 

an incentive payment between the two categories.

c

Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient 

prospective payment system.

Table 5 examines the extent to which the size of hospitals, measured in various 

ways, is related to whether hospitals were awarded Medicare EHR incentive 

payments for 2011. We found that large hospitals were generally more likely to have 

been awarded a Medicare EHR incentive payment for 2011 than either small or 

medium-sized hospitals. Specifically,

• hospitals with the highest number of total beds were 2.4 times more likely than 

hospitals with the lowest number of total beds to have been awarded an incentive 

payment; and

• hospitals with the highest number of total discharges were 1.4 times more likely 

to have been awarded an incentive payment than hospitals with fewer 

discharges.
Enclosure II

Page 28 GAO-12-778R Electronic Health Records

Table 5: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for 

2011, by Hospital Size 

Number (percentage)

Characteristics Categories

Number of 

eligible 

hospitalsa

Awarded a 

Medicare EHR 

incentive payment 

Not awarded a 

Medicare EHR 

incentive 

payment 

Relative 

risk ratiob

Overall 4,855 761 (15.7) 4,094 (84.3)

Total beds Low (39 beds or fewer) 1,619 142 (8.8) 1,477 (91.2) — 

Middle (40-175 beds) 1,616 271 (16.8) 1,345 (83.2) 1.9

High (176 or more beds) 1,620 348 (21.5) 1,272 (78.5) 2.4

Medicare 

inpatient bed 

days

Low (4,209 or fewer 

inpatient bed days)

1,135 194 (17.1) 941 (82.9) 1.0

Middle (4,210-18,525 

inpatient bed days)

1,138 187 (16.4) 951 (83.6) — 

High (18,526 or more 

inpatient bed days)

1,135 267 (23.5) 868 (76.5) 1.4

Missingc 1,447 113 (7.8) 1,334 (92.2) N/A

Total 

discharges 

Low (2,442 or fewer 

discharges)

1,137 190 (16.7) 947 (83.3) 1.0

Middle (2,443-9,045 

discharges)

1,140 190 (16.7) 950 (83.3) — 

High (9,046 or more 

discharges)

1,137 269 (23.7) 868 (76.3) 1.4

Missingc 1,441 112 (7.8) 1,329 (92.2) N/A

Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the 

characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose 

incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other

eligible hospitals that were not awarded a payment for that year.

a

We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of

whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were 

(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access 

hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the 

Medicare program on or before January 2, 2011.

b

The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive 

payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative 

risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two 

categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded 

an incentive payment between the two categories.

c

Data on Medicare inpatient bed days and total discharges from CMS’s Fiscal Intermediary Standard System were missing for 

453 acute care hospitals (about 13 percent of eligible acute care hospitals) and 988 critical access hospitals (about 74 percent 

of eligible critical access hospitals) because, at the time of our data extract, CMS had not yet populated the system with 

information on those hospitals. We excluded an additional 6 hospitals from our analysis of Medicare inpatient bed days after 

determining that the hospitals’ data were unreliable because the number of Medicare inpatient bed days exceeded the total 

number of inpatient bed days.
Enclosure II

Page 29 GAO-12-778R Electronic Health Records

Table 6 examines the relationship between receiving Medicare EHR incentive 

payments for 2011 and the type and amount of hospital charges. We found that 

hospitals with the highest charges were more likely to receive a Medicare EHR 

incentive payment for 2011 compared to hospitals with lower charges. Specifically,

• hospitals with high total charges were 1.5 times more likely to have been 

awarded an incentive payment than hospitals with middle-level total charges; and

• hospitals with middle or high-level charity charges were 1.3 and 1.5 times more 

likely, respectively, to have been awarded an incentive payment than hospitals 

with low charity charges.

Table 6: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for 

2011, by Hospital Charges

Number (percentage)

Characteristics Categories

Number of 

eligible 

hospitalsa

Awarded a 

Medicare EHR 

incentive 

payment 

Not awarded a 

Medicare EHR 

incentive 

payment 

Relative 

risk ratiob

Overall 4,855 761 (15.7) 4,094 (84.3)

Total charges Low 

($118,590,920 or less) 1,136 199 (17.5) 937 (82.5) 1.1

Middle 

($118,590,921-$471,392,814) 1,139 184 (16.2) 955 (83.8) — 

High ($471,392,815 or more) 1,136 266 (23.4) 870 (76.6) 1.5

Missingc 1,444 112 (7.8) 1,332 (92.2) N/A

Charity 

chargesd Low ($356,312 or less) 1,136 169 (14.9) 967 (85.1) — 

Middle 

($356,313-$15,279,600) 1,139 219 (19.2) 920 (80.8) 1.3

High 

($15,279,601 or more) 1,136 261 (23.0) 875 (77.0) 1.5

Missingc 1,444 112 (7.8) 1,332 (92.2) N/A

Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the 

characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose 

incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other 

eligible hospitals that were not awarded a payment for that year.

a

We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of 

whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were 

(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access 

hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the 

Medicare program on or before January 2, 2011.

b

The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive 

payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative 

risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two 

categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded 

an incentive payment between the two categories.

c

Data on hospital charges were missing from CMS’s Fiscal Intermediary Standard System for 453 acute care hospitals (about 

13 percent of eligible acute care hospitals) and 988 critical access hospitals (about 74 percent of eligible critical access 

hospitals) because, at the time of our data extract, CMS had not yet populated the system with information on those hospitals. 

We excluded an additional three hospitals from our analysis of hospital charges after determining that the hospitals’ data were 

unreliable because the amount of charity charges exceeded the total charges.

d

Charity charges reflect the cost for providing inpatient and outpatient hospital services for which the hospital is not 

compensated.
Enclosure III

Page 30 GAO-12-778R Electronic Health Records

Information on Professionals Who Were Awarded Medicare 

EHR Incentive Payments for 2011

This enclosure provides information on the number and percentage of professionals 

who were awarded Medicare EHR incentive payments for 2011, the amount of 

incentive payments awarded to professionals, and the characteristics of 

professionals who were awarded incentive payments. This enclosure also compares 

different categories of eligible professionals to determine which were more likely and 

which were less likely to have been awarded an incentive payment.

Of the estimated 600,172 eligible professionals, 9.4 percent or 56,585 professionals 

were awarded a Medicare EHR incentive payment for 2011. The percentage of 

eligible professionals who were awarded a Medicare EHR incentive payment varied 

across states. For example, more than 20 percent of eligible professionals in New 

Hampshire were awarded a Medicare EHR incentive payment for 2011, whereas 

less than 5 percent of eligible professionals in New Mexico were awarded an 

incentive payment. (See fig. 4.)
Enclosure III

Page 31 GAO-12-778R Electronic Health Records

Figure 4: Percentage of Eligible Professionals Who Were Awarded a Medicare EHR Incentive Payment 

for 2011, by State

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the 

number of professionals who were awarded a Medicare EHR incentive payment includes professionals who had a Medicare 

EHR incentive payment for 2011 that was disbursed or had an incentive payment that was approved and being processed by 

CMS but had not yet been disbursed. Our analysis does not, in general, include data on participating professionals who were 

affiliated with Medicare Advantage Organizations.

Of the approximately $2.3 billion in Medicare EHR incentive payments that were 

awarded to providers for 2011, $967 million was awarded to professionals. Among 

participating professionals, about 80 percent were awarded an incentive payment of 

$18,000, which was the maximum amount for most professionals.1

 

1

The amount of the Medicare EHR incentive payment for professionals who practice predominately in 

a health professional shortage area could not exceed $19,800 for 2011. Health professional shortage 

areas are areas designated by the Health Resources and Services Administration as having 

shortages of primary medical care, dental, or mental health providers. 

Slightly less than 

8 percent of professionals were awarded an incentive payment of greater than 

$18,000, but less than or equal to $19,800. (See fig. 5.) Eighty-nine percent of the 
Enclosure III

Page 32 GAO-12-778R Electronic Health Records

total amount of incentive payments awarded to professionals was awarded to 

general practice and specialty practice physicians.

Figure 5: Percentage of Professionals Who Were Awarded Medicare EHR Incentive Payments for 2011, 

by Amount

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. This analysis includes 

incentive payments that were awarded to professionals for 2011, including those that had not yet been disbursed, but were 

approved and being processed by CMS. Our analysis does not, in general, include data on participating professionals who 

were affiliated with Medicare Advantage Organizations. The amount of the incentive payment for 2011 cannot exceed $18,000 

for most professionals. The amount of the incentive payment for professionals who practice predominately in a health 

professional shortage area cannot exceed $19,800.

As illustrated in table 7, among professionals who were awarded a Medicare EHR 

incentive payment for 2011:

• the largest proportion (32 percent) were located in the South and the lowest 

proportion (17 percent) were in the West;

• a significant majority (89 percent) were in urban areas;

• half (50 percent) were specialty practice physicians, and over one-third 

(38 percent) were general practice physicians;

• nearly three-quarters (71 percent) did not previously participate in CMS’s 

incentive program for electronic prescribing; and

• about half had relatively high amounts of 2010 Medicare Part B charges 

(46 percent) and numbers of 2010 Medicare Part B patient encounters 

(51 percent).
Enclosure III

Page 33 GAO-12-778R Electronic Health Records

Table 7: Selected Characteristics of Professionals Who Were Awarded a Medicare EHR Incentive 

Payment for 2011

Characteristics Categories Number (percentage) 

Geographic region Midwest 15,529 (27.4)

Northeast 13,545 (23.9)

South 17,805 (31.5)

West 9,656 (17.1)

Location Rural 6,108 (10.8)

Urban 50,464 (89.2)

Professional specialty General practice physician 21,588 (38.2)

Specialty practice physician 28,446 (50.3)

Chiropractor 1,265 (2.2)

Dentist 18 (<0.1)

Optometrist 2,340 (4.1)

Podiatrist 2,893 (5.1)

Received an incentive payment from CMS’s 

Electronic Prescribing Program for 2010

Yes 16,505 (29.2)

No 40,080 (70.8)

Total amount of 2010 Medicare Part B 

charges (dollars)

Low ($27,117.01 or less) 7,892 (13.9)

Medium ($27,117.02-$128,567.51) 21,265 (37.6)

High ($128,567.52 or more) 26,233 (46.4)

Total number of 2010 Medicare Part B 

encounters

Low (615 or fewer encounters) 7,428 (13.1)

Medium (616-2,665 encounters) 19,402 (34.3)

High (2,666 or more encounters) 28,560 (50.5)

Total 56,585 (100)

Source: GAO analysis of CMS and Health Resources and Services Administration data.

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. This analysis includes 

professionals who had a Medicare EHR incentive payment for 2011 that was disbursed to them and professionals whose 

payment was approved and being processed by CMS. Our analysis does not, in general, include data on participating 

professionals who were affiliated with Medicare Advantage Organizations. The sum of the number of professionals listed by 

category may not equal the total number of professionals due to missing data. The sum of the percentage of professionals 

listed for each characteristic may not equal 100 percent due to missing data.

Among eligible professionals, the percentage of professionals who were awarded a 

Medicare EHR incentive payment for 2011 varied by certain characteristics, such as 

professional specialty and amount of Medicare Part B charges. (See fig. 6.)
Enclosure III

Page 34 GAO-12-778R Electronic Health Records

Figure 6: Percentage of Eligible Professionals Who Were Awarded a Medicare EHR Incentive Payment 

for 2011, by Selected Professional Characteristics

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the 

number of professionals who were awarded a Medicare EHR incentive payment includes professionals who had a Medicare 

EHR incentive payment for 2011 that was disbursed to them and professionals whose payment was approved and being 

processed by CMS. Our analysis does not, in general, include data on participating professionals who were affiliated with 

Medicare Advantage Organizations.

While 8 percent of all specialty practice physicians were awarded a Medicare EHR 

incentive payment for 2011, the percentage varied substantially by specialty. For 

example, 17 percent of cardiologists were awarded a Medicare EHR incentive 

payment, compared to 2 percent of psychiatrists. (See fig. 7.)
Enclosure III

Page 35 GAO-12-778R Electronic Health Records

Figure 7: Percentage of Specialty Practice Physicians Who Were Awarded a Medicare EHR Incentive 

Payment for 2011, by Selected Specialty

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the 

number of professionals who were awarded a Medicare EHR incentive payment includes professionals who had a Medicare 

EHR incentive payment for 2011 that was disbursed to them and professionals whose payment was approved and being 

processed by CMS. Our analysis does not, in general, include data on participating professionals who were affiliated with 

Medicare Advantage Organizations.

Tables 8 through 10 below compare the characteristics of professionals who were 

awarded Medicare EHR incentive payments for 2011 to those of other eligible 

Medicare professionals who did not receive a payment for that year. Each 

characteristic is divided into two or more categories. For example, the characteristic 

“geographic region” is divided into four categories—Midwest, Northeast, South, and 

West regions. As part of this analysis, we calculated relative risk ratios that indicate 

how much more likely a professional in each category was to have been awarded an 

EHR incentive payment than a professional in the category that was least likely to 

have been awarded a payment. Professionals least likely to receive an incentive 

payment are labeled “ – ”. For example, as table 8 shows, under the characteristic 

“geographic region,” the relative risk ratio of 1.4 for the category “Midwest” indicates 

that professionals in this census region were 1.4 times more likely to have been 

awarded an incentive payment for 2011 than professionals in the West, who were 

the least likely to receive an incentive payment. A relative risk ratio of 1.0 indicates 

no difference in the likelihood of having been awarded an incentive payment 
Enclosure III

Page 36 GAO-12-778R Electronic Health Records

between the two categories, and, as relative risk ratios approach 1.0, there is less

and less difference in the likelihood of having been awarded an incentive payment 

between the two categories.

Table 8 examines the relationship between professionals receiving Medicare EHR 

incentive payments for 2011 and characteristics of the regions in which the 

professionals are practicing. We found that geographic location had a modest effect 

on the likelihood that professionals were awarded an EHR incentive payment for 

2011. For example,

• professionals practicing in health professional shortage areas were 1.4 times less 

likely to have been awarded a payment than other professionals; and

• in contrast, professionals practicing in urban areas were no more likely to have 

been awarded an incentive payment than rural professionals.

There was an inconsistent relationship between the level of county involvement in 

selected health information technology initiatives—such as Beacon communities—

and the likelihood that professionals in that location were awarded an EHR incentive 

payment.
Enclosure III

Page 37 GAO-12-778R Electronic Health Records

Table 8: Number and Percentage of Professionals Who Were Awarded Medicare EHR Incentive Payments 

for 2011, by Regional Characteristics 

Number (percentage)

Characteristic Category

Number of 

eligible 

professionalsa

Awarded a 

Medicare EHR 

incentive 

payment 

Not awarded a 

Medicare EHR 

incentive 

payment 

Relative 

risk ratiob

Overall 600,172 56,585 (9.4) 543,587 (90.6)

Geographic location

Geographic regionc Midwest 142,159 15,529 (10.9) 126,630 (89.1) 1.4

Northeast 133,236 13,545 (10.2) 119,691 (89.8) 1.3

South 197,703 17,805 (9.0) 179,898 (91.0) 1.1

West 121,715 9,656 (7.9) 112,059 (92.1) — 

Location Rural 65,684 6,108 (9.3) 59,576 (90.7) —

Urban 534,273 50,464 (9.4) 483,809 (90.6) 1.0

Located in a health 

professional shortage 

area

Yes 19,385 1,290 (6.7) 18,095 (93.3) — 

No 580,580 55,283 (9.5) 525,297 (90.5) 1.4

Level of participation in 

selected health 

information technology 

initiativesd

Average county 

volume of electronic 

prescribing based on 

transactions per 

professional who

submits electronic 

prescriptions

Low 

(117.83 or fewer 

transactions)

202,811 18,196 (9.0) 184,615 (91.0) 1.0

Middle 

(117.84-152.53 

transactions)

192,988 16,864 (8.7) 176,124 (91.3) — 

High 

(152.54 or more 

transactions)

199,471 21,393 (10.7) 178,078 (89.3) 1.2

Located in a county 

with a Beacon 

Community

Yes 38,853 2,993 (7.7) 35,860 (92.3) — 

No 561,112 53,580 (9.5) 507,532 (90.5) 1.2

Source: GAO analysis of CMS, Office of the National Coordinator for Health Information Technology, Health Resources and Services Administration, and Surescripts 

data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis does not, 

in general, include participating professionals who were affiliated with Medicare Advantage Organizations. We compared the 

characteristics of the 56,585 professionals who were awarded a Medicare EHR incentive payment for 2011 including those 

whose incentive payment was disbursed to them and those whose payment was approved and being processed by CMS, to 

those of other eligible professionals who were not awarded a payment for that year. The sum of the number of professionals 

listed by category may not equal the overall number of professionals due to missing data.

a

We use the term eligible professionals to refer to those professionals who were eligible for the Medicare EHR program, 

regardless of whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible professionals are 

those who (1) were permissible types of providers: doctors of medicine, dental medicine or surgery, optometry, osteopathy, and 

podiatric medicine, and chiropractors; (2) were not hospital-based, and (3) had greater than $0 in Medicare Part B charges in 

calendar year 2010.

b

The relative risk ratios indicate how much more likely a professional in each category was to have been awarded an EHR 

incentive payment than a professional in the category that was least likely to have been awarded a payment, which is labeled 

“–”. A relative risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between 

the two categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been 

awarded an incentive payment between the two categories.

c

Five thousand three hundred fifty-five eligible professionals practiced in U.S. insular areas, which are not included in the four 

U.S. census regions. Of those, 46 (about 1 percent) were awarded a Medicare EHR incentive payment.

d

These characteristics describe the level of participation in selected health information technology initiatives across all the 

professionals in a given county, rather than the level of participation for any particular professional.
Enclosure III

Page 38 GAO-12-778R Electronic Health Records

Table 9 examines the relationship between professional characteristics, such as 

specialty, longevity, and involvement in other health IT initiatives, and receipt of a 

Medicare EHR incentive payment for 2011. We found that

• among general practice physicians and specialty practice physicians—the two 

specialty categories that together account for most of the eligible professionals—

general practice physicians were 1.8 times more likely than specialty practice 

physicians to have been awarded a Medicare EHR incentive payment;

2 and

• professionals who received an incentive payment from CMS’s Electronic 

Prescribing Program for 2010 were 3.7 times more likely to have been awarded a 

Medicare EHR incentive payment for 2011 than professionals who did not.

 

2

To determine how much more likely a general practice physician was to have been awarded a 

Medicare EHR incentive payment for 2011 than a specialty practice physician, we divided the 

probability that a general practice physician was awarded an incentive payment (21,588/153,402 = 

0.1407) by the probability that a specialty practice physician was awarded an incentive payment 

(28,446/355,926 = 0.0799). 
Enclosure III

Page 39 GAO-12-778R Electronic Health Records

Table 9: Number and Percentage of Professionals Who Were Awarded Medicare EHR Incentive Payments 

for 2011, by Professional Characteristics 

Number (percentage)

Characteristic Category

Number of 

eligible 

professionalsa

Awarded a 

Medicare EHR 

incentive 

payment 

Not awarded a 

Medicare EHR 

incentive 

payment 

Relative 

risk ratiob

Overall 600,172 56,585 (9.4) 543,587 (90.6)

Professional specialty General practice 

physician

153,402 21,588 (14.1) 131,814 (85.9) 27.2

Specialty practice 

physician

355,926 28,446 (8.0) 327,480 (92.0) 15.4

Chiropractor 45,108 1,265 (2.8) 43,843 (97.2) 5.4

Dentist 3,479 18 (0.5) 3,461 (99.5) —

Optometrist 27,745 2,340 (8.4) 25,405 (91.6) 16.3

Podiatrist 14,477 2,893 (20.0) 11,584 (80.0) 38.6

Number of professionals 

in practice 

Solo practice 54,938 4,234 (7.7) 50,704 (92.3) — 

2-10 

professionals

101,315 12,266 (12.1) 89,049 (87.9) 1.6

11-50 

professionals 

70,297 7,103 (10.1) 63,194 (89.9) 1.3

51 or more 

professionals

159,056 17,893 (11.2) 141,163 (88.8) 1.5

More than one 

group practice

127,716 11,974 (9.4) 115,742 (90.6) 1.2

Missingc 86,850 3,115 (3.6) 83,735 (96.4) N/A

Signed an agreement to 

receive technical 

assistance from a 

Regional Extension 

Center

Yes 65,029 12,155 (18.7) 52,874 (81.3) 2.3

No 535,143 44,430 (8.3) 490,713 (91.7) — 

Received an incentive 

payment from CMS’s 

Electronic Prescribing 

Program for 2010

Yes 59,575 16,505 (27.7) 43,070 (72.3) 3.7

No 540,597 40,080 (7.4) 500,517 (92.6) — 

Years since degree 

awarded

Low 

(18 years or fewer)

203,884 21,500 (10.5) 182,384 (89.5) 1.2

Middle 

(19-28 years)

165,563 17,634 (10.7) 147,929 (89.3) 1.2

High 

(29 years or more)

203,064 17,318 (8.5) 185,746 (91.5) — 

Source: GAO analysis of CMS and Office of the National Coordinator for Health Information Technology data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis does not, 

in general, include participating professionals who were affiliated with Medicare Advantage Organizations. We compared the 

characteristics of the 56,585 professionals who were awarded a Medicare EHR incentive payment for 2011 including those 

whose incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of 

other eligible professionals who were not awarded a payment for that year. The sum of the number of professionals listed by 

category may not equal the overall number of professionals due to missing data.

a

We use the term eligible professionals to refer to those professionals who were eligible for the Medicare EHR program, 

regardless of whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible professionals are 

those who (1) were permissible types of providers: doctors of medicine, dental medicine or surgery, optometry, osteopathy, and 

podiatric medicine, and chiropractors; (2) were not hospital-based, and (3) had greater than $0 in Medicare Part B charges in 

calendar year 2010.
Enclosure III

Page 40 GAO-12-778R Electronic Health Records

b

The relative risk ratios indicate how much more likely a professional in each category was to have been awarded an EHR 

incentive payment than a professional in the category that was least likely to have been awarded a payment, which is labeled 

“ – ”. A relative risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between 

the two categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been 

awarded an incentive payment between the two categories.

c

Our analysis of the number of professionals in eligible professionals’ practices includes only a subset of professionals. That is, 

information on the number of professionals in the practice was missing for 86,850 professionals (about 14.5 percent).

Table 10 examines the extent to which the size of professionals’ practices under 

Medicare, measured in various ways, is related to whether professionals were 

awarded Medicare EHR incentive payments for 2011. We found that professionals 

who saw the largest number of Medicare patients and billed Medicare the largest 

amounts were the most likely to have been awarded a Medicare EHR incentive 

payment for 2011. Specifically,

• professionals with the highest total amount in 2010 Medicare Part B charges 

were 3.3 times more likely to have been awarded an incentive payment than 

professionals with the lowest amount of 2010 Medicare Part B charges; and

• professionals with the highest number of 2010 Medicare Part B encounters were 

3.8 times more likely to have been awarded an incentive payment than 

professionals with the smallest number of encounters.
Enclosure III

Page 41 GAO-12-778R Electronic Health Records

Table 10: Number and Percentage of Professionals Who Were Awarded Medicare EHR Incentive 

Payments for 2011, by Practice Size

Number (percentage)

Characteristic Category

Number of 

eligible 

professionalsa

Awarded a 

Medicare EHR 

incentive 

payment 

Not awarded a 

Medicare EHR 

incentive 

payment 

Relative 

risk ratiob

Overall 600,172 56,585 (9.4) 543,587 (90.6)

Total amount of 

2010 Medicare 

Part B charges 

(dollars)

Low 

($27,117.01 or less)

199,460 7,892 (4.0) 191,568 (96.0) — 

Medium

($27,117.02-128,567.51)

200,057 21,265 (10.6) 178,792 (89.4) 2.7

High 

($128,567.52 or more)

199,460 26,233 (13.2) 173,227 (86.8) 3.3

Total number of 

2010 Medicare 

Part B encounters

Low 

(615 or fewer encounters)

199,648 7,428 (3.7) 192,220 (96.3) — 

Medium 

(616-2,665 encounters)

199,825 19,402 (9.7) 180,423 (90.3) 2.6

High 

(2,666 or more encounters)

199,504 28,560 (14.3) 170,944 (85.7) 3.8

Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis does not, 

in general, include participating professionals who were affiliated with Medicare Advantage Organizations. We compared the 

characteristics of the 56,585 professionals who were awarded a Medicare EHR incentive payment for 2011 including those 

whose incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of 

other eligible professionals who were not awarded a payment for that year. The sum of the number of professionals listed by 

category may not equal the overall number of professionals due to missing data.

a

We use the term eligible professionals to refer to those professionals who were eligible for the Medicare EHR program, 

regardless of whether they participated in the program and were awarded a Medicare EHR incentive payment for 2011. 

Specifically, eligible professionals are those that (1) were permissible types of providers: doctors of medicine, dental medicine 

or surgery, optometry, osteopathy, and podiatric medicine, and chiropractors; (2) were not hospital-based, and (3) had greater 

than $0 in Medicare Part B charges in calendar year 2010.

b

The relative risk ratios indicate how much more likely a professional in each category was to have been awarded an EHR 

incentive payment than a professional in the category that was least likely to have been awarded a payment, which is labeled 

“ – ”. A relative risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between 

the two categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been 

awarded an incentive payment between the two categories.
Enclosure IV

Page 42 GAO-12-778R Electronic Health Records

Comments from the Department of Health and Human Services

Note: Page 

and footnote 

numbers in the 

draft report 

may differ from 

those in this 

report.
Enclosure IV

Page 43 GAO-12-778R Electronic Health Records

(290988)
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