Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

PROGRESS IN ELECTRONIC 

HEALTH RECORD 

IMPLEMENTATION THROUGH 

HRSA GRANTS TO HEALTH 

CENTER CONTROLLED 

NETWORKS 

Daniel R. Levinson 

Inspector General 

January 2014 

OEI-09-11-00380 
 

EXECUTIVE SUMMARY: PROGRESS IN ELECTRONIC HEALTH RECORD 

IMPLEMENTATION THROUGH HRSA GRANTS TO HEALTH CENTER 

CONTROLLED NETWORKS, OEI-09-11-00380 

WHY WE DID THIS STUDY 

One goal of the Health Resources and Services Administration (HRSA) is to ensure that all of its 

health centers implement health information technology (HIT), including electronic health record 

(EHR) systems. Since 2007, HRSA has awarded $176.9 million in grants to networks of health 

centers known as health center controlled networks (HCCNs) to support this goal through the 

acquisition, implementation, and “meaningful use” of EHR systems. To assess the grants’ 

contributions toward HRSA’s HIT goal, we assessed health centers’ progress in using HRSA 

grants—funded by the American Recovery and Reinvestment Act (ARRA)—to implement EHR 

systems that support meaningful use. HRSA did not require demonstration of meaningful use as 

a condition of the grants, but has stated that Stage 1 meaningful use objectives, as set forth by the 

Centers for Medicare & Medicaid Services, are a reasonable baseline to assess health center 

progress in implementing EHR systems. We also did this study to determine whether health 

centers face challenges related to the financial sustainability of their EHR systems. 

HOW WE DID THIS STUDY 

We surveyed health centers that participated in HRSA’s ARRA-funded HCCN grant projects 

that supported EHR implementations and enhancements. Using survey responses, we 

determined the extent to which health centers established the capability for the Stage 1 

meaningful use objectives. We also determined whether health centers reported facing 

challenges related to the financial sustainability of their EHR systems. To supplement the survey 

responses, we reviewed grantee progress reports and conducted visits at 11 health centers. 

WHAT WE FOUND 

Most health centers established the capability for meaningful objectives related to capturing data. 

However, fewer health centers established the capability for meaningful use objectives related to 

sharing data. Establishing the capability for objectives relating to sharing data often requires 

health centers to incur additional EHR-related costs. Although 76 percent of health centers 

reported facing financial sustainability challenges, grantee progress reports contained limited 

information related to the financial sustainability of EHR systems at health centers. 

WHAT WE RECOMMEND 

We recommend that HRSA (1) use data to understand progress towards meaningful use 

objectives and to provide guidance and technical assistance to health centers, (2) ensure that 

HCCN grantees provide information on the financial sustainability of EHR systems at health 

centers, and (3) examine the feasibility of collecting information directly from health centers 

regarding the financial sustainability of their EHR systems. HRSA concurred with all of our 

recommendations. 
TABLE OF CONTENTS 

Objectives ....................................................................................................1 

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

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

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

Most health centers established the capability for meaningful 

use objectives related to capturing data; fewer established the 

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

Seventy-six percent of health centers reported facing 

financial sustainability challenges .................................................12 

HCCNs’grantee progress reports contained limited information 

related to the financial sustainability of EHR systems at 

health centers .................................................................................14 

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

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

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

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

B: Stage 1 Meaningful Use Objectives and the Percentage
 

of Health Centers With the Capability for Each Objective ............24 

C: The Extent to Which Eligible Professionals at Health 

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

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

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

 

 

 

 

 

OBJECTIVES 

1.	 To assess health centers’ progress toward implementing electronic 

health record (EHR) systems that support “meaningful use” through 

Health Resources and Services Administration (HRSA) Health Center 

Controlled Network (HCCN) grants funded by the American Recovery 

and Reinvestment Act (ARRA). 

2.	 To determine whether health centers face challenges related to the 

financial sustainability of their EHR systems that were implemented or 

enhanced with HRSA’s ARRA-funded HCCN grants. 

BACKGROUND 

Between 2007 and 2013, HRSA awarded $176.9 million in health 

information technology (HIT) grants, with the majority of this amount 

coming from ARRA.1 These grants support HRSA’s goal to ensure that all 

of its health centers2 implement HIT, which includes the implementation 

and meaningful use of EHR systems.3 EHR systems enable users to record 

patient health information and medical history electronically instead of 

using paper records. Professionals at health centers may become 

“meaningful users” of EHR systems if they meet a set of meaningful use 

objectives as defined in Federal regulations.4 These objectives encompass 

capabilities that are meant to improve health care quality and efficiency by 

electronically capturing and sharing data. Health centers must first 

establish these capabilities so that professionals can become meaningful 

users by using the capabilities. 

HRSA HIT Grants 

To support the implementation and meaningful use of EHR systems at 

health centers, HRSA awarded its HIT grants to health center controlled 

networks (HCCN). An HCCN is a group of health centers that use group 

purchasing power and shared resources, infrastructure, and training to 

adopt and implement HIT in a more cost-efficient manner.5 Although 

1

 HRSA awarded $35.3 million from 2007 through 2008; $120.5 million from 2009
 

through 2010 (with funds made available through ARRA § 3011, amending Titles XVIII 

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

made available through the Patient Protection and Affordable Care Act).
 2

 HRSA-funded health centers provide comprehensive primary care services to medically 

underserved communities and vulnerable populations. Public Health Service Act § 330
 

(codified at 42 U.S.C. § 254b). 

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

4 42 CFR § 495.6.
 5

 HRSA, Affordable Care Act—HCCNs, HRSA-13-327, June 19, 2012, pp. 1–2. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 1 
 

 

 

 

 

 

 

 

HCCNs received the funding, the HIT grants supported projects for the 

HCCNs’ member health centers. 

EHR Implementation Grants. Between 2009 and 2010, HRSA awarded 

$98.9 million in ARRA-funded grants to 43 HCCNs for EHR 

implementation projects.6 (In this report, we refer to these grants as EHR 

implementation grants.) A total of 260 health centers, varying in size and 

location (i.e., rural or urban), participated in EHR implementation grant 

projects through their respective HCCNs.7 Some of these health centers 

were already using an EHR system prior to participating in grant projects. 

The EHR implementation grants funded two types of projects to support 

meaningful use at health centers: new EHR implementation projects 

and—to expand the capabilities of existing EHR systems—EHR 

enhancement projects.8 Some HCCNs received EHR implementation 

grants to support both types of projects at one or more of their health 

centers. For example, a health center participating in both types of 

projects may have implemented an EHR system at one site and expanded 

the capabilities of its EHR system at another site. 

Financial Sustainability. Once an EHR system is implemented, there are 

ongoing operational and maintenance costs related to financially 

sustaining the system and implementing the capabilities to support 

meaningful use. These ongoing costs can include hardware and software 

license/maintenance agreements and upgrades, ongoing staff training, and 

information technology (IT) support fees. In addition, hiring new staff— 

such as IT operations staff, clinical data analysts, or application analysts— 

can add to the ongoing costs.9 The estimated average yearly costs of an 

EHR system range from $4,000 to $8,000 per professional, depending on 

the type of EHR system.10 

6 We did not include $21.6 million of the $120.5 million in grant funds made available 

through ARRA because they were only for HIT innovation projects. 

7

 The number of HRSA-funded health centers that participated in EHR implementation
 

grant projects is based on Office of Inspector General (OIG) verification with HCCN
 

grantees. 

8

 Examples of enhancement projects include integrating with State-wide Health
 

Information Exchanges, expanding data reporting capabilities, implementing a patient
 

portal, and creating data registries. 

9

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

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

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

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

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

to cost me? Accessed at http://www.healthit.gov/providers-professionals/faqs/howmuch-going-cost-me on September 16, 2013.
 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 2 
 

 

 

 

 

 

HRSA awarded the EHR implementation grants as one-time funding; the 

grants were not intended to cover the ongoing maintenance and 

operational costs. HRSA expects HCCNs and their participating health 

centers to have a plan for how grant projects will be financially sustained 

during and after the period of Federal grant funding (grant period), 

particularly for ongoing maintenance and operational costs.11 

Grantee Progress Reports. For EHR implementation grants, HRSA 

required HCCN grantees to submit quarterly progress reports during the 

grant period. During the September 2011 grant period, HRSA updated the 

format of the grantee progress reports. The updated format includes (1) a 

narrative section to collect information on any challenges—whether 

related to financial sustainability or to other issues—experienced by 

HCCNs and participating health centers to date and (2) another field to 

collect sustainability plans. HRSA asked HCCNs to describe their 

sustainability plans because it expects HCCNs and their participating 

health centers to plan how grant projects will be sustained during and after 

the grant period. 

Meaningful Use of EHR Systems 

HRSA awarded the EHR implementation grants in 2009 and 2010 with the 

goal of implementing EHR systems to prepare health centers for 

meaningful use, without any requirement to meet any specific meaningful 

use objectives because such objectives had not yet been established.12 

HRSA required that grant funds be used only to implement or enhance an 

EHR system certified by an organization recognized by the Secretary of 

Health and Human Services.13, 14 Such certification provides assurance that 

the EHR system offers the necessary electronic capability to help health 

center professionals become meaningful users (i.e., demonstrate 

meaningful use objectives as defined in Federal regulations).15 

CMS is defining and rolling out the meaningful use objectives in three 

stages; each stage is adding increased capabilities to improve patient care, 

11 HRSA, HIT Implementation for HCCNs, HRSA-10-154, December 9, 2009, p. 28. 12 HRSA announced the latest funding opportunity for the ARRA-funded EHR 

implementation grants in December 2009, and applications were due in February 2010. 

The Centers for Medicare & Medicaid Services (CMS) did not finalize the definitions 

and requirements for Stage 1 meaningful use until July 2010. HRSA, HIT 

Implementation for HCCNs, HRSA-10-154, December 9, 2009; 42 CFR § 495.6. 13 HRSA, HIT Implementation for HCCNs, HRSA-10-154, December 9, 2009, p. 6. 14 ONC issued the initial set of certification criteria on January 13, 2010, which 

established the capabilities and related standards that certified EHR systems needed to 

support the achievement of the proposed Stage 1 meaningful use rule. ONC defined 

EHR certification requirements and the process for certification in Federal regulations. 

45 CFR pt. 170, subparts C–E. 

15 42 CFR § 495.6. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 3 
 

 

 

 

 

 

 

enhance care coordination, and increase patient engagement. For each 

meaningful use objective, CMS defines a specific measure that must be 

met to demonstrate the objective. In July 2010, CMS defined the Stage 1 

meaningful use objectives and their associated measures.16 These 

objectives set the baseline for two types of capabilities: 

	 capturing data (i.e., electronically capturing health information in a 

structured format17 and using it for evidence-based clinical 

decisions) and 

	 sharing data (i.e., electronically sharing health information for care 

coordination, patient engagement, and public health reporting).18 

In September 2012, CMS defined the Stage 2 meaningful use objectives, 

which expand on Stage 1 with a focus on sharing data for continued 

quality improvement.19 Stage 2 meaningful use objectives became 

effective on January 1, 2014 for professionals.20 CMS expects to define 

Stage 3 meaningful use objectives related to improved health outcomes in 

2016.21 

Under the Medicaid EHR incentive program, a professional who is 

eligible for the program (eligible professional)22 and demonstrates all 

three stages of meaningful use can receive incentive payments totaling 

$63,750 over 6 years.23 Eligible professionals who register for the 

Medicaid EHR incentive program have until 2017 to demonstrate Stage 1 

meaningful use to receive the maximum amount of incentive payments. 

16 75 Fed. Reg. 44314 (July 28, 2010). 17 “Structured data” is another way of referring to data that are entered into a specific 

field, as opposed to “free text” in a chart note. Structured data enable patient information
 

to be easily retrieved and transferred. CMS, Certified EHR Technology. Accessed at 

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

Certification.html on April 4, 2013. 18 ONC, How to Implement EHRs — Step 5: Achieve Meaningful Use. Accessed at 

http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-5-

achieve-meaningful-use on September 16, 2013.
 19 77 Fed. Reg. 53968, 53970 (Sept. 4, 2012). When CMS finalized Stage 2 meaningful
 

use objectives, it included minor changes to Stage 1 that take effect outside our period of 

review.
 20 CMS, Stage2. Accessed at http://www.cms.gov/Regulations-and-Guidance/Legislation 

/EHRIncentivePrograms/Stage_2.html on January 22, 2014. 21 ONC, Meaningful Use Definition & Objectives. Accessed at 

http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives on
 

September 16, 2013.
 22 42 CFR § 495.304(b). Eligible professionals include physicians, nurse practitioners, 

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

Medicaid EHR incentive program.
 23 42 CFR § 495.310. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 4 
 

 

 

Stage 1 Meaningful Use. After CMS finalized the Stage 1 meaningful use 

objectives, HRSA stated that the Stage 1 mandatory objectives (“core 

objectives”) are a reasonable baseline to assess health center progress on 

implementing EHR systems.24 The Stage 1 meaningful use core objectives 

include 15 objectives, of which 9 are related to capturing data and 5 are 

related to sharing data.25 Stage 1 also includes 10 additional objectives 

(“menu objectives”). An eligible professional who is participating in the 

Medicaid EHR incentive program would need to demonstrate Stage 1 

meaningful use by meeting the measures for all 15 of the core objectives 

and 5 of the 10 menu objectives, 1 of which must be a public health 

objective.26 Although a health center may have established the capability 

for Stage 1 meaningful use, it is up to the individual eligible professional 

to meet the measures for the objectives to receive incentive payments. See 

Appendix A for a list of the core and menu objectives for Stage 1 

meaningful use, along with the type of capability the objectives represent 

(i.e., capturing data or sharing data) and their associated measures for 

eligible professionals. 

METHODOLOGY 

Scope 

In July 2012, we surveyed health centers that fell within the scope of our 

study—namely, health centers that participated in EHR implementation 

grant projects and that are funded by HRSA through section 330 of the 

Public Health Services Act. These health centers are associated with the 

55 EHR implementation grants that HRSA awarded to 43 HCCNs with 

funds made available through ARRA. To supplement survey responses, 

we reviewed grantee progress reports submitted to HRSA by HCCNs in 

2011 and 2012 and we conducted site visits at a purposive sample of 

11 health centers from May to September 2012. 

To assess health centers’ progress toward implementing EHR systems that 

support meaningful use, we examined the extent to which health centers 

reported having the capability for Stage 1 meaningful use objectives, 

which set the baseline for capturing and sharing data. We use the Stage 1 

24 HRSA, UDS Reporting Instructions for Section 330 Grantees, January 2011, p. 114. 

Accessed at http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/2010manual.pdf on 

August 25, 2011; HRSA, UDS Reporting Instructions for Section 330 Grantees, 

December, 2012, p. 153. Accessed at http://www.bphcdata.net/docs/uds_rep_instr.pdf on 

July 23, 2013. 

25 42 CFR § 495.6. The core objectives also include one objective related to ensuring the 

privacy of health information. 

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

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

syndromic surveillance data). 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 5 
 

 

 

meaningful use objectives, as initially finalized by CMS, because HRSA 

stated that this set of Stage 1 core objectives is a reasonable baseline to 

assess health center progress in implementing EHR systems. 

We also determined whether health centers had reported facing challenges 

related to the financial sustainability of their EHR systems. 

Data Collection and Analysis 

Health Center Survey. We administered a survey to health centers to 

collect information on their progress toward implementing EHR systems 

that support meaningful use and any issues related to the financial 

sustainability of their EHR systems. To identify our survey population, we 

obtained from HRSA a list of HCCNs that received an EHR 

implementation grant(s) and these HCCNs’ section 330-funded health 

centers that participated in EHR implementation grant projects. However, 

HRSA could not confirm that the list was complete, as participating health 

centers may leave or join HCCNs. Therefore, we contacted all 43 HCCNs 

on HRSA’s list and asked them to verify their respective lists of health 

centers that were participating in grant projects. We also asked the 

HCCNs to provide names and contact information for any participating 

health centers that were not included on these lists. 

As a result, we compiled a list of 260 section 330-funded health centers 

participating in EHR implementation grant projects. We pretested the 

survey with six of these health centers and excluded them from the survey 

population. We administered the survey to the remaining 254 health 

centers. We received 246 responses, a 97-percent response rate. We 

excluded 13 health centers that reported they had not yet implemented an 

EHR system, because our survey questions focused on issues that are 

relevant only for health centers that have already implemented an EHR 

system.27 Therefore, our findings are based on 233 health centers. 

For the health centers that reported using an EHR system, we analyzed 

their survey responses to examine their progress toward implementing 

EHR systems that support meaningful use. For each Stage 1 meaningful 

use objective, the survey asked whether “all,” “most,” “some,” “few,” or 

“none” of the health center’s eligible professionals met the measure for the 

objective for the preceding 90 days.28 If the health center reported that all, 

most, some, or few of its eligible professionals met the measure, we 

concluded that the health center had established the capability for the 

27 These health centers had purchased an EHR system but had not yet implemented it at 

the time of our review. 

28 42 CFR § 495.4. We used a 90-day reporting period because the Medicaid EHR
 

incentive program uses a 90-day reporting period for the first year in which the eligible 

professional is demonstrating meaningful use.
 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 6 
objective. If the health center reported that none of its eligible 

professionals met the measure, we concluded that the health center had not 

established the capability for the objective. We asked health centers that 

did not establish the capability for the objective when they expected to 

establish it. If we concluded that a health center had established the 

capability for 15 core objectives and 5 menu objectives (including 1 of the 

public health menu objectives), we concluded that the health center had 

established the capability for all the objectives necessary for Stage 1 

meaningful use. Finally, we analyzed survey responses to determine the 

extent to which eligible professionals at health centers are registered for 

the Medicaid EHR incentive program. 

We analyzed survey responses from the health centers that reported using 

an EHR system to determine whether they reported facing challenges 

related to the financial sustainability of their EHR systems. For those 

health centers that reported facing such sustainability challenges, we 

analyzed open-ended survey responses to describe their challenges and 

their efforts to offset the ongoing costs of operating and maintaining the 

systems. 

Grantee Progress Reports. We obtained from HRSA all grantee progress 

reports submitted by HCCNs as of August 2012. We reviewed two fields 

in the narrative section of the most recent progress reports: challenges and 

sustainability plans. We reviewed the challenges to determine whether 

HCCNs reported to HRSA that their health centers were facing financial 

sustainability challenges during the grant period and whether these 

challenges, if any, were similar to those reported by health centers through 

our survey. We reviewed HCCN’s sustainability plans to determine 

whether the plans addressed the challenges that health centers reported 

facing related to the sustainability of their EHR systems. 

Health Center Site Visits. We visited a purposive sample of 11 health 

centers chosen on the basis of their location and size. We visited health 

centers in California, Delaware, Illinois, Maryland, Oregon, and Utah that 

varied in size (3,000 to 70,000 patient encounters per year), location 

(urban/rural), and duration of EHR system use. At each health center, we 

conducted structured onsite interviews with staff members (e.g., eligible 

professionals, the medical director, and executive management) who 

perform key roles in the health center’s EHR implementation and progress 

toward meaningful use. We asked the staff about their experiences in 

implementing the EHR system, including challenges they faced, and about 

the strategies they used to establish the capability for Stage 1 meaningful 

use objectives and to financially sustain the EHR system. Staff from five 

health centers completed our survey prior to our onsite visits. We asked 

these staff to elaborate on select responses from their survey. We analyzed 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 7 
the information from health center staff interviews for additional or 

supporting information on health centers’ progress toward implementing 

EHR systems that support meaningful use and challenges related to 

sustaining their EHR system. 

Limitations 

This study relies on self-reported data from health center respondents. We 

did not request documentation to verify their responses. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 8 
FINDINGS 

Most health centers established the capability for 

meaningful use objectives related to capturing data;

fewer established the capability for objectives related 

to sharing data 

Although the grants that HRSA awarded to HCCNs did not require 

participating health centers to demonstrate Stage 1 meaningful use, the 

health centers have made significant progress toward establishing the 

capability for objectives related to capturing data. However, they have not 

made commensurate progress with regard to the objectives related to 

sharing data, thus hindering their progress toward implementing EHR 

systems that support meaningful use. Seventy-two percent (168 of 233) of 

health centers had established the capability for all the core objectives 

related to capturing data.29 In contrast, only 24 percent (56 of 233) of 

health centers had done so for all the core objectives related to sharing 

data.30 Although most of the health centers (192 of 233) had established 

the capability for at least 5 menu objectives, only 36 percent (83 of 233) 

had done so for 1 of 2 public health menu objectives related to sharing 

data. Overall, 14 percent (32 of 233) of health centers had established the 

capability for all of the objectives necessary for Stage 1 meaningful use, 

i.e., all 15 of the core objectives plus 5 of the 10 menu objectives. 

Although only a small percentage of health centers had established the 

capability for all the objectives necessary for Stage 1 meaningful use, 

more than half of health centers had established the capability for each 

individual objective, with the exception of four objectives—one core, 

three menu—related to sharing data. (See Appendix B for an ordered list 

of the Stage 1 meaningful use objectives by the percentage of health 

centers with the capability for each objective.) 

Although only 14 percent of health centers had established the capability 

for all the objectives necessary for Stage 1 meaningful use, at the time of 

our review, an additional 27 percent (62 of 233) of health centers reported 

that they would establish the capability for Stage 1 by mid-2013. 

Furthermore, almost all health centers (221 of 233) reported that they 

expected all of their eligible professionals to register for the Medicaid 

EHR incentive program to demonstrate Stage 1 meaningful use and 

29 Core objectives related to capturing data include vital signs, active medication, 

medication allergy lists, demographics, drug interaction checks, problem lists, smoking 

status, computerized provider order entry, and clinical decision support. 

30 Core objectives related to sharing data include electronic prescribing, clinical 

summaries, clinical quality objectives, electronic copy of health information, and 

electronic exchange of clinical information. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 9 
receive incentive payments. Eligible professionals who register for the 

Medicaid EHR incentive program have until 2017 to demonstrate Stage 1 

meaningful use to receive the maximum amount of incentive payments. 

Therefore, participation in the Medicaid EHR incentive program indicates 

that the majority of health centers plan to establish the capability to enable 

all of their eligible professionals to demonstrate Stage 1 meaningful use by 

2017 or earlier. 

Establishing the capability for objectives related to sharing 

data often requires health centers to incur additional 

EHR-related costs 

Establishing the capability for objectives related to sharing data may be 

challenging for health centers because these objectives can require health 

centers to incur additional EHR-related costs. Health centers reported that 

they have to purchase separate applications or pay separate fees for 

specific software capabilities for objectives related to sharing data with 

other providers of care,31 public health agencies, and patients. Health 

centers reported that such costs can be unanticipated because they 

expected their certified EHR systems to include all the capabilities 

necessary to demonstrate meaningful use. 

Establishing the Capability To Share Data With Other Providers of Care 

and Public Health Agencies May Create Financial Challenges. On 

average, only 27 percent (63 of 233) of health centers had established the 

capability for the 3 objectives related to sharing data with other providers 

of care and public health agencies. Establishing this capability may 

require health centers to purchase additional technology to establish an 

interface (i.e., a data connection to an external system). In their surveys, 

health centers provided supplementary information about the financial 

challenges associated with establishing interfaces. For example, one 

health center reported that every different connection with outside entities 

“requires the purchase of a very expensive interface [along with] the cost 

of IT support and training.” Another health center reported that its health 

31 For the purposes of this report, “provider of care” is a general term that includes not 

only professionals, but also hospitals and other patient-authorized entities (i.e., any 

individual or organization to which the patient has granted access to his or her clinical 

information). 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 10 
 

 

 

 

 

 

 

information exchange32 interface will cost $39 per professional per month, 

which will create an additional expense in excess of $10,000 per year. 

Additionally, health centers reported that establishing interfaces to share 

information can also be challenging because such sharing is dependent on 

the readiness of other entities. Even if the health center is prepared to 

send information electronically, some organizations—such as 

immunization registries and State health departments—may not have the 

ability to receive the electronic data. 

Establishing the Capability To Share Data With Patients May Create 

Financial Challenges. Only 29 percent (68 of 233) of health centers had 

established the capability for the objective related to providing patients 

with electronic access to their health information. A common way to 

establish this capability is to implement a patient portal, which is an online 

application that can enable patients to access their health records and 

allow them to interact and communicate with their professionals. 

However, patient portals may be costly for health centers to implement 

and financially sustain. During our site visit to one health center, staff 

reported that the center’s patient portal technology cost $80,000. Another 

health center reported that its vendor charges it $49 per month per 

professional, which increases its annual expenses by $15,000 per year. A 

third health center reported that its vendor charges it $150 per month per 

professional. This objective was optional for Stage 1 meaningful use, but 

it will be required for Stage 2 along with additional objectives that can be 

met through the use of a patient portal.33 

32 The term “health information exchange,” or HIE, refers to the process of sharing 

health-related information among organizations according to nationally recognized 

standards. The term is often used interchangeably to refer both to a process and an entity, 

with many organizations referring to themselves as HIEs. Search HealthIT, Briefing: 

What is Health Information Exchange? Accessed at 

http://searchhealthit.techtarget.com/tutorial/FAQ-What-is-health-informationexchange#HIEstandards on January 29, 2013. Health information exchanges are 

different from health insurance exchanges, which are entities that are meant to create a 

more organized and competitive market for health insurance. Kaiser Family Foundation, 

Explaining Health Care Reform: Questions About Health Insurance Exchanges, 

April 2010. Accessed online at 

http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7908-02.pdf on July 11, 2013. 33 Stage 2 Core Objective 12 (send reminders for preventive care) and Core Objective 17 

(use secure electronic messaging) can be met through the use of a patient portal. 

77 Fed. Reg. 54031 (Sept. 4, 2012). ONC, How to Implement EHRs — Step 5: Achieve 

Meaningful Use, Patient Reminders. Accessed at http://www.healthit.gov/providersprofessionals/achieve-meaningful-use/menu-objectives/patient-reminders on July 11, 

2013. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 11 
The extent to which eligible professionals met the Stage 1 

meaningful use objectives related to capturing and sharing 

data varied 

We concluded that a health center had established the capability for a 

meaningful use objective if the health center reported that “all,” “most,” 

“some,” or “few” of its eligible professionals met the objective. Although 

a health center may have established the capability for an objective, the 

extent to which its eligible professionals actually met the objective varied 

from a “few” to “all” eligible professionals. This variation may indicate 

how difficult it is for eligible professionals to meet an objective once the 

health center has established the capability. For example, although 

93 percent (216 of 233) of health centers established the capturing-data 

capability related to recording the smoking status for all patients 13 years 

old or older, only 37 percent (86 of 233) of health centers reported that all 

of their eligible professionals met that objective. Health centers reported 

that this objective is difficult for their eligible professionals to meet for a 

variety of reasons, including difficulties in capturing the data in a 

structured format and resistance to requesting the information from 

patients as young as 13. Furthermore, some eligible professionals, such as 

dentists, do not normally request this information from patients. 

Although 82 percent (191 of 233) of health centers had established the 

sharing-data capability related to providing clinical summaries to patients 

following a visit, only 21 percent (50 of 233) of health centers reported 

that all of their eligible professionals met that objective. Health centers 

reported that this objective is difficult for their eligible professionals to 

meet, because it is challenging to accurately record the health information 

in a meaningful way. Specifically, sometimes it is challenging for eligible 

professionals to accurately record health information in plain language 

and—for patients whose native language is not English—to provide it in a 

clinical summary in the patient’s native language. Other health centers 

reported that this objective is difficult because of the logistics of having to 

print the summary before the patient leaves the health center. (See 

Appendix C for a breakdown of the Stage 1 meaningful use objectives by 

the extent to which eligible professionals at health centers met them.) 

Seventy-six percent of health centers reported facing 

financial sustainability challenges 

Seventy-six percent (177 of 233) of health centers reported that they face, 

or anticipate facing, challenges related to the financial sustainability of 

their EHR systems. Health centers reported facing such challenges largely 

as a result of increased costs and loss of productivity and despite their 

efforts to offset the costs of sustaining an EHR system. Health centers’ 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 12 
 

use of EHR systems and ability to provide services may be negatively 

impacted when the centers face financial sustainability challenges that 

they are unable to overcome. 

Health centers face financial sustainability challenges because 

of increased costs and loss of productivity associated with 

their EHR systems 

The health centers that reported facing financial sustainability challenges 

commonly reported challenges related to increased costs and a loss of 

productivity associated with the EHR system. Of the health centers that 

reported facing such challenges, 66 percent (116 of 177) cited increased 

costs and 25 percent (45 of 177) cited a loss of productivity. Health 

centers generally reported facing more than one type of sustainability 

challenge at the same time. 

The Increased Costs Associated With Operating and Maintaining an EHR 

System Can Be Challenging for Health Centers. Of the health centers that 

reported facing financial sustainability challenges, almost a third cited 

challenges related to the costs of operating an EHR system. These 

operational costs include ongoing staff training costs, IT support fees, 

interface costs, software licensing fees, and telecommunications fees. At 

the same time, approximately a quarter of health centers cited challenges 

related to the costs of maintaining the EHR system. These maintenance 

costs include hardware and software maintenance agreements and 

upgrades. Other health centers cited EHR-related costs in general that 

could not be categorized as operational or maintenance costs specifically. 

A Loss of Productivity—Or a Decline in the Number of Patient Visits— 

Can Be Associated With Lower Reimbursement From Payers and 

Decreased Revenue. Thirty-six health centers reported that loss of 

productivity was one of the most costly aspects of EHR implementation. 

These health centers reported a range of lost revenues that were due to a 

loss of productivity. For example, one health center reported that the loss 

of productivity has resulted in $900,000 in lost revenues per year, whereas 

another health center estimated its loss at $15,000. 

A persistent loss of productivity following EHR implementation may 

occur as a result of usability issues with the EHR system. When a health 

centers’ EHR system is difficult for professionals to use, they may not be 

able to see as many patients as they were able to see prior to EHR 

implementation. For example, on one of our site visits to a health center, 

professionals explained that it takes longer for them to navigate through 

the EHR and check all the appropriate boxes than it took for them to fill 

out the paper record. Furthermore, professionals explained that the EHR 

system and the meaningful use objectives place a larger documentation 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 13 
burden on them than on other staff. The 45 health centers that reported 

facing sustainability challenges that are due to a loss of productivity 

implemented their EHR system almost 2 years prior to our review, on 

average. Eight of these health centers implemented their EHR system 

more than 3 years prior to our review. 

Health centers face financial sustainability challenges despite 

efforts to offset the costs of sustaining an EHR system 

The health centers that reported facing financial sustainability challenges 

also reported that they are trying to offset the costs of sustaining their 

EHR systems. Their efforts to offset costs included identifying additional 

sources of funding (e.g., external funding opportunities and Medicaid 

EHR incentive payments), increasing efficiencies with their respective 

EHR systems (e.g., enhancing collections of billable claims and 

optimizing billing), and increasing productivity through training and 

optimizing EHR systems to enable professionals to navigate them more 

quickly. 

Health centers’ use of their EHR systems and their ability to provide 

services could be negatively impacted if the centers are not able to 

overcome financial sustainability challenges. Health centers provided 

supplementary information on their surveys about the difficult decisions 

they have had to make to address sustainability challenges. Centers stated 

that because of the high costs of operating and maintaining EHR systems, 

they have had to delay purchasing and implementing interfaces, patient 

portals, and other capabilities. Other health centers reported that their 

sustainability challenges affect their ability to provide services to patients. 

One health center stated that “reduced productivity compounded with 

extra [EHR-related] costs have caused the health center to be operating at 

a loss and [we are] faced with cutting positions to continue providing the 

same level of services to our patients.” Some health centers reported that 

their only option has been to charge patients more for services. Other 

health centers reported that staff dissatisfaction with the EHR system has 

led some experienced professionals to quit. 

HCCNs’ grantee progress reports contained limited 

information related to the financial sustainability of 

EHR systems at health centers 

HCCNs, not health centers, wrote and submitted quarterly grantee 

progress reports to HRSA during the grant periods. We found that as a 

result, the narratives in the grantee progress reports were generally written 

from the HCCN perspective and contained limited information about the 

financial sustainability of EHR systems at their health centers. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 14 
 

First, some of the financial sustainability challenges reported by health 

centers were not reflected in the grantee progress reports. Second, most 

grantee progress reports did not include the HCCNs’ plans to sustain EHR 

systems at health centers beyond the grant period. As a result of these 

limitations, HRSA may lack information on the challenges that health 

centers are facing and on how HCCNs are supporting their health centers’ 

efforts to financially sustain their EHR systems. 

Financial sustainability challenges reported by health centers 

were generally not reflected in HCCNs’ grantee progress 

reports 

HRSA requested information related to challenges experienced during the 

grant period to date, but it did not specify whether these challenges should 

be those experienced by the HCCN or those experienced by the health 

center. The grantee progress reports that we examined generally did not 

mention challenges specific to health centers’ ability to sustain their EHR 

systems. As a result, financial sustainability challenges reported by health 

centers through our survey were generally not reflected in the grantee 

progress reports that HCCNs submitted to HRSA. For example, in 

response to our survey, 45 health centers associated with 25 different 

HCCNs reported loss of productivity as a sustainability challenge. 

However, only 4 of those 25 HCCNs reported their health centers’ loss of 

productivity as a challenge in their grantee progress reports. Furthermore, 

for five HCCNs, the field for “challenges” in the grantee progress reports 

was left blank in at least one of the two most recent submissions. When 

HCCNs’ grantee progress reports do not mention the sustainability 

challenges that their health centers are facing, HRSA may not be aware of 

the extent of these challenges. 

Most sustainability plans did not include plans to sustain EHR 

systems at health centers 

HRSA requested that in their grantee progress reports, HCCNs describe 

their respective sustainability plans, including a brief description of their 

plans to sustain the grant projects beyond the grant period. However, 

three HCCNs did not include such plans in their most recent grantee 

progress reports. Furthermore, the majority of the sustainability plans in 

progress reports did not include information specific to the HCCNs’ plans 

to sustain EHR systems at the health-center level beyond the grant period. 

Instead, the majority of the sustainability plans that were submitted in 

grantee progress reports included information related to how the HCCNs 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 15 
 

 

 

planned to sustain their own operations (26 of 38).34 These plans included 

strategies such as charging membership fees, leveraging funding from HIT 

regional extension centers,35 expanding HCCN membership, and relying 

on external funding opportunities. 

When sustainability plans have limited information at the health-center 

level, HRSA may lack information on how HCCNs help or hinder health 

centers’ efforts to financially sustain their EHR systems. For example, the 

majority of sustainability plans that focused only on HCCNs included 

strategies related to relying on resource commitments (e.g., membership 

fees) from their current health center members for sustaining HCCN 

operations (18 of 26). Most HCCNs require such resource commitments 

from their member health centers, but the grantee progress reports 

generally do not include any information on the affordability of these 

resource commitments and how they affect health centers’ budgets. For 

example, one health center reported that the fees its HCCN charged were 

not “fairly divided among health centers.” (In this case, the HCCN 

charged the same fee for each health center, rather than weighting it by 

each center’s number of professionals). 

34 In addition to the three HCCNs that did not include sustainability plans in their most 

recent grantee progress reports, two HCCNs were reporting in the older format wherein 

HRSA did not request a sustainability plan. There were 43 HCCN grantees. Therefore, 

we analyzed 38 sustainability plans. 

35 Section 3012(a) of the Public Health Service Act created the HIT extension program 

that provides grants to establish HIT regional extension centers to provide technical 

assistance and guidance to all professionals. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 16 
 

 

 

 

 

CONCLUSION AND RECOMMENDATIONS 

To improve coordination of care and to implement new models of service 

delivery and payment, it is critical that EHR systems be able not just to 

capture data, but also to share data.36 Although most health centers that 

participated in EHR implementation grant projects through their respective 

HCCNs established the capability for meaningful use objectives related to 

capturing data, fewer established the capability for objectives related to 

sharing data. Establishing capabilities for objectives related to sharing 

data is a challenge that is not unique to health centers. Recent research 

indicates that there are substantial barriers to the widespread sharing of 

health information across all practice settings.37 

Although HRSA’s EHR implementation grants were not intended to cover 

the ongoing costs of operating and maintaining EHR systems, HRSA 

expects HCCNs and health centers to have sustainability plans to cover 

these costs. However, 76 percent of health centers using EHR systems 

reported facing challenges related to their financial sustainability. 

Additional costs incurred by health centers as they establish the capability 

to share data can contribute to financial sustainability challenges. Health 

centers’ use of their EHR systems and their ability to provide services may 

be negatively impacted if health centers are not able to overcome such 

challenges. 

HRSA may not have complete information regarding financial 

sustainability at health centers because grantee progress reports submitted 

by HCCNs provided limited information. These progress reports do not 

give HRSA enough information to determine whether health centers are 

able to financially sustain HRSA’s investment in EHR systems over the 

long term in the absence of future Federal grant opportunities, incentive 

payments, and new payment models under the Affordable Care Act. 

36 78 Fed. Reg. 14793 (March 7, 2013). 

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

Substantially In 2008–12,” Health Affairs 32 (8), August 2013. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 17 
 

To address these issues, we recommend that HRSA: 

Use data to understand progress towards meaningful use 

objectives and to provide guidance and technical assistance 

to health centers 

HRSA is updating its progress-reporting process for grantees to reflect its 

most recent fiscal year 2013 funding opportunity, which will require 

HCCNs to report on their participating health centers’ attainment of 

meaningful use objectives as well as emerging needs and challenges 

encountered related to meaningful use.38 HRSA also collects similar 

meaningful use information from all health centers reporting to HRSA’s 

Uniform Data System, its annual reporting tool for health centers. Moving 

forward, HRSA should use this information to determine what types of 

assistance—technical or financial—health centers need to implement the 

capabilities related to sharing data. 

Ensure that HCCN grantees provide information on the 

financial sustainability of EHR systems at health centers 

The goal of HRSA’s HIT-related grants is to serve the interests of health 

centers through HCCNs. We found that most grantee progress reports did 

not contain information on financial sustainability of EHR systems at 

health centers. As part of its ongoing monitoring of HCCN grantees, 

HRSA could gather information from HCCNs about the financial impact 

of implementation on participating health centers, including information 

on health centers’ current and anticipated challenges. HRSA could also 

gather information from HCCNs about the specific actions they are taking 

to assist health centers’ efforts to financially sustain their EHR systems. 

Examine the feasibility of collecting information directly from 

health centers regarding the financial sustainability of their 

EHR systems 

Grantee progress reports are submitted only by current HCCN grantees. 

To determine whether health centers are able to financially sustain HRSA’s 

investment in EHR systems over the long term, HRSA should consider the 

feasibility of gathering information directly from all health centers 

regarding the financial sustainability of their EHR systems. Specifically, 

HRSA could do so by using existing tools—such as its Uniform Data 

System—for monitoring health centers. This would enable HRSA to 

annually collect sustainability information on all of its health centers, as 

opposed to only those currently participating in HRSA HIT-related grant 

projects. 

38 77 Fed. Reg. 72870 (Dec. 6, 2012). 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 18 
 

This information would be helpful for HRSA as it plans for future funding 

opportunities. HRSA could also use this information to provide guidance 

and technical assistance to health centers to help them financially sustain 

their EHR systems. For example, HRSA could use the information to 

identify promising practices and to reach out to health centers that report 

facing financial sustainability challenges. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 19 
 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

HRSA concurred with all of our recommendations. 

To address our recommendation that HRSA use data to understand 

progress towards meaningful use objectives and to provide guidance and 

technical assistance to health centers, HRSA stated it will continue to 

analyze information from health center UDS reports and HCCN progress 

reports on meaningful use attainment. HRSA will use this information to 

inform future HIT technical assistance and training webinars. 

To address our recommendation that HRSA ensure HCCN grantees 

provide information on the financial sustainability of EHR systems at 

health centers, HRSA commented that it has increased its focus on 

sustaining EHR systems as part of its recent funding opportunity 

announcements. 

To address our final recommendation that HRSA examine the feasibility of 

collecting information directly from health centers regarding the financial 

sustainability of their EHR systems, HRSA stated that it will update its 

Site Visit Protocol to ensure a portion of the visit focuses on financial 

sustainability, addresses health center concerns, and provides targeted 

guidance. HRSA commented that it uses information submitted by health 

centers in the annual UDS reports and required independent audits to 

monitor financial sustainability of health centers. 

For a full text of HRSA’s comments, see Appendix D. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 20 
 

 

 

 

 

 

 

APPENDIX A 

Stage 1 Meaningful Use Objectives 

Core objectives 

Objective Type of Capability Measure 

1. Use computerized 

provider order entry 

(CPOE) 

Capturing data 

More than 30 percent of all 

unique patients with at least one 

medication in their medication 

list have at least one medication 

order entered using CPOE. 

2. Implement drug 

interaction checks Capturing data 

The eligible professional (EP) 

enables drug-drug and 

drug-allergy check functionality 

for the entire reporting period. 

3. Maintain problem 

lists Capturing data 

More than 80 percent of all 

unique patients have at least one 

entry (or an indication that no 

problems are known for the 

patient) recorded as structured 

data. 

4. Use electronic 

prescribing Sharing data 

More than 40 percent of all 

permissible prescriptions written 

by the EP are transmitted 

electronically using certified 

EHR systems. 

5. Maintain active 

medication lists Capturing data 

More than 80 percent of all 

unique patients have at least one 

entry (or an indication that the 

patient is not currently 

prescribed any medication) 

recorded as structured data. 

6. Maintain medication 

allergy lists Capturing data 

More than 80 percent of all 

unique patients have at least one 

entry (or an indication that the 

patient has no known medication 

allergies) recorded as structured 

data. 

7. Record 

demographics Capturing data 

More than 50 percent of all 

unique patients have 

demographics recorded as 

structured data. 

8. Record vital signs Capturing data 

More than 50 percent of all 

unique patients age 2 and over 

have height, weight, and blood 

pressure recorded as structured 

data. 

9. Record smoking 

status Capturing data 

More than 50 percent of all 

unique patients 13 years old or 

older have smoking status 

recorded as structured data. 

continued on next page 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 21 
 

 

 

 

 

 

Stage 1 Meaningful Use Objectives 

Core objectives (continued) 

Objective Type of Capability Measure 

10. Report clinical 

quality measures 

(CQMs) 

Sharing data 

The EP successfully reports 

ambulatory CQMs selected by CMS 

in the manner specified by CMS. 

11. Implement 

clinical decision 

support rule 

Capturing data The EP implements one clinical 

decision support rule. 

12. Provide 

electronic copy 

of health 

information 

Sharing data 

More than 50 percent of all patients 

who request electronic copies of their 

health information are provided with 

copies within 3 business days. 

13. Provide clinical 

summaries Sharing data 

For more than 50 percent of all office 

visits, clinical summaries are provided 

to patients within 3 business days. 

14. Exchange 

clinical 

information 

electronically 

Sharing data 

The EP performs at least one test of 

the certified EHR system’s capacity to 

electronically exchange key clinical 

information. 

15. Protect 

electronic health 

information 

Ensuring privacy 

The EP conducts or reviews a security 

risk analysis in accordance with the 

requirements under 

45 CFR 164.308(a)(1). The EP 

implements security updates as 

necessary and corrects identified 

security deficiencies as part of the 

risk-management process. 

Menu objectives 

Objective Type of Capability Measure 

1. Implement drug 

formulary checks Capturing data 

The EP enables the functionality to 

check drug formularies and has access 

to at least one internal or external 

formulary for the entire EHR 

reporting period. 

2. Incorporate 

clinical lab test 

results 

Capturing data 

More than 40 percent of all clinical 

lab test results ordered by the EP 

during the EHR reporting period 

whose results are either in a 

positive/negative or numerical format 

are incorporated in certified EHR 

system as structured data. 

3. Generate patient 

lists Capturing data 

The EP generates at least one report 

listing patients with a specific 

condition. 

4. Send patient 

reminders Sharing data 

More than 20 percent of all patients 65 

years old or older or 5 years old or 

younger were sent an appropriate 

reminder during the EHR reporting 

period. 

continued on next page 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 22 
 

 

 

Stage 1 Meaningful Use Objectives 

Menu objectives (continued) 

Objective Type of Capability Measure 

5. Provide patients with 

electronic access Sharing data 

At least 10 percent of all unique 

patients are provided timely 

(available to the patient within 

4 business days of being updated 

in the certified EHR system) 

electronic access to their health 

information subject to the EP’s 

discretion to withhold certain 

information. 

6. Provide patientspecific education 

resources 

Sharing data 

More than 10 percent of all 

unique patients are provided 

patient-specific education 

resources. 

7. Perform medication 

reconciliation Capturing data 

The EP performs medication 

reconciliation for more than 

50 percent of transitions of care. 

8. Provide transition of 

care summaries Sharing data 

The EP who transitions or refers a 

patient to another setting of care 

or provider of care provides a 

“summary of care” record for 

more than 50 percent of 

transitions of care and referrals. 

9. Submit electronic 

data to immunization 

registries 

Sharing data 

The EP performs at least one test 

of the certified EHR system’s 

capacity to submit electronic data 

to immunization registries and a 

followup submission if the test is 

successful. 

10. Submit electronic 

syndromic 

surveillance data 

Sharing data 

The EP performs at least one test 

of the certified EHR system’s 

capacity to provide electronic 

syndromic surveillance data to 

public health agencies and a 

followup submission if the test is 

successful (unless none of the 

public health agencies to which 

an EP submits such information 

has the capacity to receive the 

information electronically). 

Source: OIG analysis of Federal regulations (42 CFR § 495.6), 2013. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 23 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX B 

Stage 1 Meaningful Use Objectives and the Percentage of 

Health Centers With the Capability for Each Objective 

Objective 

Percentage 

with Capability 

(N=233) 

Type of 

Capability 

Core or Menu 

Objective 

Record vital signs 96% Capturing data Core 

Maintain active medication lists 95% Capturing data Core 

Maintain medication allergy lists 95% Capturing data Core 

Record demographics 95% Capturing data Core 

Implement drug interaction checks 93% Capturing data Core 

Maintain problem lists 94% Capturing data Core 

Record smoking status 93% Capturing data Core 

Use computerized provider order entry 92% Capturing data Core 

Use electronic prescribing 91% Sharing data Core 

Generate patient lists 90% Capturing data Menu 

Provide patient-specific education 

resources 

87% Sharing data Menu 

Incorporate clinical lab test results 85% Capturing data Menu 

Provide clinical summaries 82% Sharing data Core 

Perform medication reconciliation 78% Capturing data Menu 

Implement clinical decision support rule 77% Capturing data Core 

Provide transition of care summaries 74% Sharing data Menu 

Implement drug formulary checks 73% Capturing data Menu 

Protect electronic health information 66% Ensuring 

privacy Core 

Send patient reminders 67% Sharing data Menu 

Report clinical quality measures 60% Sharing data Core 

Provide electronic copy of health 

information 58% Sharing data Core 

<50% 

Exchange clinical information 

electronically 37% Sharing data Core 

Submit electronic data to immunization 

registries 33% Sharing data Menu* 

Provide patients with electronic access 29% Sharing data Menu 

Submit electronic syndromic 

surveillance data 10% Sharing data Menu* 

*One of the two public health menu objectives is necessary to demonstrate Stage 1 meaningful use. 

Source: OIG analysis of survey responses and Federal regulations (42 CFR § 495.6), 2013. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 24 
APPENDIX C 

The Extent to Which Eligible Professionals (EP) at Health Centers Met the Stage 1 Meanin

Table C-1: Percentage of Health Centers by the Extent to Which Their EPs Met the Stage Objectives for At Least 90 Days 

Core Objectives 

Use 

computerized 

provider order 

entry 

Implement 

drug 

interaction 

checks 

Maintain problem lists 

Use 

electronic 

prescribing 

Maintain 

active 

medication 

lists 

Maintain 

medication 

allergy lists 

Record 

demographics 

Record 

vital 

signs 

Record 

smoking 

status 

Report clinical 

quality 

measures 

Implement 

clinical 

decision 

support 

rule 

Provide 

electroni

copy of 

health 

informatio

Percentage of Health Centers (N=233)** 

All EPs met 52% 60% 53% 47% 58% 54% 72% 61% 37% 28% 37% 25% 

Most EPs met 28% 23% 31% 31% 30% 32% 18% 29% 41% 19% 24% 14% Some EPs met 9% 8% 7% 9% 6% 7% 4% 4% 12% 11% 12% 10% Few EPs met 3% 3% 3% 3% 2% 2% 1% 2% 3% 3% 4% 9% No EPs met 5% 5% 4% 6% 3% 3% 3% 3% 5% 26% 12% 23% Don’t know 1% 2% 3% 3% 2% 2% 2% 2% 2% 14% 11% 9% 

* Yes/no-only objective that can be attested to at the health center level versus the EP level.** Some column percentages do not total 100 percent because of rounding and/or because health centers claimed an exclusion to an objective. An exclusion maobjective is not applicable to the EP. Source: OIG analysis of survey responses, 2012. Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 
Table C-2: Percentage of Health Centers by the Extent to Which Their EPs Met the Stage 

Objectives for At Least 90 Days 

Menu Objectives 

Implement 

drug 

formulary 

checks 

Incorporate 

clinical lab 

test results 

Generate 

patient 

lists 

Send 

patient 

reminders 

Provide 

patients 

with 

electronic 

access 

Provide 

patientspecific 

education 

resources 

Perform 

medication 

reconciliation 

Provide 

transition of 

care 

summaries 

e

im

r

Percentage of Health Centers (N=233)** 

All EPs met 45% 61% 65% 16% 9% 31% 31% 21% 

Most EPs met 16% 15% 12% 18% 6% 27% 27% 26% Some EPs met 6% 7% 9% 19% 8% 21% 14% 17% Few EPs met 5% 2% 4% 13% 6% 7% 6% 10% No EPs met 17% 12% 7% 26% 67% 10% 14% 16% Don’t know 9% 3% 3% 6% 4% 3% 7% 9% 

* Yes/no-only objectives that can be attested to at the health center level versus the EP level.** Some column percentages do not total 100 because of rounding and/or because health centers claimed an exclusion to a objective. An exmeaningful use objective is not applicable to the EP. Source: OIG analysis of survey responses, 2012.

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 
APPENDIX D 

Agency Comments 

Health Resources and Services 

DEPARTMENT OF HEALTH &. HUMAN SERVICES Administration 

Rockville MD 20857 

TO: Deputy Inspector General 

Inspector General, HHS OIG 

FROM: Administrator, Health Resources and Services Administration 

SUBJECT: HRSA's comments on Progress In Electronic Health Record Imp/emenation 

through HRSA Grants to Health Center Controlled Networks, (OEI-09-11­

00830) 

Thank you for the opportunity to review and provide comments on OIG's report. Attached 

please find HRSA's comments. 

If you have any questions, please contact Rebeca Sanchez-Barrett in HRSA's Office of Planning, 

Analysis and Evaluation at (301) 443-0324. 

Mary K. Wakefield, Ph.D., R.N. 

Attachments 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 27 
 

Agency Comments Continued 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 28 
 

Agency Comments Continued 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 29 
ACKNOWLEDGMENTS 

This report was prepared under the direction of Timothy Brady, Regional 

Inspector General for Evaluation and Inspections in the San Francisco 

regional office, and Michael Henry, Deputy Regional Inspector General. 

China Tantameng served as the team leader for this study, and 

Tiffany Stanley served as the lead analyst. Other Office of Evaluation and 

Inspections staff from the San Francisco regional office who conducted 

the study include Linda Min. Central office staff who provided support 

include Clarence Arnold, Heather Barton, Kevin Manley, Christine Moritz, 

and Sherri Weinstein. 

Progress in EHR Implementation Through HRSA Grants to Health Center Controlled Networks (OEI-09-11-00380) 30 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.