ELECTRONIC 

HEALTH RECORD 

PROGRAMS

Participation Has 

Increased, but Action 

Needed to Achieve 

Goals, Including 

Improved Quality of 

Care

Report to Congressional Committees

March 2014

GAO-14-207

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-207, a report to 

congressional committees

March 2014

ELECTRONIC HEALTH RECORD PROGRAMS

Participation Has Increased, but Action Needed to 

Achieve Goals, Including Improved Quality of Care

Why GAO Did This Study

The Health Information Technology for 

Economic and Clinical Health 

(HITECH) Act established the EHR 

programs, which provide incentive 

payments for—and later are expected 

to apply penalties to—certain 

providers, such as hospitals and 

professionals, to encourage them to 

demonstrate meaningful use of 

certified EHR technology and meet 

other program requirements. For 

example, one measure of meaningful 

use requires providers to implement 

checks for potential drug interactions 

with patients’ other drugs and allergies.

As mandated by the HITECH Act, GAO 

(1) assessed the extent of current and 

expected participation in the EHR 

programs, (2) examined information 

reported by providers and others to 

measure meaningful use in the EHR 

programs, (3) evaluated HHS efforts to 

ensure that EHR data can be reliably 

used to measure quality of care, and 

(4) evaluated HHS efforts to assess 

the effect of the EHR programs on 

program goals related to adoption and 

meaningful use of EHRs and improved 

outcomes. GAO analyzed data from 

CMS and other sources; reviewed 

applicable statutes, regulations, and 

guidance; and interviewed officials 

from HHS and stakeholder groups.

What GAO Recommends

GAO recommends that HHS develop a 

comprehensive strategy to better 

ensure the reliability of CQM data 

collected using EHRs and develop and 

use outcome-oriented performance 

measures to monitor progress toward 

goals. HHS agreed data reliability and 

performance monitoring are important 

but neither agreed nor disagreed with 

GAO’s recommendations.

What GAO Found

Based on the number of providers awarded incentive payments, participation in 

the Department of Health and Human Services’ (HHS) Medicare and Medicaid 

Electronic Health Record (EHR) programs increased substantially from their first 

year in 2011 to 2012. For hospitals, participation increased from 45 percent of 

those eligible for 2011 to 64 percent of those eligible for 2012. For professionals, 

such as physicians, participation increased from 21 percent of those eligible for 

2011 to 48 percent of those eligible for 2012. While increases occurred, a 

substantial percentage of providers that participated in 2011 did not participate in 

2012. Officials who oversee the programs at the Centers for Medicare & 

Medicaid Services (CMS) noted there could be several reasons for this, such as 

challenges in demonstrating meaningful use, and are monitoring the issue. 

Various program changes make future participation difficult to estimate. For 

example, increased stringency of requirements for the programs’ second phase 

beginning in 2014—Stage 2—may slow participation, while the introduction of 

penalties in 2015 for some providers may motivate participation.

Reporting on meaningful use for 2011 and 2012 indicates that providers who 

have already participated in the programs’ first phase—Stage 1—used their 

certified EHR systems more often than required. For example, for both 2011 and 

2012, Medicare hospitals reported using computerized provider order entry for 

over 84 percent of patients—in excess of the required threshold for Stage 1 of 30 

percent. However, some meaningful use measures may be more challenging for 

providers, including measures involving the electronic exchange of information. 

For example, less than 15 percent of professionals reported on an optional 

Stage 1 measure to provide a summary of care document at each care transition 

or referral, which is mandatory in Stage 2. A CMS official said the agency is 

taking steps to help providers prepare for Stage 2 meaningful use measures.

The lack of a comprehensive strategy limits HHS’s ability to ensure the 

department can reliably use the clinical quality measures (CQM) collected in 

certified EHRs for quality measurement activities. Reliability issues persist, 

although CMS and HHS’s Office of the National Coordinator for Health 

Information Technology (ONC) have made efforts to address concerns. For 

example, different providers may report CQMs based on and tested to different

requirements depending on whether their EHRs have incorporated technical 

updates. Without a comprehensive strategy, efforts to address reliability issues 

(in accordance with the internal control standard requiring relevant and reliable 

information) and improve quality and efficiency may be limited.

Consistent with law and GAO guidance on assessing agency performance, HHS, 

CMS, and ONC have established some performance measures for the EHR 

programs that are tied to strategic goals regarding adoption and meaningful use 

of EHRs; however, they have not established measures that would help them to 

track progress toward program outcomes such as health care quality, efficiency, 

and patient safety. Although HHS expects that the use of EHRs can help achieve 

improved outcomes and support other efforts that are also intended to improve 

care, that result is not yet assured. CMS and ONC may lack critical information 

necessary to establish program priorities and subsequently make program 

adjustments based on progress toward outcomes.

View GAO-14-207. For more information, 

contact Linda T. Kohn at (202) 512-7114 or 

kohnl@gao.gov.
Page i GAO-14-207 Electronic Health Record Programs

Letter 1 

Background 8

Participation in the EHR Programs Has Increased, but Program 

Changes Make It Difficult to Estimate Future Participation 19

Providers Exceeded Meaningful Use Requirements for Most 

Stage 1 Measures, but May Face Challenges with Certain More 

Stringent Stage 2 Measures 27

HHS Lacks a Comprehensive Strategy to Help Ensure Reliability 

of EHR Data Collected to Improve Quality of Care 34

Performance Measures for the EHR Programs Do Not Assess 

Outcomes Such As Improved Quality, Efficiency, and Patient 

Safety 39

Conclusions 42

Recommendations for Executive Action 43

Agency Comments and Our Evaluation 44

Appendix I Effect of the HITECH Act on Health Insurance Premiums 48

Appendix II Scope and Methodology 50

Appendix III Stage 1 and Stage 2 Meaningful Use Measures 55

Appendix IV Meaningful Use Measure Reporting for the Medicare EHR 

Program, 2011 and 2012 62

Appendix V Strategic Goals and Associated Performance Measures Relevant 

to the EHR Programs 67

Appendix VI Program Evaluations Assessing the EHR Programs’ Effects 

on Outcomes 70

Contents
Page ii GAO-14-207 Electronic Health Record Programs

Appendix VII Comments from the Department of Health and Human Services 72

Appendix VIII GAO Contact and Staff Acknowledgments 75

Tables

Table 1: Stages of Meaningful Use Measures 14

Table 2: Numbers of Meaningful Use Measures by Stage 15

Table 3: Description of Process and Outcome Measures 19

Table 4: Changes to Selected Meaningful Use Measures from 

Stage 1 to Stage 2 of the Electronic Health Record (EHR) 

Programs 32

Table 5: Meaningful Use Measures for Professionals and 

Hospitals, Stages 1 and 2 of the Electronic Health Record 

(EHR) Programs 56

Table 6: Average Percentage Reported by Medicare Providers for 

Meaningful Use Measures with Reporting Thresholds in 

the Electronic Health Record (EHR) Programs, by 

Measure, 2011 and 2012 63

Table 7: Percentage of Medicare Providers That Reported 

Mandatory Stage 1 Meaningful Use Measures That Allow 

for Exemptions or Optional Stage 1 Measures in the 

Electronic Health Record (EHR) Programs, by Measure, 

2011 and 2012 65

Table 8: Department- and Agency-Level Strategic Goals and 

Associated Performance Measures Related to “Adoption 

and Meaningful Use of Electronic Health Records” 68

Table 9: Department- and Agency-Level Strategic Goals Related 

to “Improving Quality, Efficiency, and Patient Safety” 69

Table 10: Summary of Program Evaluations Assessing the 

Electronic Health Record (EHR) Programs on Outcomes 70

Figures

Figure 1: Years in Which Incentive Payments Are Available and 

When Penalties Will Be Assessed in the Medicare and 

Medicaid Electronic Health Record (EHR) Programs 9
Page iii GAO-14-207 Electronic Health Record Programs

Figure 2: Percentage of Eligible Hospitals and Professionals 

Participating in the Electronic Health Record (EHR) 

Programs, 2011 and 2012 21

Figure 3: Total Payments from the Electronic Health Record 

(EHR) Programs for 2011 and 2012, by Program and 

Provider Type 23

Figure 4: Percentage of 2011 Electronic Health Record (EHR) 

Programs Participants, by Participation in 2011 Alone or 

in Both 2011 and 2012 24

Abbreviations

CHIME College of Healthcare Information Management Executives

CMS Centers for Medicare & Medicaid Services 

CQM clinical quality measure

EHR electronic health record

GPRAMA Government Performance and Results Act Modernization 

 Act of 2010

HHS Department of Health and Human Services

HIT health information technology

HITECH Act Health Information Technology for Economic and Clinical 

 Health Act

IQR Inpatient Quality Reporting

ONC Office of the National Coordinator for Health Information 

 Technology

PQRS Physician Quality Reporting System

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Page 1 GAO-14-207 Electronic Health Record Programs

441 G St. N.W.

Washington, DC 20548

March 6, 2014

Congressional Committees

The Medicare and Medicaid Electronic Health Record (EHR) programs 

began in 2011 with a goal of promoting the adoption and meaningful use 

of certified EHR technology.1 As of 2009, before the programs began, 

studies estimated that 78 percent of office-based physicians and 

91 percent of hospitals had not adopted EHRs.2 Such technology has the 

potential to improve the quality of care patients receive and to reduce 

health care costs, if the technology is used in a way that improves 

providers’ and patients’ access to critical information. The Medicare and 

Medicaid EHR programs are the largest of the activities, in terms of 

potential federal expenditures, and are funded by the Health Information 

Technology for Economic and Clinical Health (HITECH) Act, which was 

enacted as part of the American Recovery and Reinvestment Act of 2009 

and provides funding for various activities to promote the adoption and 

meaningful use of certified EHR technology.3

 

1

See Pub. L. No. 111-5, §§ 4101-4201, 123 Stat. 115, 467-494. Medicare is a federal 

program financing health care for individuals age 65 and older, certain disabled 

individuals, and individuals with end-stage renal disease. In 2012, Medicare covered over 

49 million beneficiaries. Medicaid is a federal-state program financing health care for 

certain low-income individuals. In fiscal year 2011, Medicaid covered about 70 million 

beneficiaries.

The Congressional Budget 

2

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.

3

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

American Recovery and Reinvestment Act of 2009. 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). The HITECH Act 

created incentive programs for Medicare fee-for-service, Medicare Advantage, and 

Medicaid. Under the Medicare Advantage EHR program, Medicare Advantage 

Organizations—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. In this report we focus 

primarily on the Medicare fee-for-service EHR program, which we refer to as the Medicare 

EHR program, and the Medicaid EHR program. Other activities funded by the HITECH Act 

include, for example, grants to Regional Extension Centers to assist certain providers, 

such as physicians in small primary care practices, with adopting, implementing, and 

meaningfully using EHRs; and assistance to higher education institutions to establish or 

expand medical health informatics education programs.
 

Page 2 GAO-14-207 Electronic Health Record Programs

Office estimated total spending for these activities to be $30 billion from 

2011 through 2019.4

To increase the adoption and meaningful use of certified EHR technology, 

the Medicare and Medicaid EHR programs provide incentive payments 

for providers—that is, certain types of hospitals, such as critical access 

hospitals, and certain types of professionals, such as physicians and 

nurse practitioners.5 Additionally, beginning in 2015, the Medicare EHR 

program is to begin applying a payment adjustment, referred to in this 

report as a penalty, for hospitals and professionals that treat Medicare 

patients but do not meet the Medicare EHR program requirements.6 In 

establishing the EHR programs, Congress defined “a meaningful EHR 

user” as a hospital or professional that meets the following three criteria: 

(1) demonstrates use of certified EHR technology in a meaningful 

manner; (2) demonstrates that certified EHR technology is connected in a 

manner that provides for the electronic exchange of health information to 

improve the quality of health care, such as promoting care coordination; 

and (3) uses certified EHR technology to submit information on clinical 

quality measures (CQM) and other measures.7

 

4

Congressional Budget Office, “Health Information Technology for Economic and Clinical 

Health Act” (Washington, D.C.: Jan. 21, 2009). This estimate includes spending estimates 

for bonuses and payment reductions from the penalties.

The EHR programs were 

designed to last for multiple years to increase, over time, the widespread 

adoption and meaningful use of EHRs, which is viewed by the 

Department of Health and Human Services (HHS) and others as a 

necessary step toward transforming health care into a system that can 

achieve goals of improved quality, efficiency, and patient safety. For 

example, use of EHRs could improve efficiency by reducing the 

5

Providers permitted to participate vary by program. Permissible hospitals under the 

Medicare EHR program are acute care 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; and critical access hospitals. Permissible hospitals 

under the Medicaid EHR program are acute care hospitals, critical access hospitals, 

cancer hospitals, and children’s hospitals. Permissible professionals under the Medicare 

EHR program are doctors of medicine or osteopathy, doctors of dental surgery or dental 

medicine, doctors of podiatry, doctors of optometry, and chiropractors. Permissible 

professionals under the Medicaid EHR program are doctors of medicine or osteopathy, 

doctors of dental surgery or dental medicine, nurse practitioners, certified nurse-midwives, 

and physician assistants who furnish services in a federally qualified health center or rural 

health clinic that is led by a physician assistant.

6

See Pub. L. No. 111-5, § 4101(a)-(b), 123 Stat. 467-473.

7

See Pub. L. No 111-5, § 4101 (a) 123 Stat. 467-472, 477-485.
 

Page 3 GAO-14-207 Electronic Health Record Programs

duplication of diagnostic tests, or improve patient safety by preventing 

medical errors resulting from, for example, incomplete medical histories 

for new patients. Additionally, CQM data collected by providers using 

EHRs could be used by HHS to measure and improve health care quality 

by, for example, designing programs that compensate providers for 

meeting quality and efficiency targets—that is, pay for performance.

Within HHS, the Centers for Medicare & Medicaid Services (CMS) and 

the Office of the National Coordinator for Health Information Technology 

(ONC) have developed the EHR programs’ requirements.8 CMS is 

responsible for administering the Medicare EHR program and overseeing 

and funding most of the Medicaid EHR program, which is administered by 

the states and U.S. insular areas.9 ONC is responsible for overseeing the 

certification of EHR technology, including establishing technical standards 

and certification criteria for it.10 Additionally, ONC is charged with 

formulating the federal government’s health information technology (HIT) 

strategy and coordinating federal HIT policies, programs, and 

investments.11

The HITECH Act requires us to report on the effect of the act on a 

number of important areas.12

 

8

See Medicare and Medicaid Programs: Electronic Health Record Incentive Program, 

75 Fed. Reg. 44314 (July 28, 2010), codified at 42 C.F.R. pts. 412, 413, 422 and 495; 

Health Information Technology: Initial Set of Standards, Implementation Specifications, 

and Certification Criteria for Electronic Health Records Technology, 75 Fed. Reg. 44590 

(July 28, 2010), codified at 45 C.F.R. pt. 170; Medicare and Medicaid Programs; 

Electronic Health Record Incentive Program—Stage 2, 77 Fed. Reg. 53968 (Sept. 4, 

2012), codified at 42 C.F.R. pts. 412, 413, and 495; and Health Information Technology: 

Standards, Implementation Specifications, and Certification Criteria for Electronic Health 

Records Technology, 2014 Edition, 77 Fed. Reg. 54163 (Sept. 4, 2012), codified at 

45 C.F.R. pt. 170.

Our work has focused on the Medicare and 

Medicaid EHR programs because of the potential magnitude of federal 

expenditures for those programs. In April 2012 we reported on CMS’s 

9

CMS provides states with 100 percent of the cost of incentive payments made to 

Medicaid providers and 90 percent of the costs related to reasonable administrative 

expenses and planning activities related to the Medicaid EHR program. 42 U.S.C. 

§ 1396b(a)(3)(F)(i) and (ii).

10To receive incentive payments from the EHR programs, providers must use certified 

EHR technology.

11Pub.L. No. 111-5, § 13001, 123 Stat. 230-234.

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

Page 4 GAO-14-207 Electronic Health Record Programs

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, HHS agreed with most of 

our recommendations. In July 2012 we reported information on providers 

that were awarded Medicare EHR incentive payments for 2011, including 

the number of award recipients and their characteristics.14 In December 

2012 we reported information on providers that were awarded Medicaid 

EHR incentive payments for 2011, including the number of award 

recipients and their characteristics.15 In October 2013 we reported 

information on providers that were awarded Medicare EHR incentive 

payments for 2011 and 2012, including the number of award recipients 

and their characteristics.16

 

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

Opportunities to Improve Processes to Verify Providers Met Requirements, 

Ongoing work is examining the key challenges 

to the electronic exchange of health information that have been reported 

by providers and stakeholders and HHS’s efforts to address those 

challenges. In this report, we (1) assess the extent of current and 

expected participation in the EHR programs; (2) examine information 

reported by providers and others to measure meaningful use in the EHR 

programs; (3) evaluate HHS’s efforts to ensure that EHR data can be 

reliably used to measure quality of care; and (4) evaluate HHS’s efforts to 

assess the effect of the EHR programs on program goals related to 

adoption and meaningful use of EHRs and improved outcomes such as 

quality, efficiency, and patient safety. In addition, the HITECH Act 

specified that we report on the effect of the act on, among other things, 

health insurance premiums, and such information is provided in 

appendix I.

GAO-12-481

(Washington, D.C.: Apr. 30, 2012).

14See GAO, Electronic Health Records: Number and Characteristics of Providers 

Awarded Medicare Incentive Payments for 2011, GAO-12-778R (Washington, D.C.: 

July 26, 2012).

15GAO, Electronic Health Records: Number and Characteristics of Providers Awarded 

Medicaid Incentive Payments for 2011, GAO-13-146R (Washington, D.C.: Dec. 13, 2012).

16GAO, Electronic Health Records: Number and Characteristics of Providers Awarded 

Medicare Incentive Payments for 2011–2012, GAO-14-21R (Washington, D.C.: Oct. 24, 

2013).
 

Page 5 GAO-14-207 Electronic Health Record Programs

To assess the extent of current participation in the Medicare and 

Medicaid EHR programs, we analyzed data related to the 2011 and 2012 

program years that CMS collected in its National Level Repository 

through October 23, 2013.17

• estimated the percentage of eligible providers awarded a Medicare or 

Medicaid (or both) EHR incentive payment for 2011 and for 2012;

Using these data, we

• determined the total amount of Medicare and Medicaid EHR incentive 

payments awarded to providers each year; and

• estimated the percentage of providers that were awarded a Medicare 

or Medicaid (or, in the case of some hospitals, both) EHR incentive 

payment for 2011 but not for 2012.18

To assess the extent of expected participation in the EHR programs, we 

interviewed CMS officials regarding agency activities to increase 

participation and efforts to ensure that providers continue to participate in 

the EHR programs after their first year. We also interviewed individuals 

from organizations representing stakeholders, including the American 

Hospital Association and the College of Healthcare Information 

Management Executives (CHIME), whose members include health care 

chief information officers; and reviewed an analysis of 2012 survey data 

of hospitals collected by the American Hospital Association. In addition, 

we reviewed applicable regulations and other relevant agency 

documents.

To examine information reported by providers and others to measure 

meaningful use in the EHR programs, we analyzed data CMS collected in 

its National Level Repository through October 23, 2013. Specifically, we 

 

17In this report, we use the term “participation” to mean providers awarded incentive 

payments for meeting the requirements of either the Medicare or the Medicaid (or, in the 

case of some hospitals, both) EHR program. 

At the time of our analysis, according to CMS, 14 states and the District of Columbia had 

not completed their determinations of which providers would receive incentive payments 

for the 2012 program year. As a result, our analyses of the Medicaid EHR program do not 

reflect payments incorporated into CMS’s National Level Repository after October 23, 

2013.

18For the Medicaid EHR program, we limited this analysis to providers that were awarded 

incentive payments from 36 states that, according to CMS, had completed their 

determinations of which providers would receive incentive payments for the 2011 and 

2012 Medicaid EHR program years as of October 23, 2013.
 

Page 6 GAO-14-207 Electronic Health Record Programs

analyzed data that providers reported to CMS for the 2011 and 2012 

program years to demonstrate meaningful use under the Medicare EHR 

program—known as meaningful use measures. We analyzed the CMS 

data to identify

• the extent to which providers exceeded reporting thresholds, which 

are specified percentages of patients or actions that providers must 

meet or exceed to satisfy the requirements of a subset of the 

meaningful use measures (14 hospital measures and 16 professional 

measures); and

• the frequency with which providers reported meaningful use measures 

without claiming exemptions, which are allowed under the program for 

some measures if providers meet certain criteria specific to the 

individual measures (e.g., the measure is not relevant to their patient 

populations or clinical practices, the providers conducted too few 

actions to be measured, or the providers were not able to perform the 

action).19

As part of our analysis, we also reviewed a CMS analysis of meaningful 

use measure data submitted by professionals to states to demonstrate 

meaningful use in the Medicaid EHR program for the 2012 program year, 

reviewed an analysis of 2012 survey data of hospitals collected by the 

American Hospital Association, and analyzed 2012 survey data collected 

by the National Center for Health Statistics in the Centers for Disease 

Control and Prevention from office-based physicians. We identified 

meaningful use measures related to electronic health information 

exchange based on information obtained from officials from CMS and 

ONC. We interviewed officials from CMS, ONC, the American Hospital 

Association, the American Medical Association, and CHIME, and 

reviewed letters submitted by stakeholder organizations to HHS related to 

the EHR programs. In addition, we reviewed regulations and other 

relevant agency documentation.

 

19An exclusion for a nonapplicable measure is permitted if the provider meets certain 

requirements specified in the regulation. 42 C.F.R. § 495.6. In this report, we use the term 

“exemption” to refer to the exclusion of a nonapplicable measure. The agency allows 

providers to claim exemptions from reporting certain meaningful use measures to help 

ensure that providers with all types of patient populations and clinical practices could 

potentially demonstrate meaningful use. See 75 Fed. Reg. 44328-44329 (July 28, 2010). 

For 2011 and 2012, hospitals were permitted to claim exemptions from reporting 7 

meaningful use measures, and professionals from reporting 14 meaningful use measures.
 

Page 7 GAO-14-207 Electronic Health Record Programs

To evaluate HHS’s efforts to ensure that EHR data can be reliably used to 

measure quality of care, we reviewed letters submitted by stakeholder 

organizations to HHS related to the EHR programs; reviewed the EHR 

programs’ requirements and agency documentation describing HHS’s 

quality measurement activities, including the Inpatient Prospective 

Payment System and the Physician Fee Schedule regulations; reviewed 

other materials related to quality measurement; and interviewed officials 

from CMS, ONC, the American Hospital Association, and CHIME.20 We 

also reviewed relevant internal control standards regarding information 

used by agencies and compared them against HHS activities.21 We 

analyzed CQM data that providers reported to CMS to demonstrate 

meaningful use under the Medicare EHR program for the 2011 and 2012 

program years and that are captured in CMS’s National Level Repository. 

Specifically, we analyzed the extent to which Medicare providers had few 

patients who could be included in the calculation of at least one clinical 

quality measure.22

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

officials from CMS, 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 were sufficiently reliable 

for our analysis. (For more information on our data analysis, see app. II.)

To evaluate HHS’s efforts to assess the effect of the EHR programs on 

program goals, we reviewed HHS’s Fiscal Years 2010-2015 Strategic 

Plan, ONC’s 2011-2015 Federal Health Information Technology Strategic 

Plan, and the EHR programs’ requirements to identify department and 

 

20See Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care 

Hospitals and the Long Term Care; Hospital Prospective Payment System and Fiscal 

Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital 

Conditions of Participation; Payment Policies Related to Patient Status, 78 Fed. Reg. 

50496 (August 19, 2013), codified at 42 C.F.R. pts. 412, 413, 414, 419, 424, 482, 485 and 

489; and Medicare Program; Revisions to Payment Policies Under the Physician Fee 

Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014, 

78 Fed. Reg. 74230 (December 10, 2013), codified at 42 C.F.R. pts. 405, 410, 411, 414, 

423 and 425.

21See GAO, Government Operations: Internal Control Management and Evaluation Tool 

(Supersedes GAO-01-131G), GAO-01-1008G (Washington, D.C.: Aug. 1, 2001).

22Measures that capture a small number of patients may be unreliable measures of quality 

because relatively small changes in the number of patients who experienced the care 

processes or outcomes targeted by the measure can generate large shifts in the 

calculated percentage for the measure.
 

Page 8 GAO-14-207 Electronic Health Record Programs

agency goals particularly relevant to the EHR programs. We also 

reviewed HHS’s Fiscal Year 2014 Annual Performance Report and 

Performance Plan, CMS’s Fiscal Year 2014 Budget Justification, and 

ONC’s Fiscal Year 2014 Budget Justification to identify department and 

agency performance measures relevant to the EHR programs. In 

addition, we interviewed CMS and ONC officials regarding performance 

measures and program evaluations relevant to the EHR programs. We 

assessed this evidence against relevant criteria from the Government 

Performance and Results Act Modernization Act of 2010 (GPRAMA) as 

incorporated in our guidance on assessing performance and our guidance 

on designing evaluations.23

We conducted this performance audit from February 2013 through March

2014 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.

Through use of incentive payments and penalties, the EHR programs are 

intended to help address the significant barriers to the adoption and use 

of EHRs, such as cost, and the technical challenges associated with their 

use. Beginning in 2011, the first year of the Medicare and Medicaid EHR 

programs, the programs have provided incentive payments to 

participating providers, that is, eligible providers that met program 

 

23See Pub. L. No. 111-352, 124 Stat. 3866 (Jan. 4, 2011). GPRAMA amends the 

Government Performance and Results Act of 1993, Pub. L. No. 103-62, 107 Stat. 285 

(1993); GAO, Executive Guide: Effectively Implementing the Government Performance 

and Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1, 1996); and GAO, 

Designing Evaluations: 2012 Revision, GAO-12-208G (Washington, D.C.: January 31, 

2012).

Background

Incentive Payments and 

Penalties
 

Page 9 GAO-14-207 Electronic Health Record Programs

requirements.24

Figure 1: Years in Which Incentive Payments Are Available and When Penalties Will Be Assessed in the Medicare and 

Medicaid Electronic Health Record (EHR) Programs

Beginning in 2015, CMS is generally required to begin 

applying a penalty to hospitals and professionals that do not meet the 

Medicare EHR program requirements. There is no statutory end-point 

provided for the penalties. The Medicaid EHR program does not impose 

penalties on Medicaid providers that do not meet the Medicaid EHR 

program’s requirements by a specific date; however, if Medicaid providers 

also treat Medicare patients, they are required to meet the Medicare EHR 

program’s requirements from 2015 onward to avoid penalties from the 

Medicare EHR program. (See fig. 1.)

Notes: Program years are determined and awarded on a fiscal year basis for hospitals and on a 

calendar year basis for professionals. Professionals may not receive incentive payments under both 

the Medicare EHR program and the Medicaid EHR program during the same year; they must choose 

one of the two programs under which they will participate. In contrast, hospitals may qualify for 

incentive payments under both programs during the same year.

a

If Medicaid providers also treat Medicare patients, they are required to meet the Medicare EHR 

program’s requirements from 2015 onward to avoid penalties from the Medicare EHR program.

b

 

24References in this report to a year conform to the concept of program year, which for 

hospitals is based on the fiscal year and for professionals is based on the calendar year. 

For example, for hospitals, the 2011 program year was from October 1, 2010, to 

September 30, 2011, whereas for professionals, the 2011 program year was from 

January 1, 2011, to December 31, 2011.

In the Medicare and Medicaid EHR programs, professionals include doctors of medicine and dental 

surgery. In the Medicaid EHR program, professionals also include nurse practitioners, certified nursemidwives, and certain physician assistants.
 

Page 10 GAO-14-207 Electronic Health Record Programs

The amount of incentive payment varies depending on the type of 

provider (hospital or professional) and the program in which the provider 

participates (Medicare EHR program or Medicaid EHR program). For 

most hospitals, the incentive payment amount for any given year is 

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

(i.e., percentage of the hospital’s inpatient bed days that were attributable 

to Medicare patients) for the Medicare EHR program, or Medicaid share 

(i.e., percentage of the hospital’s inpatient bed days that were attributable 

to Medicaid patients) for the Medicaid EHR program.25 However, for 

critical access hospitals in the Medicare EHR program, the incentive 

payment amount is generally based on the hospital’s Medicare share as 

well as the reasonable costs incurred for the purchase of depreciable 

assets necessary to administer certified EHR technology, such as 

computers and associated hardware and software. Professionals in the 

Medicare EHR program generally cannot earn more than $18,000 in 

incentive payments in their first year, and total payments cannot exceed 

$44,000.26

Beginning in 2015, CMS will apply penalties to Medicare providers if they 

did not meet Medicare EHR program requirements.

In the Medicaid EHR program, professionals cannot earn more 

than $21,250 in incentive payments in the first year, and total payments 

cannot exceed $63,750.

27 For most hospitals, 

penalties will be applied by reducing the Medicare Inpatient Prospective 

Payment System payment rate increase by 25 percent each year, with a 

maximum cumulative reduction of 75 percent.28

 

25We previously reported that the median payments to hospitals in the Medicare EHR 

program and Medicaid EHR program for 2011 were $1.6 million and $613,512, 

respectively. See 

However, for critical 

access hospitals, the penalty is applicable to the hospital’s Medicare 

GAO-14-21R and GAO-13-146R. 

26CMS will increase the incentive payments that would otherwise apply by 10 percent 

each year for Medicare professionals who predominantly furnish services in geographic 

areas designated as health professional shortage areas, such as areas that have a 

shortage of primary medical care.

27Most providers must meet program requirements prior to the start of the 2015 program 

year in order to avoid penalties from the Medicare EHR program. For example, 

professionals first participating in 2014 must meet the requirements in the first 9 months of 

calendar year 2014 to avoid penalties in 2015. In general, providers must continue to 

demonstrate meaningful use each year to avoid penalties in later years.

28For example, if the increase to the Medicare Inpatient Prospective Payment System 

payment rate in 2015 was 2 percent, then an acute care hospital that did not meet 

Medicare EHR program requirements would only receive a 1.5 percent increase that year.
 

Page 11 GAO-14-207 Electronic Health Record Programs

reimbursement for inpatient services. For professionals, penalties will be 

assessed by reducing the reimbursement that the provider would 

ordinarily receive for furnishing Medicare Part B services by 1 percent for 

each year the professional did not meet the requirements, with a 

cumulative penalty of up to 3 percent per year.29 CMS may exempt 

hospitals and professionals from penalties if it determines that complying 

with the program requirements would result in a significant hardship to the 

provider; such exemptions are to be granted on a case-by-case basis 

subject to annual renewal.30 Examples of permissible hardship 

circumstances include lacking necessary infrastructure, such as internet 

broadband; facing unforeseen circumstances such as a natural disaster; 

or, for professionals, lacking patient interaction.

CMS has established requirements for the EHR programs that specify the 

providers eligible to participate—that is, providers that are permitted to 

earn incentive payments or that may be subject to penalties. For 

example, providers must be a permissible provider type, such as an acute 

care hospital or a doctor of medicine and, for the Medicaid EHR program, 

providers must generally meet a patient volume requirement to be 

eligible.31

In addition to meeting program eligibility requirements, to receive 

incentive payments or avoid penalties, eligible providers must also satisfy 

reporting requirements by submitting information to CMS for the Medicare 

EHR program, to the states for the Medicaid EHR program, or to both. 

The reporting requirements generally incorporate the three statutory 

criteria for “meaningful use” established in HITECH—(1) demonstrate use 

of certified EHR technology in a meaningful manner; (2) demonstrate that 

certified EHR technology is connected in a manner that provides for the 

electronic exchange of health information; and (3) submit information on 

 

29For 2018 and each subsequent year, if CMS finds that less than 75 percent of 

professionals meet the Medicare EHR Program’s requirements, CMS may increase the 

penalty percentage in the Medicare EHR Program beginning in 2018 by up to 1 percent 

per year, with a maximum cumulative penalty of up to 5 percent per year. See 42 U.S.C. 

§§ 1395w-4(a)(7)(A)(iii). 

30See 42 U.S.C. §§ 1395w-4(a)(7)(B). 

31For the Medicaid EHR program, hospitals must generally have a Medicaid patient 

volume of at least 10 percent and professionals must generally have a Medicaid patient 

volume of at least 30 percent.

Medicare EHR Program 

and Medicaid EHR 

Program Requirements
 

Page 12 GAO-14-207 Electronic Health Record Programs

CQMs using certified EHR technology. To receive incentive payments 

from the Medicare EHR program, the information reported by providers 

must satisfy all three statutory criteria; that is, providers must 

“demonstrate meaningful use.” However, to receive incentive payments 

from the Medicaid EHR program in their first year of participation, 

providers need not satisfy the three statutory criteria. Instead, they must 

only report that they adopted, implemented, or upgraded to certified EHR 

technology.32

Certified EHR technology. Certified EHR technology is technology that 

has been determined by ONC-authorized organizations—referred to as 

certification bodies and testing laboratories—to conform to the standards 

and certification criteria developed by ONC. ONC has changed the 

certification criteria since the EHR programs began. Specifically, 

providers who participated in the EHR programs from 2011 through 2013 

were generally required to use 2011-edition EHRs and all providers who 

participate in the EHR programs from 2014 through 2016—regardless of 

whether the provider participated in the program in earlier years—are 

required to use 2014-edition EHRs.

In subsequent years, though, they must demonstrate 

meaningful use to receive incentive payments.

33 ONC is expected to develop 

another set of certification criteria for EHRs that providers would be 

required to use beginning in 2017.34

Meaningful use measures. These measures are intended to promote 

the use of EHRs in the delivery of health care and to ensure that 

providers capture information in their EHRs consistently. For example, 

one measure requires providers to enable a technical capability of their 

EHRs to notify the provider of potential interactions among the patients’ 

medications and with patients’ allergies. Providers must report certain 

mandatory measures and also must report a set of optional measures 

that they may choose from a menu. The meaningful use measures are 

being implemented in three stages that will apply to different providers in 

 

32See Pub.L. No. 111-5, § 4201, 123 Stat. 493.

33In this report, when we use the term EHR, we are generally referring to certified EHR 

technology.

34ONC is planning to issue an interim set of standards and certification criteria (2015-

edition) intended to be responsive to stakeholder feedback and to address issues found in 

the 2014-edition EHRs. These standards would be optional—providers participating in the 

EHR programs would not be required to use EHRs certified using the interim criteria.
 

Page 13 GAO-14-207 Electronic Health Record Programs

different years.35 This approach is consistent with the HITECH Act, which 

directed the Secretary of HHS to seek to improve health care quality and 

the use of EHRs by requiring more stringent requirements over time. 

According to CMS, using the staged approach is intended to help 

overcome two important deficiencies—the lack of widespread use of 

capable EHRs and the lack of an HIT infrastructure—that existed when 

the requirements were being developed, with the hope that those 

deficiencies would be addressed over time as a result of the EHR 

programs. The stage that is applicable to each provider in each year is 

based on the first year in which the provider demonstrated meaningful 

use in the Medicare EHR program or the Medicaid EHR program. For 

example, a Medicare professional that first demonstrated meaningful use 

in 2011 must report the Stage 1 meaningful use measures for 2011, 

2012, and 2013 to receive incentive payments for those years and must 

report the Stage 2 meaningful use measures beginning in 2014 to receive 

an incentive payment for that year.36 The Stage 3 requirements have not 

yet been developed but are expected to be finalized in 2015 and to apply 

beginning in 2017. (See table 1.)

 

35HHS regulations specify the stage that is applicable to a provider in each year. The start 

of Stage 2, which was originally expected to begin in 2013, was delayed by HHS for 

1 year due to concerns expressed by providers and in response to recommendations from 

the HIT Policy Committee, which advises ONC on HIT policy. As a result of this change, 

the start of Stage 3 would have been 2016; however, on December 6, 2013, CMS 

announced that the start of Stage 3 would be pushed back to 2017.

36In this example, by demonstrating meaningful use for 2013 and 2014, the professional 

would also avoid penalties for 2015 and 2016, respectively.
 

Page 14 GAO-14-207 Electronic Health Record Programs

Table 1: Stages of Meaningful Use Measures

Stage of measures 

(●Stage 1; ●●Stage 2; ●●●Stage 3)

First year provider 

demonstrates 

meaningful use 2011 a 2012 2013 2014 2015 2016 2017 2018

2011 ● ● ● ●● ●● ●● ●●●

2012

b

● ● ●● ●● ●● ●●●

2013

b

● ● ●● ●● ●●● ●●●

2014 ● ● ●● ●● ●●●

2015 ● ● ●● ●●

2016 ● ● ●●

2017 ● ●

Source: CMS.

Notes: Providers participating in the Medicare Electronic Health Record (EHR) program are subject to 

the stage of meaningful use measures as indicated above even if they stop participating in one year 

and resume in a later year. For example, if a Medicare provider first demonstrated meaningful use in 

2012 but did not participate in the Medicare EHR program again until 2014, that provider would be 

required to report the Stage 2 measures in 2014, 2015, and 2016. However, this is not the case for 

providers participating in the Medicaid EHR program. Instead, a Medicaid provider that first 

demonstrated meaningful use in 2012 but did not participate in the Medicaid EHR program again until 

2014 would be required to report the Stage 1 measures in 2014 and the Stage 2 measures in 2015. 

Except for 2014, providers must collect data related to the meaningful use measures in any 

90 consecutive days in their first year of reporting meaningful use and for a full year in subsequent 

years. For 2014 only, all providers, regardless of their stage of meaningful use, are only required to 

collect data related to the meaningful use measures for 3 months.

a

The table assumes Medicaid providers’ first year of participation is for adopting, implementing, or 

upgrading to a certified EHR system and that those providers participate in consecutive years.

b

The meaningful use measures in Stage 1 are intended to promote the 

electronic capture of health information in a structured format and to 

encourage providers to use that information to track key clinical 

conditions. The Stage 2 meaningful use measures were chosen to 

encourage continuous quality improvement at the point of care and are 

more stringent than the Stage 1 measures. For example, measures that 

were formerly optional are now mandatory, and some measures require 

that the provider perform the action for a greater percentage of patients or 

implement more interventions. Additionally, ONC and CMS have stated 

that Stage 2 places a stronger emphasis on electronic health information 

CMS has not yet determined whether additional meaningful use stages will be developed or when 

those would apply.
 

Page 15 GAO-14-207 Electronic Health Record Programs

exchange with other providers compared to Stage 1.37

Table 2 provides information on the number and type of measures that 

providers must report for Stage 1 and Stage 2.

CMS has stated its 

intention to develop even more stringent meaningful use measures for 

Stage 3 that would promote activities that can lead to improved health 

outcomes, such as using decision support tools or providing patient 

access to self-management tools.

Table 2: Numbers of Meaningful Use Measures by Stage

Provider Stage 1 Stage 2 a

Hospitals Mandatory 14 16

Optional 5 of 10 menu 3 of 6 menu

Total 19 19

Professionals Mandatory 15 17

Optional 5 of 10 menu 3 of 6 menu

Total 20 20

Source: CMS.

Note: For a list of the meaningful use measures by stage, see appendix III.

a

Clinical quality measures (CQM). Health care quality measures, also 

known as CQMs, can be used to assess provider performance and to 

drive quality improvement and accountability. For example, one CQM for 

professionals measures the use of high-risk medications in the elderly. 

CQMs are composed of a number of clinical data elements, or pieces of 

data, that must be collected in order to determine performance on any 

given measure. Using those data elements, a score for the measure can 

then be calculated.

CMS made changes to the Stage 1 requirements that apply after 2012 which are not reflected in this 

table.

38

 

37According to ONC, the Stage 2 meaningful use measures require the use of more 

specific interoperability standards, which are incorporated into 2014-edition EHRs.

In order to demonstrate meaningful use in the 

38For example, the CQM that measures use of high-risk medications in the elderly 

comprises the following data elements—the number of patients with a medication order for 

at least one high-risk medication and at least two high-risk medications during the 

measurement period and the number of patients treated by the professional. Two scores 

are then calculated by (1) dividing the number of patients with at least one medication by 

the number of patients treated, and (2) dividing the number of patients with at least two 

medications by the number of patients treated.
 

Page 16 GAO-14-207 Electronic Health Record Programs

Medicare or Medicaid EHR programs, providers are required to collect 

CQMs electronically using EHRs and report those data to CMS 

(Medicare), the states (Medicaid), or both. However, historically, CQMs 

have been collected through other data collection methods, such as 

through a detailed, manual review of paper medical records, a process 

referred to as chart abstraction. Most of the CQMs identified by CMS for 

use in the EHR programs were originally developed for paper medical 

records or other data collection methods and later modified so they could 

be collected using EHRs.39

The CQMs that providers must collect using EHRs and report to 

demonstrate meaningful use are determined by the edition of certified 

EHRs providers must use. Specifically, using their 2011-edition certified 

EHRs that applied from 2011 to 2013, hospitals were required to report all 

15 CQMs identified by CMS, and professionals were required to report 

6 CQMs from a list of 44 measures.40 Using their 2014-edition certified 

EHRs that will apply from 2014 to 2016, hospitals are required to report 

16 CQMs from a list of 29 measures, and professionals are required to 

report 9 CQMs from a list of 64 measures.41 Medicare providers are being 

encouraged to electronically report the results of CQMs to CMS, but they 

have the option of reporting CQMs by manually entering information into 

CMS’s web-based tools, a process known as attestation.42

 

39In 2012, we reported on activities conducted by the National Quality Forum under 

contract with HHS, including efforts to modify CQMs so they could be collected using 

EHRs. See GAO, Health Care Quality Measurement: HHS Should Address Contractor 

Performance and Plan for Needed Measures, GAO-12-136 (Washington, D.C.: Jan. 13, 

2012). The National Quality Forum is the entity in the United States with the lead 

responsibility for endorsing CQMs.

40Professionals had to report 3 core or alternative core measures and had to report an 

additional 3 measures from the list of measures.

41Hospitals and professionals must report CQMs that cover at least three of the following 

six domains, which are based on the six National Quality Strategy priorities: patient and 

family engagement; patient safety; care coordination; population and public health; 

efficient use of healthcare resources; and clinical processes or effectiveness.

42For the 2012 and 2013 program years, providers were permitted but not required to 

submit CQM data to CMS electronically for the Medicare EHR program through electronic 

reporting pilot programs—one for hospitals and one for professionals. For 2012, no 

hospitals and less than 2 percent of professionals who received incentive payments 

submitted CQM data to CMS electronically for the Medicare EHR program through a pilot 

in order to demonstrate meaningful use. CMS is working with the states to develop 

capabilities to receive electronically submitted CQM results from providers for the 

Medicaid EHR program.
 

Page 17 GAO-14-207 Electronic Health Record Programs

In addition to the EHR programs, HHS requires providers to collect and 

report CQMs for a number of other programs in order to measure health 

care quality, some of which provide financial incentives to health care 

providers to help achieve the goals of improved quality and efficiency. For 

example, CMS is to impose penalties on providers who do not 

satisfactorily report quality data to the Hospital Inpatient Quality Reporting 

(IQR) program and to the Physician Quality Reporting System (PQRS). 

The Patient Protection and Affordable Care Act directed HHS to 

implement new programs that will use CQMs, including pay-forperformance programs such as the Physician Value Based Payment 

Modifier program, which bases Medicare payments in part on CQM 

results, and the Medicare Shared Savings Program, which rewards

Accountable Care Organizations that lower growth in health care costs 

while meeting performance standards.43

Across its programs, HHS has a goal to use CQMs that are broad based, 

patient centered, and prioritized based on their potential to achieve 

population-wide improvements. In order to do this in its programs, CMS 

has set a goal of collecting and submitting data using EHRs, which HHS 

officials have indicated can be used to collect CQMs as a byproduct of 

the routine delivery of health care. To minimize the burden on providers of 

collecting and reporting similar CQMs for different CMS programs using 

differing methods, CMS has modified some of its programs’ requirements 

such that providers may submit data collected through EHRs as part of 

the Medicare or Medicaid EHR programs instead of separately collecting 

and submitting data through other methods such as chart abstraction. For 

example,

• Hospitals electronically reporting to CMS one-quarter of CQM data 

collected in 2014 using 2014-edition EHRs for 16 CQMs will satisfy 

the IQR program’s four-quarter reporting requirement for those 16 

measures for 2016 payment determinations and the Medicare EHR 

program’s CQM reporting requirement for 2014.44

 

43See Pub. L. No. 111-148, §§ 3007, 3022, 124 Stat. 119, 373-376, 395-399 (2010). In its 

quality reporting programs, CMS gives consideration to CQMs that have been endorsed

by the National Quality Forum.

44Hospitals choosing this option would have to report data for the remaining IQR 

measures using the traditional manual data collection techniques that are based on chart 

abstraction.

HHS’s Quality 

Measurement Activities
 

Page 18 GAO-14-207 Electronic Health Record Programs

• Professionals electronically reporting one year of CQM data 

generated from 2014-edition EHRs to CMS for PQRS in 2014 will 

satisfy the CQM reporting requirements for both PQRS and the 

Medicare EHR program.45 CMS will use those data for professionals 

in practices of 10 or more individuals to generate the Physician Value 

Based Payment Modifier that will be applied to payments made under 

the Medicare physician fee schedule starting January 1, 2016.46

GPRAMA requires federal agencies to prepare performance reports and 

establish performance measures to assess performance of federal 

programs. Performance measures assess performance via ongoing 

monitoring and reporting of program accomplishments, which include 

progress toward pre-established goals. Our previous work notes that 

performance measures can serve as an early warning system to 

management and as a vehicle for improving accountability to the public.47

We have also published guidance on assessing performance that 

incorporates GPRAMA criteria and which states that it is important for 

performance measures to be tied to program goals and for agencies to 

ensure their activities support their organizational missions and move 

them closer to accomplishing their strategic goals.48

 

45Professionals choosing this option must report CQMs from the list of 64 CQMs identified 

for the EHR programs. To meet the criteria for satisfactory reporting to PQRS, 

professionals must report at least 1 CQM with at least one patient in the denominator 

of the measure. Additionally, professionals must report CQM data collected over the 

12-month period required by PQRS instead of the 3-month period required by the EHR 

programs in 2014.

In addition, our 

Professionals submitting CQM data generated from 2014-edition EHRs to “qualified” 

clinical data registries in 2014—established under a new program enacted under the 

American Taxpayer Relief Act of 2012—will also satisfy the CQM reporting requirements 

for both PQRS and the Medicare EHR program. In 2013, we reported on HHS’s plans for 

this new program and recommended several actions that HHS could take to help ensure 

that qualified clinical data registries promote improved quality and efficiency of physician 

care for Medicare beneficiaries. See GAO, Clinical Data Registries: HHS Could Improve 

Medicare Quality and Efficiency through Key Requirements and Oversight, GAO-14-75

(Washington, D.C.: Dec. 16, 2013).

46By 2017, the Physician Value Based Payment Modifier will apply regardless of the 

professional’s practice size.

47GAO, Performance Measurement and Evaluation: Definitions and Relationships, 

GAO-11-646SP (Washington, D.C.: May 2, 2011).

48GAO, Executive Guide: Effectively Implementing the Government Performance and 

Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1, 1996).

Performance Assessment
 

Page 19 GAO-14-207 Electronic Health Record Programs

guidance to federal agencies on designing evaluations suggests that 

performance measures should include both process and outcome 

measures (see table 3).49

Table 3: Description of Process and Outcome Measures

Outcome measures are particularly useful in 

assessing the status of program operations, identifying areas that need 

improvement, and ensuring accountability for end results. Furthermore, 

our guidance on assessing performance notes that leading organizations 

not only establish performance measures but also use information from 

these performance measures to continuously improve processes, identify 

program priorities, and set improvement goals.

Type of measure Description Example

Process Addresses the type or level of program activities 

conducted and the direct products or services delivered 

by a program

The number of participants enrolled in a job training 

program

Outcome Addresses the results of products and services The percentage of participants who find employment 

after successfully completing the job training program

Source: GAO.

Participation in CMS’s EHR programs increased substantially from 2011 

to 2012, but some providers who participated in 2011 did not continue in 

2012. It is difficult to estimate future participation in the EHR programs 

because of various program changes, including the planned increase in

stringency of the meaningful use measures, the introduction of penalties 

for some providers in 2015, CMS’s efforts to increase participation among 

certain providers, and changes to eligibility requirements.

 

49GAO, Designing Evaluations: 2012 Revision, GAO-12-208G (Washington, D.C.: Jan. 31, 

2012).

Participation in the 

EHR Programs Has 

Increased, but 

Program Changes 

Make It Difficult to 

Estimate Future 

Participation
 

Page 20 GAO-14-207 Electronic Health Record Programs

Participation in CMS’s EHR programs increased substantially from 2011 

to 2012.50 For hospitals, participation increased from 45 percent of those 

eligible for 2011 to 64 percent of those eligible for 2012.51 For 

professionals, participation increased from 21 percent of those eligible for 

2011 to 48 percent of those eligible for 2012.52 (See fig. 2.)

 

50Only a subset of providers that participated in the Medicaid EHR programs for 2011 and 

2012 demonstrated meaningful use. For the Medicaid EHR program, providers are not 

required to demonstrate meaningful use for their first year of participation; they need only 

report that they adopted, implemented, or upgraded to EHRs. Of the providers that 

participated in the Medicaid EHR program in 2011, 27 percent of hospitals and less than 

1 percent of professionals demonstrated meaningful use. Of the providers that participated 

in the Medicaid EHR program in 2012, 73 percent of hospitals and 29 percent of 

professionals demonstrated meaningful use.

51An additional 31 hospitals participated in the Medicare Advantage EHR program for 

2011, and an additional 32 hospitals did so for 2012.

52An additional 11,137 professionals participated in the Medicare Advantage EHR 

program for 2011, and an additional 11,340 professionals did so for 2012.

Participation in 2012 

Increased Even Though 

Some Providers Did Not 

Continue after 2011
 

Page 21 GAO-14-207 Electronic Health Record Programs

Figure 2: Percentage of Eligible Hospitals and Professionals Participating in the Electronic Health Record (EHR) Programs, 

2011 and 2012

Notes: We analyzed data CMS collected pertaining to the EHR programs through October 23, 2013. 

This figure illustrates the percentage of eligible providers awarded EHR program incentive payments 

for 2011 and for 2012, as indicated by the length of each bar. As designated by the legend, these 

bars are divided to indicate the percentage of eligible providers that were awarded an incentive 

payment for the Medicare EHR program or the Medicaid EHR program or, in the case of hospitals, 

both EHR programs. These figures do not include participation in the Medicare Advantage EHR 

program. The sums of the percentages listed by EHR program may not equal the percentage 

reported for the entire year due to rounding. We estimated the percentage of eligible providers 

awarded incentive payments by dividing the number of providers awarded incentive payments by the 

total number of eligible providers CMS estimated in its Stage 1 final rule. Specifically, CMS estimated 

that 5,013 hospitals and 521,600 professionals were eligible for the Medicare or Medicaid EHR 

program 2011 and 5,013 hospitals and 527,200 professionals for 2012.

a

In the Medicare and Medicaid EHR programs, professionals include doctors of medicine and dental 

surgery. In the Medicaid EHR program, professionals also include nurse practitioners, certified nursemidwives, and certain physician assistants.
 

Page 22 GAO-14-207 Electronic Health Record Programs

The amount CMS paid in incentive payments to providers for participating 

in the Medicare EHR program, Medicaid EHR program, or both programs 

increased from $5.2 billion for 2011 to $9.5 billion for 2012.53 In total, 

CMS paid $14.7 billion in incentive payments to providers for 2011 and 

2012.54

 

53CMS paid an additional $232 million in incentive payments to providers for participating 

in the Medicare Advantage EHR program for 2011 and an additional $180 million to 

providers for participating in the Medicare Advantage EHR program for 2012, for a total of 

$412 million for both years—$96 million of which was paid for hospitals’ participation and 

the remaining $316 million for professionals’ participation.

Of this total, hospitals received nearly $8.6 billion and 

professionals received almost $6.1 billion. Incentive payments for 

hospitals and professionals under the Medicare EHR program amounted 

to $8.8 billion, while incentive payments for hospitals and professionals 

under the Medicaid EHR program were $5.9 billion. (See fig. 3.)

54Prior to the implementation of the EHR programs, CMS estimated (in its final rule for 

Stage 1 of meaningful use) the total payments that would be awarded to providers during 

fiscal year 2011 and fiscal year 2012, with a low estimate of $3.4 billion and a high 

estimate of $8.6 billion. These estimates were based on fiscal year payments and cannot

be directly compared with the payments reported above, which are based on program 

years and not when the payments were made. Thus, we also determined total payments 

awarded to providers during fiscal year 2011 and fiscal year 2012: a total of $7.6 billion

was awarded to providers during fiscal years 2011 and 2012, which is lower than CMS’s 

high estimate
 

Page 23 GAO-14-207 Electronic Health Record Programs

Figure 3: Total Payments from the Electronic Health Record (EHR) Programs for 

2011 and 2012, by Program and Provider Type

Notes: We analyzed data CMS collected pertaining to the EHR programs through October 23, 2013. 

These figures do not include participation in the Medicare Advantage EHR program. In the Medicare 

and Medicaid EHR programs, professionals include doctors of medicine and dental surgery. In the 

Medicaid EHR program, professionals also include nurse practitioners, certified nurse-midwives, and 

certain physician assistants.

Although participation in the EHR programs has increased overall, a 

substantial percentage of providers that participated in the Medicare EHR 

program or Medicaid EHR program in 2011 did not participate in either 

program in 2012. (See fig. 4.) Specifically, within the 36 states that had 

completed their determinations of which providers would receive incentive 

payments for the 2012 Medicaid EHR program year, 61 percent of 

professionals and 36 percent of hospitals that participated in the Medicaid 

EHR program in 2011 did not continue in 2012.55

 

55At the time of our analysis, according to CMS, 14 states and the District of Columbia had 

not completed their determinations of which providers would receive incentive payments 

for the 2011 and 2012 Medicaid EHR program years. As a result, to calculate the 

percentage of professionals and the percentage of hospitals that participated in the 

Medicaid EHR program in 2011 but did not continue in 2012, we excluded those states 

that had not completed their determinations.

Sixteen percent of 

professionals and 10 percent of hospitals participating in the Medicare 

EHR program in 2011 did not continue to participate in 2012.
 

Page 24 GAO-14-207 Electronic Health Record Programs

Figure 4: Percentage of 2011 Electronic Health Record (EHR) Programs 

Participants, by Participation in 2011 Alone or in Both 2011 and 2012

Notes: We analyzed data CMS collected pertaining to the EHR programs through October 23, 2013. 

The information presented for Medicaid providers is based on an analysis of data for 36 states that, 

according to CMS, had completed their determinations of which providers would receive incentive 

payments for the 2011 and 2012 Medicaid EHR program years as of October 23, 2013. The “2011 

and 2012” bars include providers that switched between participating in the Medicare EHR program in 

2011 and the Medicaid EHR program in 2012, or vice versa. In the Medicare and Medicaid EHR 

programs, professionals include doctors of medicine and dental surgery. In the Medicaid EHR 

program, professionals also include nurse practitioners, certified nurse-midwives, and certain 

physician assistants.

CMS officials are aware that some providers participating in 2011 did not 

continue in 2012 and told us that they are monitoring the issue and taking 

steps to reverse this trend. One CMS official told us there are various 

possible reasons Medicare and Medicaid providers did not continue to 

participate in the EHR programs. Noteworthy for the Medicaid EHR 

program, and in contrast to the Medicare EHR program, providers do not 

need to participate in consecutive years to maximize their incentive 

payments, and there are no penalties for not participating. Another 

possible reason providers did not continue to participate in the Medicaid 
 

Page 25 GAO-14-207 Electronic Health Record Programs

EHR program in 2012 is that providers are not required to demonstrate 

meaningful use for their first year of participation, but must do so for their 

second year. One CMS official noted that a provider who received an 

incentive payment for adopting, implementing, or upgrading to a certified 

EHR could still be far from having the capability to demonstrate 

meaningful use. The CMS official also noted that the agency conducted a 

survey of a sample of providers to learn why they did not continue to 

participate in the EHR programs and found the following additional 

reasons:

• some providers did not realize they needed to participate in the 

program again;

• some providers did not know the deadline for submitting the required 

information to CMS for the Medicare EHR program, to the states for 

the Medicaid EHR program, or to both;

• some providers switched EHR vendors and were not ready in time to 

submit the required information; and

• some providers found it more difficult than anticipated to go from a 

90-day reporting period to a full-year reporting period, as required for 

the second year of participation.

In an effort to reverse this trend, a CMS official told us CMS is working to 

ensure providers are well-informed regarding program requirements and 

data submission deadlines. For example, the official told us that CMS is 

emphasizing requirements and deadlines at meetings with providers, 

modifying educational materials, and reorganizing the agency’s website 

devoted to the EHR programs.
 

Page 26 GAO-14-207 Electronic Health Record Programs

Various program changes may affect participation in the EHR programs in 

the future, making future participation difficult to estimate. Beginning in 

2014, Stage 2 requirements for demonstrating meaningful use will be 

introduced for many providers participating in the EHR programs, 

requiring providers to demonstrate that they are using their systems in 

more advanced ways.56 The increased stringency of these Stage 2 

requirements for demonstrating meaningful use may slow participation in 

the EHR programs. While CMS and ONC have developed guidance 

materials and trainings to help providers prepare for Stage 2, survey data 

and statements by organizations representing providers suggest that 

some providers may be much less capable of demonstrating Stage 2 

meaningful use, compared to Stage 1 meaningful use, which might result 

in reduced participation.57

Conversely, other factors may encourage future participation. Penalties 

for Medicare providers not participating in the Medicare EHR program 

begin in 2015 and may motivate providers to begin participating in the 

program or to continue participating in the program.58

 

56To receive incentive payments, providers that demonstrated meaningful use for the first 

time in 2011 and 2012 must meet Stage 2 requirements for demonstrating meaningful use 

starting in 2014. Providers that demonstrated meaningful use for the first time in 2013 or 

2014 must meet Stage 2 requirements starting in 2015 and 2016, respectively.

In addition, CMS 

and ONC have identified certain provider groups as having more difficulty 

participating in the program and are taking steps to increase participation 

among these providers. For example, CMS officials told us the agency 

has partnered with the American Association of Pediatricians to identify 

states in need of more outreach to encourage pediatricians to participate 

in the Medicaid EHR program, and ONC’s Regional Extension Center 

program has provided assistance to providers such as professionals in 

solo practices or rural areas to help them participate in the EHR 

57Specifically, an analysis of the American Hospital Association’s 2012 survey of hospitals 

indicates that 5.1 percent of acute care hospitals could meet all 16 of the mandatory 

meaningful use measures for Stage 2. See C.M. DesRoches, D. Charles, M.F. Furukawa, 

M.S. Joshi, P. Kralovec, F. Mostashari, C. Worzala, and A.K. Jha, “Adoption of Electronic 

Health Records Grows Rapidly, but Fewer Than Half of US Hospitals Had at Least a Basic 

System in 2012,” Health Affairs, no. 32 (2013): 1478-1485.

58To avoid penalties in 2015, most eligible providers who first demonstrated meaningful 

use in 2011 or 2012 were required to do so again for a full year in 2013. Otherwise, by first 

demonstrating meaningful use in 2013 or in 2014 (that is, by July 1, 2014, for hospitals or 

October 1, 2014, for professionals), eligible providers could avoid penalties in 2015. In 

general, providers must continue to demonstrate meaningful use each year to avoid 

penalties in subsequent years.

Program Changes, 

Including the Increasing 

Stringency of 

Requirements and the 

Implementation of 

Penalties, Make It Difficult 

to Estimate Future 

Participation
 

Page 27 GAO-14-207 Electronic Health Record Programs

programs.59 As we previously reported, participation in the Medicare EHR 

program among rural hospitals and professionals in solo practices 

increased faster from 2011 to 2012 than participation by hospitals and 

professionals overall.60 Furthermore, CMS has made changes to certain 

program eligibility requirements that may increase the number of 

providers participating. For example, beginning in 2014, professionals 

that are hospital-based may receive incentive payments if they can 

demonstrate that they fund the acquisition, implementation, and 

maintenance of EHRs in lieu of using a hospital’s EHRs.61 Previously, 

these professionals were ineligible to participate in the EHR programs.

The meaningful use measures reported by providers for 2011 and 2012 

indicate that providers used their certified EHR systems more often than 

required and suggest that many providers who have already reported 

certain Stage 1 measures will be able to meet most of the more stringent 

reporting thresholds for similar measures in Stage 2. (See app. IV, 

table 6.) For 2011 and 2012, Medicare providers that received EHR 

incentive payments consistently exceeded most meaningful use measure 

reporting thresholds—that is, a specified percentage of patients or actions 

required to satisfy the measure—established by CMS and ONC for the 

EHR programs.62

 

59ONC funding to Regional Extension Centers—approximately $721 million in grants—will 

not be available after 2015. ONC indicated that Regional Extension Centers will continue 

to provide services to providers but anticipates that the scope and scale of these services 

will be dramatically reduced.

Of the 14 hospital meaningful use measures that had 

thresholds, on average, Medicare hospitals exceeded thresholds by at 

least 10 percentage points for all measures and by considerably more for 

many measures. For example, hospitals are required to use computerized 

provider order entry for more than 30 percent of patients with at least one 

medication for Stage 1. For both 2011 and 2012, Medicare hospitals 

60See GAO-14-21R. Although participation among rural hospitals and solo practitioners 

grew rapidly, for 2011 and 2012, hospitals in urban areas and professionals in larger 

practices were more likely to have participated in the Medicare EHR program.

61In general, hospital-based professionals are not eligible to receive incentive payments or 

incur penalties from the Medicare and Medicaid EHR programs. A hospital-based 

professional is a professional who performs 90 percent or more of his or her services in 

the prior year in hospital inpatient or emergency room settings.

62For meaningful use measures with reporting thresholds, those thresholds ranged from 

10 to 80 percent. See app. III for a list of the meaningful use measures and, if applicable, 

the thresholds established for them for Stage 1.

Providers Exceeded 

Meaningful Use 

Requirements for 

Most Stage 1 

Measures, but May 

Face Challenges with 

Certain More 

Stringent Stage 2 

Measures
 

Page 28 GAO-14-207 Electronic Health Record Programs

reported using computerized provider order entry for medication orders 

for over 84 percent of patients—about 2.8 times the required threshold for 

Stage 1. Medicare professionals also greatly exceeded the reporting 

thresholds.63 We did not conduct an analysis of meaningful use measures 

reported by Medicaid providers, but there is some evidence that Medicaid 

professionals also consistently exceeded required thresholds for 2012.64

While providers that have not participated in the EHR programs may have 

different experiences, the fact that Medicare providers and Medicaid 

professionals that participated in 2011 or 2012—the first two years of 

Stage 1—generally exceeded most reporting thresholds by wide margins 

for the measures they reported suggests that they will be able to meet 

most of the more stringent reporting thresholds in Stage 2.65

 

63Similarly to our finding for hospitals, of the 16 professional meaningful use measures 

that had thresholds, on average, professionals reported rates at least 10 percentage 

points above the measures’ thresholds for all measures and exceeded thresholds by 

considerably more for many measures. For example, professionals were required to 

provide patients with timely electronic access to their health information for at least 

10 percent of patients. For both 2011 and 2012, professionals reported doing so for more 

than 70 percent of their patients. 

For example, 

in Stage 2, providers are required to use their certified EHRs to record 

and chart changes in vital signs for more than 80 percent of patients. 

Medicare hospitals and professionals exceeded this threshold for both 

2011 and 2012, reporting that they met this measure for over 90 percent 

of patients.

64A CMS analysis of professionals who received incentive payments from the Medicaid 

EHR program for 2012 for demonstrating meaningful use—approximately 30 percent of 

professionals in the program—provides evidence that those Medicaid professionals 

consistently exceeded required thresholds. These professionals exceeded thresholds by 

at least 15 percentage points for all measures and by considerably more for many 

measures. CMS analyzed data it received from states on measures Medicaid 

professionals reported to demonstrate meaningful use for 2012, the first year during which 

some Medicaid providers were required to demonstrate meaningful use to receive a 

Medicaid EHR incentive payment. These data have limitations. For example, according to 

CMS officials, states reported data on only a subset of Medicaid professionals who 

demonstrated meaningful use in 2012 and we do not know how representative this sample 

is of all professionals who received incentive payments from the Medicaid EHR program 

for 2012 for demonstrating meaningful use.

65For Stage 2, CMS increased the reporting thresholds from the Stage 1 thresholds for 

five hospital measures and six professional measures. Other Stage 1 measures with 

thresholds do not have more stringent Stage 2 thresholds, changed substantially for 

Stage 2 such that a comparison to the Stage 1 thresholds is not appropriate, or are not 

Stage 2 measures.
 

Page 29 GAO-14-207 Electronic Health Record Programs

In addition to consistently exceeding most required reporting thresholds, 

other analyses identify some measures that were frequently reported by 

providers in Stage 1.66

Although providers were able to report on certain measures that involved 

the electronic exchange of information, some of the exchange measures 

may be more challenging for them.

(See app. IV, table 7.) For example, close to 

100 percent of providers for 2011 and 2012 reported the mandatory 

Stage 1 measure to record smoking status for patients 13 years and older 

without claiming allowable exemptions. Certain optional measures, 

including one related to the electronic exchange of health information, 

were also frequently reported. For example, over 80 percent of hospitals 

reported incorporating clinical lab test results into EHRs as structured 

data.

67

• Provide summary of care document for each transition of care or 

referral. Less than 10 percent of hospitals and less than 15 percent of 

professionals reported this measure for 2011 and 2012. This measure 

is optional in Stage 1 and mandatory in Stage 2.

Examples of some measures that 

may be more challenging are the following:

• Submit public health data. Fewer than 20 percent of Medicare 

providers reported the following two public health measures for 2011 

and 2012: submit electronic syndromic surveillance data (that is, data 

collection and analysis to aid identification of outbreaks) to public 

health agencies and submit electronic data on reportable lab results to 

public health agencies. Both measures are optional for hospitals in 

Stage 1 and mandatory for hospitals in Stage 2; the syndromic 

surveillance measure is optional for professionals in both stages.68

 

66For certain measures, providers were not required to report mandatory and optional 

measures that were not relevant to them—which is referred to as claiming an exemption—

and were only required to choose a subset of optional measures to report. In Stage 1, 

hospitals were permitted to claim exemptions from reporting three mandatory measures 

and four optional measures, and professionals were permitted to claim exemptions from 

reporting six mandatory measures and eight optional measures. (See app. III for the 

measures for which exemptions are permitted.)

In 

67Other measures not related to the electronic exchange of information may also be 

problematic for providers. For example, fewer than 25 percent of Medicare professionals 

in 2011 and 2012 reported sending patient reminders for preventive or follow-up care. This 

measure is optional for professionals in Stage 1 and mandatory for professionals in 

Stage 2.

68The reportable lab results measure is not a measure for professionals in either stage.
 

Page 30 GAO-14-207 Electronic Health Record Programs

addition, these measures become more stringent in Stage 2, requiring 

ongoing submission of these data rather than just a one-time test of 

the ability to submit those data, which Stage 1 required.69

• Perform medication reconciliation for patients received from 

another setting of care or provider of care. Fewer than 30 percent 

of Medicare hospitals reported this measure for 2011 and 2012. This 

measure is optional in Stage 1 and mandatory in Stage 2.

• Provide patients with their health information electronically. Less 

than 35 percent of Medicare hospitals and professionals for both 2011 

and 2012 reported the mandatory measure to provide patients with an 

electronic copy of their health information. Data submitted by the 

providers that reported this measure indicate that very few patients—

often fewer than 4 patients per year for hospitals and 12 patients per 

year for professionals—requested this electronic information. 

Additional evidence suggests that this measure was reported by a 

similar proportion of Medicaid professionals for 2012.70

Other information also indicates that providers may face challenges with 

many of the same exchange-related Stage 2 meaningful use measures 

identified above. An analysis of the American Hospital Association’s 2012 

survey of hospitals about technical capabilities related to meaningful use 

indicates that the least commonly implemented Stage 2 capabilities by 

acute care hospitals were those related to the electronic exchange of 

In Stage 2, the 

measure becomes more stringent, by requiring that 5 percent of 

patients electronically view, download, or transmit their health 

information to a third party, in addition to requiring hospitals and 

professionals to provide patients with online access to their health 

information.

 

69Ongoing submission is also necessary in Stage 2 to meet requirements of the following 

exchange-related public health measures, the last two of which are new for professionals 

in Stage 2: immunization data, cancer cases, and other specific cases.

70In the previously mentioned CMS analysis, among the mandatory meaningful use 

measures reported by the approximately 30 percent of professionals who received 

incentive payments from the Medicaid EHR program for 2012 for demonstrating 

meaningful use, this measure was the least frequently reported.
 

Page 31 GAO-14-207 Electronic Health Record Programs

information.71

Consistent with indications from the survey data, stakeholder 

organizations have also noted concern that providers may have difficulty 

satisfying certain Stage 2 meaningful use measures due to the changes 

made to them for Stage 2. Table 4 lists meaningful use measures that 

organizations identified as challenging—two of which relate to the 

electronic exchange of information—and includes the requirements for 

satisfying each measure in Stage 1 and in Stage 2.

Such capabilities included the following: submitting 

electronic data on reportable lab results to public health agencies; 

submitting electronic syndromic surveillance data to public health 

agencies; providing an electronic summary of care document for each 

transition of care or referral; and providing patients with electronic access 

to their health information by enabling them to view online, download, and 

transmit such information. These capabilities are related to optional 

Stage 1 measures but will be required in Stage 2 or become more 

complex in Stage 2. An analysis of the National Center for Health 

Statistics’ 2012 National Ambulatory Medical Care Survey shows similar 

results for physicians. Among the capabilities related to meaningful use 

measures, office-based physicians were least likely to have routinely 

submitted electronic data to immunization registries or information 

systems, or to have routinely communicated with patients using secure 

messaging. Stage 2 requires professionals to report measures that 

capture these capabilities, whereas reporting on the first capability was 

optional in Stage 1 and the second was not a Stage 1 measure. 

 

71See DesRoches et al., “Adoption of Electronic Health Records,” 1482. The survey asked 

whether hospitals had implemented specific clinical functions that may be part of an EHR 

system and that are related to many of the capabilities required to demonstrate Stage 1 

and Stage 2 meaningful use. The study authors considered the capability to have been 

implemented if the hospital’s system had the capability or had implemented it in at least 

one hospital unit.
 

Page 32 GAO-14-207 Electronic Health Record Programs

Table 4: Changes to Selected Meaningful Use Measures from Stage 1 to Stage 2 of the Electronic Health Record (EHR) 

Programs

Stage 1 Stage 2

Use computerized provider order entry

Mandatory measure

At least one medication order entered for more than 30 percent of 

patients with at least one medication

Mandatory measure

At least 60 percent of medication orders entered

At least 30 percent of laboratory orders entered

At least 30 percent of radiology orders entered

Provide patients with their health information electronically

Mandatory measure

Provide electronic copy of health information within 3 days to at 

least 50 percent of patients who requested an electronic copy

a

• The electronic information can be made available in any form

Mandatory measure

Provide electronic access to health information within 36 hours 

of discharge (hospitals) or 4 days (professionals) to at least 

50 percent of patients

b

• Internet-based access is required

More than 5 percent of patients view, download, or transmit their 

health information to a third party

Provide summary care document for each transition of care or referral of care

Optional measure

Provide for more than 50 percent of transitions of care and 

referrals 

• Document can be sent electronically or in paper copy

• Document must contain the following: diagnostic results, 

problem list, medication list, medication allergy list, and 

procedures

Mandatory measure

Provide for more than 50 percent of transitions of care and 

referrals 

• Document can be sent electronically or in paper copy

• Document must contain the following: patient name; referring 

or transitioning provider’s name and office contact 

information (professionals only); procedures; encounter 

diagnosis; immunizations; laboratory test results; vital signs 

(height, weight, blood pressure, body mass index); smoking 

status; functional status; demographic information (preferred 

language, sex, race, ethnicity, date of birth); care plan field; 

care team; reason for referral (professional only); discharge 

instructions (hospital only); current problem list; current 

medication list; and current medication allergy list

Electronically transmit document for more than 10 percent of 

transitions of care and referrals

Conduct one or more tests of successful electronic exchange of 

document with either a provider with a different certified EHR 

vendor or the CMS-designated test EHR

Source: GAO analysis of Office of the National Coordinator for Health Information Technology (ONC) regulations and CMS guidance. 

Note: The following provider organizations identified these meaningful use measures as being 

challenging in Stage 2: the American Hospital Association, the American Medical Association, and 

the College of Healthcare Information Management Executives.

a

This was the Stage 1 requirement for 2011 through 2013. Beginning in 2014 the Stage 1 requirement 

is to provide electronic internet-based access to health information within 36 hours of discharge 

(hospitals) or 4 days (professionals) to at least 50 percent of patients.

b

CMS guidance notes that the Stage 2 version of this measure replaces the following Stage 1 

measure that was required for hospitals: “provide patients with electronic copy of discharge 

instructions at the time of discharge” for more than 50 percent of patients who requested that 

information within 3 business days and the Stage 1 measure that was optional for professionals: 
 

Page 33 GAO-14-207 Electronic Health Record Programs

“provide patients with timely electronic access to their health information” to at least 10 percent of 

patients within 4 business days.

A CMS official noted that although providers have expressed concern 

about their ability to meet the Stage 2 requirements, similar concerns 

existed prior to Stage 1 regarding the thresholds established for certain 

measures and the data suggest that providers have exceeded thresholds 

established by CMS for the Stage 1 requirements. This official also 

explained efforts to help providers to prepare to satisfy the Stage 2 

meaningful use measures. CMS has been modifying its materials and 

holding training sessions and discussions with various provider groups. In 

anticipation of obstacles to the exchange of health information and in 

order to accelerate electronic exchange even among providers not 

eligible for incentive payments from the EHR programs, ONC and CMS 

issued a request for information in March 2013 to, among other things, 

solicit feedback on the challenges to the electronic exchange of health 

information and on possible mechanisms to overcome those challenges.72

Using the information collected, CMS and ONC issued a strategy in

August 2013 for how they expect to advance health information 

exchange, which includes various steps the agencies plan to take under 

three broad categories—accelerating health information exchange, 

advancing standards and interoperability, and patient engagement.73

Ongoing work is examining the key challenges to the electronic exchange 

of health information that have been reported by providers and 

stakeholders and HHS’s efforts to address those challenges.

 

7278 Fed. Reg. 14793 (March 7, 2013).

73See Principles and Strategy for Accelerating Health Information Exchange (HIE). Office 

of the National Coordinator for Health Information Technology and the Centers for 

Medicare & Medicaid Services. August 7, 2013.
 

Page 34 GAO-14-207 Electronic Health Record Programs

The lack of a comprehensive strategy limits HHS’s ability to ensure that 

the department can reliably use the CQMs collected in certified EHRs for 

quality measurement activities. According to internal control standards, an 

agency must have relevant and reliable information to help it achieve its 

mission and goals. In order to drive quality improvement and 

accountability and to effectively utilize CQM data collected in EHRs for 

HHS’s quality measurement activities, the data collected must be reliable, 

that is, both accurate and complete. Data that are not reliable limit the 

credibility of the information and may present a risk to individuals or 

entities making decisions based on the data, such as to a patient 

choosing a hospital for treatment, or to CMS when applying a payment 

modifier resulting in an increase or reduction to a physician’s 

reimbursement.

CMS and ONC have made changes to the specifications, certification 

criteria, and certification program to address some of the reliability 

concerns with the CQMs that providers were generally required to collect 

and report from 2011 to 2013 to demonstrate meaningful use (that is, 

using 2011-edition EHRs). These changes are incorporated into EHRs 

that will be used by participating providers in all stages of meaningful use 

from 2014 to 2016 (that is, 2014-edition EHRs). The changes made as a 

result of the concerns identified include the following.

Specifications. CMS made changes to CQM specifications—that is, the 

documentation that describes to providers, technology developers, and 

others how data on CQMs were to be collected through EHRs. These 

changes were made to correct previously identified errors and to help 

ensure the feasibility of implementing CQMs in the electronic format—that 

is, to ensure that the required data are readily available or can be 

collected in EHRs without undue burden. Problems with feasibility can 

compromise the accuracy or completeness of the data.74

Certification criteria. To address providers’ concern that their 2011-

edition EHRs did not collect all of the data elements necessary to 

calculate the CQMs, ONC modified the CQM-related certification criteria. 

 

74In 2012, we recommended that HHS test CQMs to help identify potential errors and 

address issues of implementation. See GAO-12-136. HHS implemented our 

recommendation by having various CMS contractors complete feasibility testing of new 

measures incorporated into 2014-edition EHRs and by establishing plans to test future 

measures.

HHS Lacks a 

Comprehensive 

Strategy to Help 

Ensure Reliability of 

EHR Data Collected 

to Improve Quality of 

Care
 

Page 35 GAO-14-207 Electronic Health Record Programs

Specifically, 2014-edition EHRs must collect each of the data elements 

associated with a specific CQM to be certified for that measure.75

Certification program. The program for certifying 2011-edition EHRs did 

not test whether the EHR system correctly collected and calculated the 

CQMs. However, beginning with the certification of 2014-edition EHRs, 

the certification bodies and testing laboratories will test whether EHRs 

accurately collect and calculate CQMs. These tests will be performed 

using a certification testing tool developed by ONC, known as Cypress.

76

CMS and ONC officials indicated the changes made thus far should help 

to address reliability concerns, but provider experience with 2014-edition 

EHRs will be an important gauge of the effectiveness of the changes.

Further, beginning in 2014, the certification bodies will be required by 

ONC to conduct specific annual surveillance activities to determine 

whether 2014-edition EHRs are functioning as intended after being 

implemented by providers. CQMs have been identified as a priority area 

for these surveillance activities, which may help to inform CMS and ONC 

on whether the changes they have made to the specifications, 

certification criteria, and certification program are improving the reliability 

of CQMs, as intended, and whether further changes are needed.

77

Furthermore, there are still issues that could result in reliability problems, 

hindering CMS’s ability to use the data for its quality measurement 

activities. For example, after EHRs are certified as 2014-edition EHRs, 

the agencies do not require them to be recertified following updates to the 

specifications, which may be made annually or more frequently, or 

following updates to the certification testing tool.78

 

75The data elements associated with each CQM collected using certified EHRs include 

lists of specific values that define clinical concepts (e.g., patient with diabetes, clinical 

visits, and reportable diseases) and are used to define the patient populations that should 

be included in the computation of CQMs.

Thus, different 

76Testing bodies use the certification testing tool—Cypress—to test that EHRs accurately 

export, calculate, and electronically submit the data. This tool includes synthetic patient 

data used in the testing process. Vendors also have access to the testing tool prior to 

submitting their EHR products for certification.

77To qualify for incentive payments from the Medicare EHR program for the 2014 program 

year, the deadline for submitting CQM data to CMS is November 30, 2014, for hospitals 

and February 28, 2015, for professionals.

78ONC officials said that the agency releases new versions of the certification testing tool 

for various reasons, including to address mistakes, to reflect changes to the specifications, 

and to improve the tool.
 

Page 36 GAO-14-207 Electronic Health Record Programs

providers may report CQMs based on and tested to different 

requirements. CMS has taken some steps to mitigate the potential effect 

of these issues on the reliability of CQM data submitted by professionals 

who electronically submit CQM data by requiring them to report CQMs 

collected using EHR technology based on and tested to the most recent 

version of the electronic specifications. However, this variability may limit 

the ability to reliably compare quality across other providers, including 

hospitals, and undermines efforts CMS officials said they are taking to 

ensure that the CQMs lead to standardized, consistent data reporting. 

Another issue that may affect reliability is that many providers reported at 

least one CQM based on few patients, which may result in data that are 

not statistically reliable and therefore should not be used in quality 

measurement.79 We analyzed data submitted by providers to demonstrate 

meaningful use under the Medicare EHR program for 2011 and 2012 and 

found that 90 percent of hospitals and 50 percent of professionals 

reported at least one CQM based on few patients for 2012, a slight 

increase compared to 2011, when 86 percent of hospitals and 46 percent 

of professionals reported at least one CQM based on few patients.80

In addition, stakeholder organizations continue to have concerns about 

reliability. CHIME members indicated that they do not think the 

specifications required to generate CQMs using 2014-edition EHRs will 

substantially improve the reliability of the data collected in Stage 2. They 

noted that the collection of CQM data includes data elements not 

currently captured by EHRs, and the data elements are not automatically 

part of most clinicians’ workflow (that is, incorporated into the tasks 

performed during the delivery of routine care). Due to these obstacles, 

 

79CMS is taking steps to address this issue in some of its programs that use CQMs. For 

example, the Physician Value Based Payment Modifier will include only CQMs that are 

based on a minimum of 20 patients. In addition, the agency’s Hospital Compare website, 

which publicly reports CQMs by hospital, indicates whether the number of patients 

included in a particular measure calculation was based on fewer than 25 patients and was

thus too small to reliably tell how well the hospital is performing.

80We defined few as fewer than 7 patients for providers who submitted data collected over 

a 90-day reporting period and as fewer than 25 patients for providers who submitted data 

collected over a full-year reporting period. The reporting period is generally 90 days for the 

first year a provider demonstrates meaningful use and a full year thereafter.

Our analysis included all patients reported by the provider, irrespective of insurance type. 

The likelihood that professionals who satisfy the Medicare EHR program’s CQM 

requirements by reporting through PQRS will report measures based on few patients 

could be greater, because these professionals report CQMs only on Medicare patients.
 

Page 37 GAO-14-207 Electronic Health Record Programs

CHIME members are concerned that clinicians will not consistently collect 

the required data elements, ultimately leading to problems with CQM 

reliability and comparability. CMS and ONC are making changes to the 

process used to develop new measures, which includes greater 

consideration of clinician workflow and provider burden. However, new 

CQMs will not be available until the beginning of Stage 3 in 2017.

Another concern expressed by stakeholder organizations such as the 

American Health Information Management Association, the American 

Hospital Association, the American Medical Association, the Healthcare 

Information and Management Systems Society, and The Joint 

Commission is that the CQMs generated from EHRs—which are based 

on electronically specified measures and are extracted automatically from 

EHRs—do not produce results that are comparable to corresponding 

measures based on data obtained through other methods, such as 

through manual abstraction of patient medical records by trained 

professionals. In its fiscal year 2014 Inpatient Prospective Payment 

System final rule, CMS noted that it intends to use the electronic CQM 

data submitted voluntarily by hospitals to assess the differences in 

performance rates from CQMs collected using EHRs and CQMs collected 

through chart-abstraction.81

Although CMS officials told us that they were beginning to develop an 

approach to validate CQM data generated from EHRs, HHS has not yet 

developed a comprehensive strategy to address concerns with the 

reliability of CQMs collected using certified EHRs. Consistent with 

GPRAMA and our prior work, which identifies several important practices 

that can guide agencies in planning and implementing an effective 

government program, a comprehensive strategy would establish 

objectives, steps to achieve results, priorities, and milestones and identify 

the steps necessary to achieve desired results. Addressing the concerns 

is important to ensure that the CQM data can be reliably used for CMS’s 

However, CMS did not indicate when this 

study would be completed or describe how it would be designed. 

Designing the study to control for any other systematic differences 

between providers that use EHRs and other providers could have an 

important effect on CMS’s ability to understand the extent and 

implications of potential differences in performance rates.

 

81For the 2012 and 2013 program years, providers were permitted but not required to 

submit CQM data to CMS electronically through electronic reporting pilot programs—one 

for hospitals and one for professionals.
 

Page 38 GAO-14-207 Electronic Health Record Programs

quality measurement activities as well as providers’ quality improvement 

activities. For example, CMS plans to use CQMs collected and submitted 

via EHRs by certain professionals in 2014 to determine which providers 

will be subject to payment modifications under the Value Based Payment 

Modifier program in 2016. For hospitals, CMS officials told us that as part 

of their approach to validating data, they plan to use electronically 

submitted CQMs to develop monitoring processes to help inform them 

about the consistency and reliability of the data reported. Also for 

hospitals, CMS officials told us that they expect to introduce a process 

that is as robust as the one that is currently used for the IQR program 

under which a CMS contractor conducts an independent analysis to verify 

that the data submitted accurately reflect the information in the medical 

record.82 CMS officials told us that the agency’s plans for validating CQM 

data are preliminary, but the agency has stated that it intends to develop 

and propose a strategy for hospital data in 2014 as part of the agency’s 

annual rulemaking process. While the IQR program may provide a model 

for validating data collected by hospitals using certified EHRs, no 

comparable model or process exists that could be considered when 

developing a validation strategy for data collected by professionals using 

certified EHRs. Until HHS establishes and implements a comprehensive 

strategy to ensure the reliability of CQMs collected using certified EHRs, it 

will be unclear whether the department’s plans are sufficient to address 

the concerns, and therefore it will be uncertain when the CQM data can 

be reliably used to help assess provider performance, improve quality, 

and adjust provider payments.

 

82GAO has previously reported on CMS’s efforts to ensure the reliability of hospital quality 

data collected for the IQR program. See GAO, Hospital Quality Data: CMS Needs More 

Rigorous Methods to Ensure Reliability of Publicly Released Data, GAO-06-54

(Washington, D.C.: Jan. 31, 2006).
 

Page 39 GAO-14-207 Electronic Health Record Programs

HHS, CMS, and ONC have established some performance measures for 

the EHR programs that are tied to strategic goals, but have not 

established performance measures for the goals most relevant to the 

intended outcomes of the EHR programs—that is, goals related to 

improving health care quality, efficiency, and patient safety. Establishing 

performance measures tied to goals is important for ensuring that 

agencies’ activities move them closer to accomplishing these goals, 

according to our guidance to federal agencies on effectively implementing 

GPRAMA, which describes leading practices for how federal agencies 

should assess their performance.83

Based on review of relevant documents, we identified two categories of 

department and agency goals that are particularly relevant to the EHR 

programs—(1) adoption and meaningful use of EHRs, which is focused 

on program processes; and (2) improving quality, efficiency, and patient 

safety, which is focused on program outcomes. For the first category, 

HHS, CMS, and ONC have established 26 performance measures that 

allow them to track program processes, such as provider participation 

levels.

Our guidance also notes that 

agencies should use information that performance measures provide to 

improve processes and set improvement goals. However, as the 

agencies have not established performance measures to assess 

outcomes, they are therefore unable to use the information such 

measures would provide.

84

 

83GAO, Executive Guide: Effectively Implementing the Government Performance and 

Results Act, 

The majority of these measures focus on participation in the EHR 

programs as measured by meeting requirements for adoption and 

meaningful use of EHRs. For example, HHS, CMS, and ONC have 

performance measures for the number of eligible providers who receive 

an incentive payment from the EHR programs for the successful adoption 

or meaningful use of EHRs. ONC has also recently established 

performance measures related to exchanging information electronically, 

in keeping with the emphasis on the electronic exchange of information in 

Stage 2. For example, ONC has established a performance measure for 

GAO/GGD-96-118 (Washington, D.C.: June 1, 1996).

84In addition, the Centers for Disease Control and Prevention has 3 performance 

measures related to the meaningful use of EHRs intended to measure the readiness of 

public health agencies to receive electronically submitted data as part of the EHR 

programs. The Centers for Disease Control and Prevention provides direct assistance to 

state public health agencies to support electronic health information systems to receive 

data from providers.

Performance 

Measures for the 

EHR Programs Do 

Not Assess 

Outcomes Such As

Improved Quality, 

Efficiency, and Patient 

Safety
 

Page 40 GAO-14-207 Electronic Health Record Programs

the percentage of nonfederal acute care hospitals that are electronically 

sharing summary of care records with providers outside their 

organization. (See app. V, table 8 for a list of the department- and 

agency-level strategic goals and 26 associated performance measures 

for this category.)

For these established performance measures, the agencies have 

developed corresponding performance targets and track results against 

those targets. For example, ONC has set a fiscal year 2014 target that 

65 percent of nonfederal acute hospitals electronically share summary of 

care records with providers outside of their organization. These 

performance targets are publicly released alongside the performance 

measures and actual results in the annual ONC and CMS budget 

justifications and the HHS online performance appendix.85

However, although HHS, CMS, and ONC have established important 

performance measures for the goals related to adoption and meaningful 

use of EHRs, they have not established measures linked to the second 

category of goals, which would help them to track program outcomes 

such as health care quality, efficiency, and patient safety. (See app. V, 

table 9 for a list of the department- and agency-level strategic goals for 

this category.) Outcome measures would enable the agencies to measure 

whether the EHR programs’ intended effects are being achieved, rather 

than just the number of providers that satisfied the requirements 

necessary to demonstrate meaningful use. ONC’s strategic plan states 

that the meaningful use of EHRs—which, as explained above, the 

agencies track using several performance measures—is a necessary 

step to improve health care quality, efficiency, and patient safety. 

However, meaningful use is not sufficient to achieve these outcomes on 

its own. The plan notes that the EHR programs are an HIT investment 

made in lockstep with various other reform efforts such as patientcentered medical homes and that EHRs will contribute to improvements 

in health care quality, efficiency, and patient safety when used in support 

The agencies 

told us they use this performance information to set the broader strategic 

direction for the agency and may also use the information to make 

changes to the programs to improve performance.

 

85For instance, see Department of Health and Human Services, Fiscal Year 2014: Office 

of the National Coordinator for Health Information Technology Justification of Estimates 

for Appropriations Committee (Washington, D.C.), accessed April 11, 2013, 

http://www.healthit.gov/newsroom/onc-budget-documents-and-performance-information. 
 

Page 41 GAO-14-207 Electronic Health Record Programs

of these other reform efforts. Therefore, outcome measures—and the 

subsequent use of the information they provide—could be beneficial to 

evaluating how the EHR programs interact with other reform efforts. 

Furthermore, ONC has acknowledged the need to develop performance 

measures to track patient safety, in part due to concerns that EHRs could 

have some unintended consequences that cause patient harm. However, 

ONC has not yet developed these potential measures.86

Without performance measures linked to the goals of improved health 

care quality, efficiency, and patient safety, CMS and ONC are limited in 

their abilities to determine the effectiveness of the EHR programs in 

improving outcomes. CMS and ONC may lack critical information 

necessary to establish program priorities and subsequently make 

program adjustments based on progress toward these outcomes. CMS 

and ONC officials have indicated that they do not expect to observe 

progress toward achieving the intended outcomes of improved health 

care quality, efficiency, and patient safety until at least Stage 3 of the 

EHR programs, which is not expected until 2017. However, establishing 

outcome-oriented performance measures before results are expected is a 

valuable practice to ensure that the agencies can make program 

adjustments as needed and are prepared to monitor outcomes and to 

establish baseline values, which can be useful for developing 

performance targets and assessing progress toward goals. Moreover, 

consistent with our guidance, outcome measures could be useful to guide 

the development and prioritization of Stage 3 requirements, which the 

agencies anticipate undertaking in 2014.

While the agencies have not established outcome-related performance 

measures, agency officials told us they are conducting some evaluations 

to assess the effect of the EHR programs on outcomes. For example, 

ONC officials told us that CMS, ONC, and the Agency for Healthcare 

Research and Quality were working on a study to assess the effect of 

electronic prescribing on quality and efficiency using Medicare Part D 

claims, specifically, to determine whether electronic prescribing for 

 

86In July 2013, ONC published a plan to strengthen patient safety efforts across 

government programs and the private sector. This plan outlines efforts to collect 

information on patient safety such as aggregate data on HIT-related adverse events and 

hazards and calls for the agency to develop performance measures for patient safety. See 

the Office of the National Coordinator for Health Information Technology, Health IT Patient 

Safety Action & Surveillance Plan (July 2, 2013), accessed August 14, 2013, 

www.healthit.gov/sites/default/files/safety_plan_master.pdf.
 

Page 42 GAO-14-207 Electronic Health Record Programs

diabetes patients is associated with a reduced risk of adverse drug 

events.87 (See app. VI for a summary of program evaluations assessing 

the EHR programs’ effects on outcomes.) However, these program 

evaluations—in contrast to performance measures—capture only a 

specific period of time, and, as a result, do not allow for ongoing 

monitoring of the EHR programs’ effectiveness.

The EHR programs were intended to be long-term solutions—with 

multiple stages implemented over several years—to help address 

longstanding, significant barriers to greater use of EHRs as tools for 

improving outcomes such as health care quality, efficiency, and patient 

safety. The first stage of the EHR programs, from 2011 to 2012, has 

shown sizeable increases in the number of providers who have adopted 

and meaningfully used EHRs. This early measure of implementation still 

leaves substantial room to further increase meaningful use among certain 

providers. Implementation of the subsequent stages, which will 

increasingly emphasize the use of more advanced features of EHRs, will 

place more demands on providers through more stringent requirements, 

but could also increase the potential for achieving better outcomes. 

Because of the programs’ design to evolve over multiple years and 

stages, HHS has opportunities to make adjustments and closely monitor 

the programs to ensure that they remain on track to achieve their 

intended results.

One key feature of EHRs that shows a need for adjustment relates to the 

CQMs. We describe several issues regarding the reliability of CQM 

data—for example, providers may be reporting CQMs based on and 

tested to different specifications. The reliability of CQM data collected 

using certified EHRs is especially important due to the potential risk of 

making decisions—such as paying providers for performance—based on 

unreliable CQM data. CMS and ONC lack a comprehensive strategy that 

would allow them to ensure the reliability of CQM data collected using 

EHRs, in accordance with the internal control standard requiring an 

agency to have relevant and reliable information to achieve its mission 

and goals. Without a comprehensive strategy, the agencies may be 

limited in their abilities to reliably compare quality across providers or use 

CQM data collected through EHRs for a variety of quality measurement 

 

87CMS’s Medicare Part D provides outpatient prescription drug benefits for Medicare 

beneficiaries.

Conclusions
 

Page 43 GAO-14-207 Electronic Health Record Programs

and pay-for-performance activities, thus restricting efforts to improve 

quality and efficiency.

Another area that merits attention relates to HHS’s ability to ensure that 

the EHR programs are on track to meet their goals. While the EHR 

programs are ultimately intended to improve outcomes such as health 

care quality, efficiency, and patient safety, the agencies have not 

established performance measures for monitoring progress toward 

achieving these improvements. Although HHS expects that EHRs can 

help achieve improved outcomes as well as support various other health 

care reform efforts that are also intended to improve care, that result is 

not yet assured. As established by our guidance to federal agencies, 

monitoring progress toward specific outcomes could allow HHS to make 

adjustments to the EHR programs throughout their implementation, such 

as adjusting priorities or requirements. Without such monitoring, the 

agencies will not be well positioned to understand how challenges 

affecting key parts of the programs, such as ensuring the reliability of 

CQM data or increasing providers’ abilities to exchange health 

information, might be affecting the programs’ overall ability to achieve 

their goals, reducing HHS’s ability to make course corrections.

To more effectively use CQMs to assess provider performance, the 

Secretary of Health and Human Services should direct CMS and ONC to 

take the following action:

• Develop a comprehensive strategy for ensuring that CQM data 

collected and reported using certified EHR technology are reliable, 

including testing for and mitigation of reliability issues arising from 

variance in certified EHR systems tested to different CQM 

specifications.

To ensure that CMS and ONC can effectively monitor the effect of the 

EHR programs and progress made toward goals, the Secretary of Health 

and Human Services should direct the agencies to take the following two 

actions:

• Develop performance measures to assess outcomes of the EHR 

programs—including any effects on health care quality, efficiency, and 

patient safety and other health care reform efforts that are intended to 

work toward similar outcomes—and

Recommendations for 

Executive Action
 

Page 44 GAO-14-207 Electronic Health Record Programs

• Use the information these performance measures provide to make 

program adjustments, as appropriate, to better achieve program 

goals.

HHS provided written comments on a draft of this report, which are 

reprinted in appendix VII, and one technical comment. HHS agreed that 

data reliability and performance monitoring are important, but neither 

agreed nor disagreed with our recommendations. Regarding our first 

recommendation, HHS stated that the reliability and validity of CQM data 

are of paramount importance. HHS also stated that ONC and CMS work 

together to continually refine strategies to improve the reliability and 

efficiency of collecting, analyzing, and sharing CQM data collected using 

certified EHR technology. HHS did not, however, identify any specific 

actions the agencies might take to improve CQM reliability or whether 

those actions would include developing a comprehensive strategy. HHS 

also noted the importance of the certification testing tool, known as 

Cypress, which it stated ensures the reliability of CQM data collected 

using 2014-edition EHRs. While the addition of testing to ensure that 

2014-edition EHRs accurately collect and calculate CQMs is an 

improvement over the process used to certify 2011-edition EHRs—during 

which such tests were not conducted—our report raises other reliability 

issues that would not be addressed by the certification testing tool alone. 

Regarding our second and third recommendations, HHS agreed that 

outcome-oriented performance measures that link participation in the 

EHR programs with discrete improvements in health care quality, 

efficiency, and safety would be useful for evaluating the extent to which 

improvements are achieved. HHS also noted that ONC oversees 

evaluation activities that have provided interim program results and 

conducts policy research and analytic projects that will enable the 

development of outcome-oriented performance measures. However, HHS 

did not provide any details on the timing or content of outcome-oriented 

performance measures that CMS and ONC might develop.

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. 

Agency Comments 

and Our Evaluation
 

Page 45 GAO-14-207 Electronic Health Record Programs

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. Other major contributors to this report are 

listed in appendix VIII. 

Linda T. Kohn

Director, Health Care
Page 46 GAO-14-207 Electronic Health Record Programs

List of Committees

The Honorable Ron Wyden

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Tom Harkin

Chairman

The Honorable Lamar Alexander

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Thomas R. Carper 

Chairman

The Honorable Tom Coburn, M.D.

Ranking Member

Committee on Homeland Security and Governmental Affairs 

United States Senate

The Honorable Tom Harkin 

Chairman 

The Honorable Jerry Moran

Ranking Member 

Subcommittee on Labor, Health and Human Services, Education, and 

Related Agencies

Committee on Appropriations

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry A. Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives
Page 47 GAO-14-207 Electronic Health Record Programs

The Honorable Darrell E. Issa

Chairman 

The Honorable Elijah E. Cummings

Ranking Member

Committee on Oversight and Government Reform 

House of Representatives

The Honorable Dave Camp

Chairman

The Honorable Sander M. Levin

Ranking Member

Committee on Ways and Means

House of Representatives

The Honorable Jack Kingston

Chairman 

The Honorable Rosa DeLauro

Ranking Member

Subcommittee on Labor, Health and Human Services, Education, and 

Related Agencies

Committee on Appropriations

House of Representatives
Appendix I: Effect of the HITECH Act on Health 

Insurance Premiums

Page 48 GAO-14-207 Electronic Health Record Programs

The Health Information Technology for Economic and Clinical Health 

(HITECH) Act mandates us to report on, among other things, the impact 

of the HITECH Act on health insurance premiums. In 2009, the 

Congressional Budget Office stated an expectation that nationwide 

adoption of health information technology such as electronic health 

records (EHR) would reduce total spending on health care and predicted 

that lower health care costs for private payers would result in lower health 

insurance premiums in the private sector.

To describe the effect of the HITECH Act on health insurance premiums, 

we contacted representatives from America’s Health Insurance Plans, the 

American Academy of Actuaries, the Blue Cross Blue Shield Association, 

and four health insurance companies.1

Five of the seven organizations offered anecdotes or speculation as to 

the potential effect of the HITECH Act—and particularly the adoption and 

meaningful use of EHRs as encouraged by the EHR programs—on health 

insurance premiums. One organization told us that there is evidence that 

widely implemented payment and delivery reform—particularly the 

patient-centered medical home, of which EHRs are an important 

element—has led to reductions in health care utilization and, in some 

cases, generated savings, which may eventually affect health insurance 

premiums. Another organization said that implementing the HITECH Act 

and the Patient Protection and Affordable Care Act has increased 

administrative costs and expressed concern that if the organization’s 

administrative costs increase due to changes in requirements, they may 

None of the seven organizations 

we spoke to had done any research to look at the impact of the HITECH 

Act on health insurance premiums. Three organizations also indicated 

that the HITECH Act’s effect on health insurance premiums would be 

difficult to isolate from the various other drivers of health insurance 

premium costs. For example, one organization noted that the health 

insurance industry is also in the midst of implementing the Patient 

Protection and Affordable Care Act, suggesting the reforms arising from 

that legislation are also affecting health insurance premium costs.

 

1

Three of the four health insurance companies we contacted were listed in the top 25 

health insurance companies as ranked by US News & World Report, based on nationwide 

market share.

Appendix I: Effect of the HITECH Act on 

Health Insurance Premiums
Appendix I: Effect of the HITECH Act on Health 

Insurance Premiums

Page 49 GAO-14-207 Electronic Health Record Programs

rise above the 15 to 20 percent level allowed under medical loss ratio 

requirements.2

 

2

The medical loss ratio is a basic financial indicator, traditionally referring to the 

percentage of premiums spent on medical claims.
Appendix II: Scope and Methodology

Page 50 GAO-14-207 Electronic Health Record Programs

This appendix provides additional details regarding our analysis of 

(1) participation in the Medicare and Medicaid Electronic Health Record 

(EHR) programs; (2) meaningful use measures and clinical quality 

measures (CQM) Medicare providers reported to the Centers for 

Medicare & Medicaid Services (CMS) to demonstrate meaningful use; 

and (3) 2012 survey data collected by the National Center for Health 

Statistics.

To ensure the reliability of the data, we interviewed officials from CMS, 

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 were sufficiently reliable for our analysis.

Analysis of participation in the Medicare and Medicaid EHR 

programs. We conducted several analyses to report on participation in 

the Medicare and Medicaid EHR programs for the 2011 and 2012 

program years.1 Specifically, we analyzed data that CMS collected in the 

National Level Repository through October 23, 2013. As a result, we 

generally included full-year information for both years in our analysis of 

the Medicare EHR program.2

• We estimated the percentage of eligible providers awarded an 

incentive payment from either the Medicare or the Medicaid EHR 

program. We determined the number of providers that were awarded 

a Medicare or Medicaid (or, in the case of some hospitals, both) EHR 

incentive payment by counting the number of providers that had an 

incentive payment disbursed to them for 2011 and for 2012.

However, our analysis does not contain 

complete information for the Medicaid EHR program for the 2012 program 

year because, according to CMS, 14 states and the District of Columbia 

had not yet completed their determinations of which hospitals and 

professionals had met all the requirements to receive incentive payments 

for 2012. We used these data to conduct the following analyses.

3

 

1

For the Medicare and Medicaid EHR programs, program years are determined and 

awarded on a fiscal year basis for hospitals and on a calendar year basis for 

professionals. 

We 

2

The total number of providers that received Medicare EHR incentive payments for 2011 

or 2012 and the total amount of incentive payments awarded for either year could change 

due to provider audits or appeals.

3

Using a similar approach, we determined the number of providers that met the 

participation requirements of the Medicare Advantage EHR program for both years.

Appendix II: Scope and Methodology
Appendix II: Scope and Methodology

Page 51 GAO-14-207 Electronic Health Record Programs

divided the number of providers awarded incentive payments from 

either program by the total number of eligible providers CMS 

estimated in its Stage 1 final rule.4

• We determined the total amount of Medicare and Medicaid EHR 

incentive payments awarded to providers each year by summing the 

Medicare and Medicaid EHR incentive payments awarded to 

providers for each program year.

Specifically, CMS estimated that 

5,013 hospitals and 521,600 professionals were eligible for the 

Medicare or Medicaid EHR program for 2011 and 5,013 hospitals and 

527,200 professionals for 2012.

5

• We estimated the percentage of providers that were awarded a 

Medicare or Medicaid (or, in the case of some hospitals, both) EHR 

incentive payment for 2011 but not for 2012 by determining the 

number of providers that had a Medicare or Medicaid EHR incentive 

payment disbursed to them for 2011 but not for 2012.6

Analysis of meaningful use measures and CQMs Medicare providers 

reported to CMS to demonstrate meaningful use. We conducted 

several analyses of meaningful use measures and CQMs providers 

reported to CMS to demonstrate meaningful use under the Medicare EHR 

program for 2011 and 2012. We analyzed data that CMS collected in the 

National Level Repository through October 23, 2013. We did not analyze 

meaningful use measure or CQM data submitted by hospitals or 

professionals who received incentive payments from the Medicare 

For the 

Medicaid EHR program, we limited this analysis to providers that were 

awarded incentive payments from 36 states that, according to CMS, 

had completed their determinations of which providers would receive 

incentive payments for the 2011 and 2012 Medicaid EHR program 

years as of October 23, 2013.

 

4

See 75 Fed. Reg. 44314, 44548 (July 28, 2010).

5

Using a similar approach, we determined the total amount awarded from the Medicare 

Advantage EHR program for both years.

We also determined the total amount awarded to providers from the Medicare, Medicaid, 

and Medicare Advantage EHR programs for fiscal year 2011 and fiscal year 2012 by using 

the date the payment was made to sum the payments awarded to providers in each fiscal 

year.

6

Providers that had a Medicare EHR program incentive payment disbursed to them for 

2011 and a Medicaid EHR program incentive payment disbursed to them for 2012, or vice 

versa, were included in our determination of providers awarded EHR incentive payments 

both years.
Appendix II: Scope and Methodology

Page 52 GAO-14-207 Electronic Health Record Programs

Advantage EHR program or CQM data submitted by providers to one of 

the electronic reporting pilots that were available for the 2012 program 

year.7

• We determined the extent to which providers exceeded the reporting 

thresholds CMS established for a subset of the meaningful use 

measures (14 hospital measures and 16 professional measures) by 

determining providers’ average reporting rate for each applicable 

measure and comparing this rate to the threshold CMS established for 

the measures.

For each of the following analyses, we compared reporting by 

program year.

• We determined the frequency with which providers reported 

meaningful use measures without claiming exemptions, by calculating 

the percentage of providers that reported meaningful use measures 

but excluding from the calculation those providers that reported to 

CMS that a measure was not relevant to them. A provider may claim 

exemptions from reporting some measures if the provider meets 

certain criteria specific to the individual measures. For example, the 

measure may not be relevant to the provider’s patient populations or 

clinical practices, the provider may have conducted too few actions to 

be measured, or the provider may not have been able to perform the 

action. The agency allows providers to claim exemptions from 

reporting certain meaningful use measures to help ensure that 

providers with all types of patient populations and clinical practices 

could potentially demonstrate meaningful use. For 2011 and 2012, 

hospitals were permitted to claim exemptions from reporting 7 

meaningful use measures and professionals from reporting 14 

meaningful use measures.8

 

7

For 2012, no hospitals and less than 2 percent of professionals who received incentive 

payments submitted CQM data to the electronic reporting pilots to demonstrate 

meaningful use.

8

Specifically, in Stage 1, hospitals were permitted to claim exemptions from reporting 

three mandatory measures and four optional measures, and professionals were permitted 

to claim exemptions from reporting six mandatory measures and eight optional measures.
Appendix II: Scope and Methodology

Page 53 GAO-14-207 Electronic Health Record Programs

• We determined the extent to which providers had few patients who 

could be included in the calculation of at least one CQM.9

Analysis of 2012 survey data collected by the National Center for 

Health Statistics. We analyzed output of the National Ambulatory 

Medical Care Survey, an annual, nationally representative survey of 

office-based physicians conducted by the National Center for Health 

Statistics in the Centers for Disease Control and Prevention. The survey 

captures information about computerized capabilities of office-based 

physicians’ EHRs—which are related to meaningful use measures—

including whether those capabilities are routinely used. We analyzed 

output from the 2012 survey obtained from the National Center for Health 

Statistics. We limited our analysis to office-based physicians who 

reported using an EHR or an electronic medical record system and 

who reported having patient care revenue from Medicare or Medicaid 

(69.0 percent of weighted responses). We then identified the 

computerized capabilities that were least likely to have been routinely 

used and determined, using a crosswalk of meaningful use measures and 

survey responses available from the Office of the National Coordinator for

CQMs that 

capture a small number of patients may be unreliable measures of 

quality because relatively small changes in the number of patients 

who experienced the care processes or outcomes targeted by the 

measure can generate large shifts in the calculated percentage for the 

measure. CMS has recognized in other programs that including a 

small number of patients in the calculation of a CQM is a reliability 

issue. For example, on the agency’s Hospital Compare website, which 

publicly reports CQMs by hospital, CMS indicates whether the number 

of patients included in a particular measure calculation was based on 

fewer than 25 patients and was thus too small to reliably tell how well 

the hospital was performing. For our analysis, we identified CQMs as 

unreliable if fewer than 7 patients met inclusion criteria for the 

calculation the provider reported for a 90-day reporting period—that 

is, during the provider’s first year demonstrating meaningful use. For 

providers whose second year demonstrating meaningful use was 

2012, the reporting period is a full year. Therefore, for these providers 

we identified CQMs as unreliable if fewer than 25 patients met the 

inclusion criteria for the calculation.

 

9

Some CQMs are composed of more than one submeasure. In these cases, we analyzed 

the submeasure for which providers reported the greatest number of patients in the 

denominator of the measure.
Appendix II: Scope and Methodology

Page 54 GAO-14-207 Electronic Health Record Programs

Health Information Technology (ONC), whether those capabilities were 

comparable to Stage 2 meaningful use measures.10

 

10See J. King, V. Patel, and M. Furukawa, “Physician Adoption of Electronic Health 

Record Technology to Meet Meaningful Use Objectives: 2009-2012,” ONC Data Brief, 

no. 7 (Washington, D.C.: Office of the National Coordinator for Health Information 

Technology, December 2012).

We also determined 

whether the computerized capabilities that were least likely to have been 

routinely used were related to electronic health information, based on 

information obtained from CMS and ONC.
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 55 GAO-14-207 Electronic Health Record Programs

In general, to receive incentive payments from the Medicare or Medicaid 

Electronic Health Record (EHR) programs in Stage 1 or Stage 2, 

hospitals must report on a total of 19, and professionals must report on a 

total of 20, measures regarding their use of certified EHR technology, 

known as meaningful use measures.1 For certain meaningful use 

measures, a provider may report to the Centers for Medicare & Medicaid 

Services (CMS) that the measures are not relevant if the provider meets 

certain criteria specific to the individual measures; this is referred to as 

claiming an exemption. For example, the measure may not be relevant to 

the provider’s patient population or clinical practice, the provider may 

have conducted too few actions to be measured, or the provider may not 

have been able to perform the action. Table 5 lists the meaningful use 

measures for each stage and provider type and identifies whether the 

measure was mandatory or optional and whether it was identified by the 

Office of the National Coordinator for Health Information Technology 

(ONC) and CMS as being related to the electronic exchange of health 

information.

 

1

Except for 2014, providers must collect data related to the meaningful use measures in 

any 90 consecutive days in their first year of reporting meaningful use and for a full year in 

subsequent years. For 2014 only, all providers, regardless of their stage of meaningful 

use, are required to collect data related to the meaningful use measures for only 

3 months. 

In the Medicare and Medicaid EHR programs, professionals include doctors of medicine 

and dental surgery. In the Medicaid EHR program, professionals also include nurse 

practitioners, certified nurse-midwives, and certain physician assistants.

CMS made some changes to the Stage 1 requirements that apply after 2012. For 

example, one mandatory meaningful use measure was eliminated from the requirements 

in Stage 1 beginning in the 2013 program year.

Appendix III: Stage 1 and Stage 2 

Meaningful Use Measures
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 56 GAO-14-207 Electronic Health Record Programs

Table 5: Meaningful Use Measures for Professionals and Hospitals, Stages 1 and 2 of the Electronic Health Record (EHR) 

Programs

Mandatory (●) or optional () measure

Hospitals Professionals

Meaningful use measure

Exchangerelated Stage 1 Stage 2 Stage 1 Stage 2

Use computerized provider order entry: For Stage 1: 

Use for at least one medication order for more than 

30 percent of patients with at least one medication in 

their medication lists; for Stage 2, use for more than 

60 percent of medication orders, 30 percent of 

laboratory orders, and 30 percent of radiology orders

● ● ● ● a a

Implement drug-drug and drug-allergy interaction 

checks: Enable the EHR system’s ability to check for 

these interactions

● b ● b

Maintain an up-to-date problem list of current and 

active diagnoses: Record list of current and active 

diagnoses or indicate no known problems for more 

than 80 percent of patients

● c ● c

Generate and transmit permissible prescriptions 

electronically

Yes

: For hospitals for Stage 2, generate, 

transmit, and check each prescription for the existence 

of a relevant drug formulary for more than 10 percent 

of hospital discharge prescriptions; for professionals, 

generate and transmit more than 40 percent (for Stage 

1) or more than 50 percent (for Stage 2) of permissible 

prescriptions electronically and for Stage 2 also check 

each prescription for the existence of a relevant 

formulary 

a ● ● a a

Maintain active medication list: Record at least one 

entry or indicate no current prescriptions for more than 

80 percent of patients

● c ● c

Maintain active medication allergy list: Record at least 

one entry or indicate no known medication allergies for 

more than 80 percent of patients

● c ● c

Record demographics: Record preferred language, 

sex, race, ethnicity, and date of birth for more than 

50 percent (for Stage 1) or more than 80 percent (for 

Stage 2) of patients; hospitals must also record date 

and preliminary cause of death in the event of mortality

● ● ● ●

Record and chart changes in vital signs: For Stage 1, 

record height, weight, and blood pressure for more 

than 50 percent of patients age 2 and older. For 

Stage 2, for more than 80 percent of all patients, 

record blood pressure (for patients age 3 and older) 

and/or height and weight. For both stages, calculate 

and display body mass index and plot and display 

growth charts for children age 2 through 20 (for 

Stage 1) or patients age 0 through 20 (for Stage 2) 

● ● ● ● a a
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 57 GAO-14-207 Electronic Health Record Programs

Mandatory (●) or optional () measure

Hospitals Professionals

Meaningful use measure

Exchangerelated Stage 1 Stage 2 Stage 1 Stage 2

Record smoking status for patients 13 years old or 

older: Record smoking status for more than 50 percent 

(for Stage 1) or more than 80 percent (for Stage 2) of 

patients age 13 and older

● ● a a ● ● a a

Report clinical quality measures to CMS ● d ● d

Implement clinical decision support: For Stage 1: 

implement one clinical decision support rule related to 

specialty or high clinical priority along with the ability to 

track compliance with that rule. For Stage 2: 

Implement five clinical decision support interventions 

related to four or more clinical quality measures or to 

high-priority health conditions; for hospitals, it is 

suggested that one of the five interventions be related 

to improving efficiency. For Stage 2, enable and 

implement drug-drug and drug-allergy interaction 

checks

● ● ● ●a

Provide patients with their health information 

electronically

Yes

: For Stage 1: provide information (for 

hospitals and professionals, provide diagnostic test 

results, problem list, medication lists, and medication 

allergies, and for hospitals also provide discharge 

summary and procedures) within 3 business days to 

more than 50 percent of patients who requested to 

receive that information electronically. For Stage 2: 

Provide more than 50 percent of patients with online 

access to their health information within 36 hours of 

discharge (for hospitals) or 4 days (for professionals); 

more than 5 percent of patients view, download, or 

transmit their health information to a third party.

● ● a, e a ● ● a, e a

For hospitals, provide patients with electronic copy of 

discharge instructions at the time of discharge, upon 

request; for professionals, provide patients with clinical 

summaries for each office visit

Yes

: For hospitals, provide 

information for more than 50 percent of patients who 

requested that information; for professionals, provide 

information for more than 50 percent of visits within 

3 business days for Stage 1 or 1 business day for 

Stage 2

●a f ● ● a, g a

Exchange key clinical information electronically: Yes

Perform at least one test of EHR technology’s capacity 

to exchange key clinical information

●h ●h
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 58 GAO-14-207 Electronic Health Record Programs

Mandatory (●) or optional () measure

Hospitals Professionals

Meaningful use measure

Exchangerelated Stage 1 Stage 2 Stage 1 Stage 2

Protect electronic health information created or 

maintained by the certified EHR technology: Conduct 

or review a security risk analysis (for Stage 1 and 

Stage 2) including addressing encryption/security of 

data stored in certified EHR technology (for Stage 2 

only), implement security updates as necessary, and 

correct identified security deficiencies

● ● ● ●

Implement drug formulary checks: Enable this 

functionality and maintain access to at least one 

internal or external formulary

 i a i

Incorporate clinical lab test results into EHR as 

structured data

Yes

: Incorporate into the EHR technology 

more than 40 percent (for Stage 1) or 55 percent (for 

Stage 2) of the clinical lab test results ordered whose 

results are positive, negative, or in numerical format

 ● j j  ● a, j a, j

Generate patient lists by specific conditions: Generate 

at least one report listing patients with a specific 

condition to use for quality improvement, reduction of 

disparities, research, or outreach

 ●  ●

Send patient reminders per patient preference for 

preventive or follow-up care: For Stage 1: send 

appropriate reminders to more than 20 percent of 

patients age 65 and older or age 5 and younger; 

For Stage 2: identify patients who should receive 

reminders and send reminders to more than 

10 percent of patients who have had two or more office 

visits within 24 months before the reporting period

 ● a a

Identify patient-specific education resources and 

provide those resources to the patient if appropriate: 

Provide to more than 10 percent of patients

 ●  ●a

Perform medication reconciliation for patients received 

from another setting of care or provider of care

Yes

: 

Perform for more than 50 percent of transitions of care

 ● g g  ● a, g a, g
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 59 GAO-14-207 Electronic Health Record Programs

Mandatory (●) or optional () measure

Hospitals Professionals

Meaningful use measure

Exchangerelated Stage 1 Stage 2 Stage 1 Stage 2

Provide summary of care document for each transition 

of care or referral

Yes

: For Stage 1 and Stage 2, provide 

for more than 50 percent of transitions of care and 

referrals; for Stage 2 also (a) provide for more than 

10 percent of transitions of care and referrals either 

electronically transmitted using certified EHR 

technology or through an exchange with a Nationwide 

Health Information Network Exchange participant or in 

a way that is consistent with the Nationwide Health 

Information Network (b) conduct one or more 

successful electronic exchanges of a summary of care 

document with a recipient with EHR technology 

designed by a different developer than the sender’s or 

conduct one or more successful tests with the CMSdesignated test EHR

 ●  ● a a

Submit electronic data to immunization registries or 

immunization information systems

Yes

: For Stage 1, 

perform at least one test of EHR technology’s capacity 

to submit data to immunization registries and, if test is 

successful, institute regular reporting; for Stage 2, 

demonstrate successful ongoing submission of data to 

immunization registries 

 ● a a  ● a a

Submit electronic syndromic surveillance data to public 

health agencies

Yes

: For Stage 1, perform at least one test 

of EHR technology’s capacity to submit data to public 

health agencies and, if test is successful, institute 

regular reporting; for Stage 2, demonstrate successful 

ongoing submission of data to public health agencies

 ● a a   a a

Submit electronic data on reportable lab results to 

public health agencies

Yes

: For stage 1, perform at least 

one test of EHR technology’s capacity to submit data 

(as required by state or local law) to public health 

agencies and, if test is successful, institute regular 

reporting; for Stage 2, demonstrate successful ongoing 

submission of data (as required by state or local law) 

to public health agencies 

 ● a a

Record advance directives for patients 65 years or 

older: Record indication of advance directive status for 

more than 50 percent of all unique patients age 65 and 

older

  a a

Use secure electronic messaging to communicate with 

patients

Yes

: More than 5 percent of patients sent the 

professional a secure message

●a
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 60 GAO-14-207 Electronic Health Record Programs

Mandatory (●) or optional () measure

Hospitals Professionals

Meaningful use measure

Exchangerelated Stage 1 Stage 2 Stage 1 Stage 2

Provide patients with timely electronic access to their 

health information

Yes

: Provide electronic access to health 

information (including lab results, problem list, 

medication lists, and allergies) to at least 10 percent of 

patients within 4 business days

a, k f

Automatically track medications using assistive 

technologies and an electronic medication 

administration record: Track all doses using electronic 

medication administration record for more than 

10 percent of medication orders

●a

Record electronic notes in patient records: Enter at 

least one electronic progress note that is text

searchable for more than 30 percent of patients during 

the reporting period

 

Ensure that imaging results and accompanying 

information are accessible through certified EHR 

technology

Yes

: Make more than 10 percent of all tests 

with one or more images accessible through certified 

EHR technology

 a

Record patient family health history as structured data: 

Record family health history for one or more firstdegree relatives for more than 20 percent of patients

 a

Demonstrate capability to identify and report cancer 

cases to public health central cancer registry

Yes

: 

Demonstrate successful ongoing submission of cancer 

case information from certified EHR technology to a 

public health central cancer registry

a

Demonstrate capability to identify and report specific 

cases to a specialized registry

Yes

: Demonstrate 

successful ongoing submission of specific case 

information from certified EHR technology to a 

specialized registry other than a cancer registry

a

Provide structured electronic lab results to ambulatory 

providers

Yes

: Send structured electronic clinical lab 

results to the ordering provider for more than 

20 percent of electronic lab orders



Source: GAO analysis of CMS guidance and of information obtained from CMS and ONC officials.

Notes: Mandatory meaningful use measures are designated as (●) and optional meaningful use 

measures (the set of measures from which CMS allows providers the flexibility to select a subset of 

measures to report) as (). The “exchange-related” column identifies meaningful use measures that 

are related to electronic health information exchange according to CMS, ONC, or both agencies. In 

the Medicare and Medicaid EHR programs, professionals include doctors of medicine and dental 

surgery. In the Medicaid EHR program, professionals also include nurse practitioners, certified nursemidwives, and certain physician assistants.

a

Providers may claim exemptions from reporting the measure if they meet certain criteria specific to 

the measure.
Appendix III: Stage 1 and Stage 2 Meaningful 

Use Measures

Page 61 GAO-14-207 Electronic Health Record Programs

b

For Stage 2, this measure was incorporated into the “implement clinical decision support” measure.

c

For Stage 2, this measure was incorporated into the “provide summary care document for each 

transition of care or referral care” measure.

d

Reporting clinical quality measures was a meaningful use measure in Stage 1. In Stage 2, this 

activity is still required in order to demonstrate meaningful use, but it is not a separate meaningful use 

measure.

e

Beginning in 2014, the Stage 2 criteria apply for Stage 1 with the exception that there is no 

requirement that patients view, download, or transmit their health information.

f

For Stage 2, this measure was incorporated into the “provide patients with their health information 

electronically” measure.

g

ONC did not indicate that this measure is related to health information exchange.

h

This requirement was eliminated from the Stage 1 requirements beginning in 2013.

i

For Stage 2, this measure was incorporated into the “generate and transmit permissible prescriptions 

electronically” measure.

j

CMS officials did not indicate that this measure is related to the actual transfer of health information 

between entities. However, they noted that this measure helps enable exchange by allowing 

information to be structured in such a way that when it is transferred it is usable by the recipient.

k

This requirement was eliminated from the Stage 1 requirements beginning in 2014.
Appendix IV: Meaningful Use Measure 

Reporting for the Medicare EHR Program, 2011 

and 2012

Page 62 GAO-14-207 Electronic Health Record Programs

In general, to receive incentive payments from the Medicare Electronic 

Health Record (EHR) program for 2011 or 2012, hospitals had to report 

on a total of 19, and professionals had to report on a total of 20, Stage 1 

meaningful use measures. Among those measures reported, 14 were 

mandatory for hospitals and 15 were mandatory for professionals. The 

remaining measures were selected by providers from a list of optional 

measures. For certain meaningful use measures, providers must meet or 

exceed reporting thresholds—that is, a specified percentage of patients or 

actions required to satisfy the measure—established by the Centers for 

Medicare & Medicaid Services (CMS) and the Office of the National 

Coordinator for Health Information Technology (ONC) for the EHR 

programs. Table 6 displays the average percentage reported by providers 

for those measures that require providers to meet or exceed certain 

established thresholds. Table 7 displays the percentage of providers that 

reported certain measures for 2011 and 2012 but excludes from the 

calculation providers that reported to CMS that a measure was not 

relevant to them; this is referred to as claiming an exemption. Specifically, 

table 7 displays the percentage of providers that reported Stage 1 

mandatory meaningful use measures that allow for exemptions and Stage 

1 optional meaningful use measures. For 2011 and 2012, hospitals were 

allowed to claim exemptions from reporting 7 meaningful use measures, 

and professionals were allowed to claim exemptions from reporting 14 

meaningful use measures.

Appendix IV: Meaningful Use Measure 

Reporting for the Medicare EHR Program, 

2011 and 2012
Appendix IV: Meaningful Use Measure 

Reporting for the Medicare EHR Program, 2011 

and 2012

Page 63 GAO-14-207 Electronic Health Record Programs

Table 6: Average Percentage Reported by Medicare Providers for Meaningful Use Measures with Reporting Thresholds in the 

Electronic Health Record (EHR) Programs, by Measure, 2011 and 2012 

Average percentage reported, by 

hospitals or professionals

Mandatory (●) 

or optional () 

measure

Reporting 

threshold Hospitals Professionals 

Meaningful use measure Stage 1 Stage 2 Stage 1 Stage 2

Exchangerelated 2011 2012 2011 2012

Use computerized provider 

order entry (medication orders)

● ●a 30 60 84.3 84.4 84.0 83.2

Maintain an up-to-date 

problem list of current and 

active diagnoses

● b 80 c 94.7 95.2 96.4 96.9

Generate and transmit 

permissible prescriptions 

electronically

● (P) ● (P) 

 (H)

40 (P) 50 (P)

10 (H)

Yes N/A N/A 79.1 83.1

Maintain active medication list ● b 80 c 97.2 98.0 97.1 97.3

Maintain active medication 

allergy list

● b 80 c 97.4 98.0 96.3 96.8

Record demographics ● ● 50 80 96.1 96.7 90.5 92.8

Record and chart changes in 

vital signs

● ● 50 80 93.1 92.5 90.2 91.8

Record smoking status for 

patients 13 years old or older

● ● 50 80 93.3 93.3 89.6 92.4

Provide patients with their 

health information 

electronically

● ● 50 Yes c 96.4 96.2 96.3 97.3

For hospitals, provide patients 

with an electronic copy of 

discharge instructions at the 

time of discharge, upon 

request; for professionals, 

provide patients with clinical 

summaries for each office visit 

● ● (P) d (H)50 50 (P) Yes 95.8 94.8 78.4 81.6

Incorporate clinical lab test 

results into EHR as structured 

data

 ● 40 55 Yes 95.4 e 95.5 91.5 92.9

Send patient reminders per 

patient preference for 

preventive or follow-up care

 (P) ● (P) 20 c N/A N/A 61.4 64.1

Identify patient-specific 

education resources and 

provide those resources to the 

patient if appropriate

 ● 10 10 70.7 73.3 48.9 53.5
Appendix IV: Meaningful Use Measure 

Reporting for the Medicare EHR Program, 2011 

and 2012

Page 64 GAO-14-207 Electronic Health Record Programs

Average percentage reported, by 

hospitals or professionals

Mandatory (●) 

or optional () 

measure

Reporting 

threshold Hospitals Professionals 

Meaningful use measure Stage 1 Stage 2 Stage 1 Stage 2

Exchangerelated 2011 2012 2011 2012

Perform medication 

reconciliation for patients 

received from another setting 

of care or provider of care

 ● 50 50 Yes 84.1 f 85.4 89.5 90.1

Provide summary of care 

document for each transition or 

referral 

 ● 50 50 Yes g 80.6 83.1 88.9 91.4

Record advance directives for 

patients 65 years or older

 (H)  (H) 50 50 95.5 95.8 N/A N/A

Provide patients with timely 

electronic access to their 

health information

h (P) d 10 Yes N/A N/A 72.6 75.1

Source: GAO analysis of CMS data and guidance and of information obtained from CMS and Office of the National Coordinator for

Health Information Technology (ONC) officials.

Notes: Mandatory meaningful use measures are designated as (●) and optional meaningful use 

measures (the set of measures from which CMS allows providers the flexibility to select a subset of 

measures to report) as (). Measures that apply to hospitals only are indicated by (H), and measures 

that apply to professionals only are indicated by (P). The “exchange-related” column identifies 

meaningful use measures that are related to electronic health information exchange according to 

CMS, ONC, or both agencies. Not applicable (N/A) indicates that the measure did not apply to that 

provider type.

a

In addition to medication orders, the Stage 2 measure requires the use of computerized provider 

order entry for 30 percent of laboratory orders and 30 percent of radiology orders.

b

For Stage 2, this measure was incorporated into the “provide summary of care document for each 

transition of care or referral” measure.

c

The measure has changed substantially for Stage 2 such that comparison to the Stage 1 threshold is 

not appropriate.

d

For Stage 2, this measure was incorporated into the “provide patients with their health information 

electronically” measure.

e

CMS officials did not indicate that this measure is related to the actual transfer of health information 

between entities. However, they noted that this measure helps enable exchange by allowing 

information to be structured in such a way that when it is transferred it is usable by the recipient.

f

ONC did not indicate that this measure is related to health information exchange.

g

This threshold does not apply to the components of the Stage 2 measure which require that 

10 percent of transitions of care and referrals be electronically transmitted and that at least one 

successful test of electronic exchange be conducted.

h

This measure was eliminated from Stage 1 beginning in 2014.
Appendix IV: Meaningful Use Measure 

Reporting for the Medicare EHR Program, 2011 

and 2012

Page 65 GAO-14-207 Electronic Health Record Programs

Table 7: Percentage of Medicare Providers That Reported Mandatory Stage 1 Meaningful Use Measures That Allow for 

Exemptions or Optional Stage 1 Measures in the Electronic Health Record (EHR) Programs, by Measure, 2011 and 2012 

Percentage of providers that 

reported measure

Mandatory (●) 

or optional () 

measure Hospitals Professionals 

Meaningful use measure Stage 1 Stage 2

Exchangerelated 2011 2012 2011 2012

Mandatory Stage 1 meaningful use measures 

that allow for exemptions

Use computerized provider order entry 

(medication orders)

● ●a b b 81.5 81.6

Generate and transmit permissible prescriptions 

electronically

● (P) ● (P) 

 (H)

Yes N/A N/A 77.5 79.4

Record and chart changes in vital signs ● ● b b 97.1 96.4

Record smoking status for patients 13 years old 

or older

● ● 99.5 99.7 99.5 99.8

Provide patients with their health information 

electronically

● ● Yes 30.4 34.5 31.2 29.4

For hospitals, provide patients with an electronic 

copy of discharge instructions at the time of 

discharge, upon request; for professionals, provide 

patients with clinical summaries for each office visit

● ● (P) c Yes

(H)

39.3 d 37.0 98.0 98.0

Optional Stage 1 meaningful use measures 

Implement drug formulary checks  e 87.4 83.0 70.4 70.3

Incorporate clinical lab test results into EHR as 

structured data

 ● Yes 81.2 f 86.1 58.4 59.7

Generate patient lists by specific conditions  ● 100.0 100.0 75.4 70.7

Send patient reminders per patient preference for 

preventive or follow-up care

 (P) ● (P) N/A N/A 21.3 17.2

Identify patient-specific education resources and 

provide those resources to the patient if appropriate

 ● 39.5 39.8 50.0 53.5

Perform medication reconciliation for patients 

received from another setting of care or provider of 

care 

 ● Yes 25.6 g 27.3 40.7 44.2

Provide summary of care document for each 

transition or referral

 ● Yes 7.6 8.0 12.8 13.2

Submit electronic data to immunization registries or 

immunization information systems

 ● Yes 60.4 61.7 52.2 48.2

Submit electronic syndromic surveillance data to 

public health agencies

 ● (H)

 (P) 

Yes 14.0 19.8 16.1 14.5

Submit electronic data on reportable lab results to 

public health agencies

 (H) ● (H) Yes 16.3 14.8 N/A N/A
Appendix IV: Meaningful Use Measure 

Reporting for the Medicare EHR Program, 2011 

and 2012

Page 66 GAO-14-207 Electronic Health Record Programs

Percentage of providers that 

reported measure

Mandatory (●) 

or optional () 

measure Hospitals Professionals 

Meaningful use measure Stage 1 Stage 2

Exchangerelated 2011 2012 2011 2012

Record advance directives for patients 65 years or 

older

 (H)  (H) 87.0 90.6 N/A N/A

Provide patients with timely electronic access to their 

health information

h (P) Yes c N/A N/A 33.4 32.6

Source: GAO analysis of CMS data and guidance and of information obtained from CMS and Office of the National Coordinator for 

Health Information Technology (ONC) officials.

Notes: This table provides information on the percentage of providers that reported the measure and 

did not claim an exemption from reporting the measure. The table does not list mandatory meaningful 

use measures that did not permit providers to claim exemptions from reporting since all providers 

were required to report those measures. Mandatory meaningful use measures are designated as (●), 

and optional meaningful use measures (the set of measures from which CMS allows providers the 

flexibility to select a subset of measures to report) as (). Measures that apply to hospitals only are 

indicated by (H), and measures that apply to professionals only are indicated by (P). The “exchangerelated” column identifies meaningful use measures that are related to electronic health information 

exchange according to CMS, ONC, or both agencies. Not applicable (N/A) indicates that the measure 

did not apply to that provider type.

a

In addition to medication orders, the Stage 2 measure requires the use of computerized provider for 

laboratory orders and radiology orders.

b

Hospitals were not permitted to claim an exemption from reporting the measure.

c

For Stage 2, this measure was incorporated into the “provide patients with their health information 

electronically” measure.

d

ONC did not indicate that this measure for professionals is related to health information exchange.

e

For Stage 2, this measure was incorporated into the “generate and transmit permissible prescriptions 

electronically” measure.

f

CMS officials did not indicate that this measure is related to the actual transfer of health information 

between entities. However, they noted that this measure helps enable exchange by allowing 

information to be structured in a way so that when it is transferred it is usable by the recipient.

g

ONC did not indicate that this measure is related to health information exchange.

h

This measure was eliminated from Stage 1 beginning in 2014.
Appendix V: Strategic Goals and Associated 

Performance Measures Relevant to the EHR 

Programs

Page 67 GAO-14-207 Electronic Health Record Programs

We reviewed Department of Health and Human Services (HHS), Centers 

for Medicare & Medicaid Services (CMS), and Office of the National 

Coordinator for Health Information Technology (ONC) strategic goals and 

categorized them into one of two major categories particularly relevant to 

the Electronic Health Record (EHR) programs—(1) adoption and 

meaningful use of EHRs; and (2) improving quality, efficiency, and patient 

safety.1

Note that ONC has three other goals that are relevant to the EHR 

programs but did not fall into the two categories we focused on and are 

thus not included in the table. Similarly to the measures identified in 

table 8, the performance measures associated with those additional goals 

enable the agency to track processes but not outcomes.

The first category of goals is focused on program processes, and 

the second is focused on program outcomes. For the first category—

adoption and meaningful use of EHRs—HHS, CMS, and ONC have 

established 26 performance measures. See table 8 for the departmentand agency-level strategic goals and performance measures that fall into 

this category.

2

 

1

There are other goals that we determined were not relevant to the EHR programs. For 

example, HHS has a goal to advance scientific knowledge and innovation, which includes 

the objective to invest in the regulatory sciences to improve food and medical product 

safety. A full list of strategic goals and associated performance measures can be found in

the following: HHS, U.S. Department of Health and Human Services Fiscal Years 2010-

2015 Strategic Plan (Washington, D.C.), accessed April 19, 2013, 

http://www.hhs.gov/secretary/about/priorities/strategicplan2010-2015.pdf; ONC, Federal 

Health Information Technology Strategic Plan, 2011-2015 (Washington, D.C.), accessed 

December 6, 2012, 

http://www.healthit.gov/sites/default/files/utility/final-federal-health-it-strategic-plan-0911.pd

f; and the EHR programs’ requirements (found in CMS’s Stage 1 and Stage 2 final rules), 

as well as HHS, Fiscal Year 2014 Annual Performance Report and Performance Plan

(Apr. 2013), accessed April 19, 2013, http://www.hhs.gov/budget/fy2014/opa_040513.pdf; 

HHS, Fiscal Year 2014 Centers for Medicare & Medicaid Services Justification of 

Estimates for Appropriations Committee (Baltimore, MD), accessed April 19, 2013, 

http://www.cms.gov/about-cms/agencyinformation/performancebudget/index.html?redirect=/performancebudget/; and HHS,

Fiscal Year 2014: Office of the National Coordinator for the Health Information Technology 

Justification of Estimates for Appropriations Committee (Washington, D.C.), accessed 

April 11, 2013, 

http://www.healthit.gov/newsroom/onc-budget-documents-and-performance-information. 

2

The three goals are to inspire confidence and trust in health information technology (HIT); 

to empower individuals with HIT to improve their health and the health care system; and to 

achieve rapid learning and technical advancement. See ONC, Federal Health Information 

Technology Strategic Plan, 2011-2015.

Appendix V: Strategic Goals and Associated 

Performance Measures Relevant to the EHR 

Programs
Appendix V: Strategic Goals and Associated 

Performance Measures Relevant to the EHR 

Programs

Page 68 GAO-14-207 Electronic Health Record Programs

Table 8: Department- and Agency-Level Strategic Goals and Associated Performance Measures Related to “Adoption and 

Meaningful Use of Electronic Health Records”

Department 

and/or agency Strategic goal Associated measures

HHS Promote the adoption and 

meaningful use of health 

information technology (HIT)

Number of eligible providers who receive an incentive payment from the CMS 

Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs 

for the successful adoption or meaningful use of certified EHR technology

Percentage of office-based primary care physicians who have adopted EHRs

Office of the 

National 

Coordinator for 

Health Information 

Technology (ONC)

Achieve adoption and information 

exchange through meaningful 

use of HIT

Percentage of office-based physicians who have adopted EHRs

Percentage of office-based primary care physicians who have adopted EHRs

Percentage of nonfederal acute care hospitals that have adopted EHRs

Percentage of eligible hospitals receiving meaningful use incentive payments

Percentage of eligible professionals receiving meaningful use incentive 

payments

Number of eligible providers who receive an incentive payment from the CMS 

Medicare and Medicaid EHR Incentive Programs for the successful adoption 

or meaningful use of certified EHR technology

EHR adoption rate among providers registered and working with ONC 

Regional Extension Centers for at least 10 months

Number of providers registered with ONC Regional Extension Centers that 

achieve meaningful use

Percentage of community pharmacies that are capable of exchanging health 

information electronically

Percentage of providers prescribing through an EHR

Percentage of office-based physicians who are electronically sharing any 

patient health information with other providers

Percentage of office-based physicians who are electronically sharing patient 

information with any providers outside their organization

Percentage of office-based physicians who are electronically sharing 

information using a Summary Care Record

Percentage of nonfederal acute care hospitals that are electronically 

exchanging patient health information with any providers outside their 

organization

Percentage of nonfederal acute care hospitals that are electronically sharing 

clinical/summary care records with any providers outside their organization

Percentage of nonfederal acute care hospitals that are electronically sharing 

any patient health information with ambulatory providers outside their 

organization

Percentage of eligible hospitals that have adopted EHRs

Percentage of Federally Qualified Health Centers that are affiliated with 

providers that receive Medicare and Medicaid EHR incentive programs 

payments
Appendix V: Strategic Goals and Associated 

Performance Measures Relevant to the EHR 

Programs

Page 69 GAO-14-207 Electronic Health Record Programs

Department 

and/or agency Strategic goal Associated measures

CMS Expanding the use of EHRs 

through the concept of 

meaningful use

Number of eligible professionals receiving EHR incentive payments for the 

successful demonstration of meaningful use for Medicare

Number of eligible professionals receiving EHR incentive payments for the 

successful demonstration of meaningful use under Medicaid

Number of eligible hospitals and critical access hospitals receiving EHR 

incentive payments for the successful demonstration of meaningful use under 

Medicare

Number of eligible hospitals and critical access hospitals receiving EHR 

incentive payments for the successful demonstration of meaningful use under 

Medicaid

Number of eligible professionals receiving EHR incentive payments for 

adopt/implement/upgrade under the Medicaid incentive program

Number of eligible hospitals receiving EHR incentive payments for 

adopt/implement/upgrade under the Medicaid incentive program

Source: GAO analysis of agency HHS, CMS, and ONC information.

Note: HHS, CMS, and ONC have not established performance measures for the EHR programs for 

the second category—improving quality, efficiency, and patient safety, focused on program 

outcomes. See table 9 for the department- and agency-level strategic goals that fall into this category.

Table 9: Department- and Agency-Level Strategic Goals Related to “Improving Quality, Efficiency, and Patient Safety”

Department and/or agency Strategic goals

HHS Improve health care quality and patient safety

Reduce the growth of health care costs while promoting high-value, effective care

Office of the National Coordinator for 

Health Information Technology (ONC)

Improve care, improve population health, and reduce health care costs through the use 

of health information technology

CMS Improve health care quality, efficiency, and patient safety

Source: GAO analysis of agency HHS, CMS, and ONC information.
Appendix VI: Program Evaluations Assessing 

the EHR Programs’ Effects on Outcomes

Page 70 GAO-14-207 Electronic Health Record Programs

Centers for Medicare & Medicaid Services (CMS) and Office of the 

National Coordinator for Health Information Technology (ONC) officials 

told us they are conducting some evaluations to assess the effect of the 

Electronic Health Record (EHR) programs on outcomes. See table 10 for 

a summary of these evaluations according to agency officials.

Table 10: Summary of Program Evaluations Assessing the Electronic Health Record (EHR) Programs on Outcomes

Evaluation description Data source Status 

Analysis of the association between the use of e-prescribing 

and adverse drug events

Medicare Part D claims Expected peer review in early 

2014

Analysis of the association between health information 

technology and hospital quality

Health information technology 

infrastructure data from the 

American Hospital Association 

and CMS’s National Level 

Repositorya

; Hospital quality 

data from Hospital Compare

Compiling analytic data files

b

Analysis of the extent to which laboratories have the capability 

to send results back to physicians and the extent to which they 

are doing so

Survey of laboratories 

conducted by NORC

Survey completed; compiling 

analytic data files. Preliminary 

data expected early 2014

Analysis of whether physicians report that using EHRs provides 

improved patient care overall or specific clinical benefits and 

whether benefits depend on participating in the EHR programs 

or length of EHR experience

Physician Workflow Survey Accepted for publication in 

Health Services Research

Analysis of EHR adopters versus nonadopters and their 

perceptions of the benefits of using EHRs

Physician Workflow Survey Under peer review

A global evaluation of the State Health Information Exchange 

Cooperative Agreement Program, the Regional Extension 

Center Program, the Beacon Communities Program, and the 

Information Technology Professionals in Health Care to 

assess the overall impact of the four programs on adoption 

and meaningful use of EHRs and on resulting changes in 

health quality and cost

Medicare claims

c

Developing analysis plan and 

obtaining data; final report 

expected in March 2015

Analysis of changes in quality, efficiency, and population 

health measures in Beacon Communities, comparing 

provider participants and nonparticipants

Medicare claims

c

Developing analysis plan and 

obtaining data; final report 

expected in early 2015

Literature review on the impact of EHRs on outcomes Published literature Published in Annals of Internal 

Medicine on January 7, 2014

Source: GAO analysis of CMS and Office of the National Coordinator for Health Information Technology (ONC) information.

d

a

CMS collects data about the Medicare and Medicaid EHR programs in the National Level 

Repository.

b

Hospital Compare is a CMS website that publicly reports clinical quality measures by hospital.

c

Appendix VI: Program Evaluations 

Assessing the EHR Programs’ Effects on 

Outcomes

The State Health Information Exchange Cooperative Agreement Program promotes health 

information exchange that will advance mechanisms for information sharing across the health care 

system. The Regional Extension Center program provides assistance to providers such as 

professionals in solo practices or rural areas to help them participate in the EHR programs. The 

Beacon Communities Program funds 17 selected communities throughout the United States to build 

and strengthen health information technology (HIT) infrastructure and exchange capabilities within

communities, to translate investments in HIT to measureable improvements in outcomes, and to 
Appendix VI: Program Evaluations Assessing 

the EHR Programs’ Effects on Outcomes

Page 71 GAO-14-207 Electronic Health Record Programs

develop innovative approaches to performance measurement, technology, and care delivery. 

Information Technology Professionals in Health Care funds the training and development of a 

workforce that will meet short-term programmatic needs related to the Health Information Technology 

for Economic and Clinical Health (HITECH) Act.

d

See Spencer S. Jones, Robert S. Rudin, Tanja Perry, and Paul G. Shekelle, “Health Information 

Technology: An Updated Systematic Review with a Focus on Meaningful Use,” Annals of Internal 

Medicine, vol. 160, no. 1 (2014).
Appendix VII: Comments from the Department 

of Health and Human Services

Page 72 GAO-14-207 Electronic Health Record Programs

Appendix VII: Comments from the 

Department of Health and Human Services
Appendix VII: Comments from the Department 

of Health and Human Services

Page 73 GAO-14-207 Electronic Health Record Programs
Appendix VII: Comments from the Department 

of Health and Human Services

Page 74 GAO-14-207 Electronic Health Record Programs
Appendix VIII: GAO Contact and Staff 

Acknowledgments

Page 75 GAO-14-207 Electronic Health Record Programs

Linda T. Kohn, (202)512-7114 or kohnl@gao.gov

In addition to the contact named above, Will Simerl, Assistant 

Director; Julianne Flowers; Melanie Krause; Shannon Legeer; 

Hannah Marston Minter; Monica Perez-Nelson; Roseanne Price; 

and Rebecca Rust Williamson made key contributions to this report.

Appendix VIII: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291109)
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