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Meaningful use - Will the end result be meaningful?

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Defining - and implementing - meaningful use has the potential to dramatically impact the use of electronic health records in the US. At this early stage, it is critical ask if the end goals are being served by the approach. This paper introduces the concept and considers how to implement such significant change in the context of the American health care system.

Written for a course on Quality and Performance Measurement for Brandeis University.

Published in: Health & Medicine
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Meaningful use - Will the end result be meaningful?

  1. 1. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010       Meaningful  Use:  Will  the  end  result  be  meaningful?     With  the  cost  of  health  care  in  the  United  States  continuously  increasing,  significant   efforts  are  being  made  to  make  systemic  improvements  that  save  on  cost  without   negatively  impacting  quality  of  care.    Moreover,  the  true  goal  is  to  contain  spending   while  at  the  same  time  making  improvements  to  quality.    This  endeavor  has   numerous  components  to  be  considered,  given  the  complexity  of  the  American   health  care  system.         Over  the  past  10  years,  health  information  technology  has  increasingly  been  viewed   as  a  vital  factor  in  health  reform  efforts.    To  this  end,  the  American  Recovery  and   Reinvestment  Act  (ARRA)  of  2009,  commonly  known  as  the  stimulus  bill,  included  a   provision  called  the  Health  Information  Technology  for  Economic  and  Clinical   Health  (HITECH)  Act.    Provisions  of  this  act  involve  a  number  of  regulations  and   programs  aimed  to  support  the  improvement  of  health  care  systems  and,  ultimately,   help  to  increase  the  health  of  Americans  (Blumenthal,  2010;  Centers  for  Medicare   and  Medicaid,  2006;  Glaser,  2010;  Halamka,  2010b).         Of  primary  interest  within  HITECH  is  the  development  and  utilization  of  electronic   health  records  (EHRs)  as  a  normative  part  of  the  American  health  care  experience.   As  a  part  of  this  effort,  the  federal  government  is  interested  in  boosting  the  use  of   Page 1  
  2. 2. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     EHRs  among  providers  receiving  payments  from  Medicare  and  Medicaid  in  ways   that  are  considered  to  be  “meaningful.”    How  meaningful  use  gets  defined  is  of  great   significance,  as  new  financial  incentives  rest  upon  providers  and  hospitals  meeting   minimum  standards  set  forth.    As  of  this  paper’s  writing,  no  final  decisions  have   been  issued  –  the  initial  proposed  rule  of  meaningful  use  was  issued  in  December   2009,  and  public  comments  on  the  proposed  rule  were  accepted  until  March  15   (Department  of  Health  &  Human  Services,  2009;  HHS  Press  Office,  2009).  These   comments  are  currently  under  review.     For  the  purposes  of  studying  meaningful  use  in  more  detail,  it  is  worth  taking  a   moment  to  delineate  electronic  medical  records  (EMR)  and  EHRs,  two  terms  that   are  often  conflated.    Though  frequently  used  interchangeably  they  are,  technically,   distinct.    As  defined  by  the  recently  disbanded  National  Alliance  for  Health   Information  Technology  (NAHIT),  EMRs  refer  to  the  “electronic  record  of  health-­‐ related  information  on  an  individual  that  is  created,  gathered,  managed,  and   consulted  by  licensed  clinicians  and  staff  from  a  single  organization  who  are   involved  in  the  individual's  health  and  care.”    EHRs  refer  to  the  “aggregate  electronic   record  of  health-­‐related  information  on  an  individual  that  is  created  and  gathered   cumulatively  across  more  than  one  health  care  organization  and  is  managed  and   consulted  by  licensed  clinicians  and  staff  involved  in  the  individual's  health  and   care”  (Neal,  2008).       Page 2  
  3. 3. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     Therefore,  while  an  EMR  may  be  very  useful  for  capturing  and  organizing   information  within  a  single  practice  or  for  a  single  patient,  an  EHR  can  be  utilized  to   compare  commonalities  and  difference  across  populations,  making  it  a  more  robust   mechanism  to  spot  trends,  highlight  outliers,  and  support  evidence  based  treatment.     Using  these  definitions,  an  EHR  can  be  viewed  as  an  EMR  with  the  capability  of   integrating  into  multiple  systems,  making  it  a  much  more  powerful  tool  for   measuring  quality.      Thus,  the  federal  government  is  interested  in  incentivizing   practitioners  who  meet  EHR  standards  aimed  at  improving  quality  for  patients  even   as  they  move  around  within  the  larger  health  care  system.     Despite  both  private  and  public  actions  to  date,  and  consensus  that  the  use  of  health   information  technology  will  likely  lead  to  more  efficient,  safer,  and  higher-­‐quality   care,  the  adoption  of  EHRs  in  the  US  has  been  slow.    Lethargy  in  EHR  adoption  has   been  a  topic  of  discussion  amongst  researchers,  health  providers,  consumers,  and   policy  makers  for  some  time.    At  present,  less  than  20%  of  physicians  currently  use   an  electronic  records  system.    Such  systems  are  generally  found  in  larger  care   settings  including  hospitals  and  large  practices,  while  smaller  practices  rarely  have   such  systems  in  place  (DesRoches,  et  al.,  2008;  Jha,  et  al.,  2009;  Jha,  et  al.,  2006).         Within  the  federal  government,  IT  modernization  efforts  are  an  integral  part  of  the   Health  Information  Technology  Framework.    The  US  Department  of  Health  and   Human  Services  listed  health  information  technology  as  a  priority  for  quality   Page 3  
  4. 4. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     measurement  and  data  collection,  indicating  that  interoperable  electronic  records   should  be  available  “to  patients  and  their  doctors  anytime,  anywhere”  (Centers  for   Medicare  and  Medicaid,  2006).       To  both  ease  and  encourage  the  transition  to  EHRs,  the  proposed  meaningful  use   definitions  and  goals  for  EHRs  are  broken  into  three  separate  stages,  scheduled  to   be  rolled  out  in  sequence  between  2011  and  2015.    Each  stage  builds  upon  the   previous,  with  financial  incentives  available  at  each  new  stage.    Stage  1,  which   begins  in  2011,  focuses  primarily  on  basic  EHR  capabilities,  naming  25  modules  for   eligible  professionals  (EPs)  and  23  modules  for  eligible  hospitals  that  must  be  met   to  be  deemed  a  meaningful  EHR  user.    Stage  2  expands  Stage  1  criteria  in  the  areas   of  disease  management,  clinical  decision  support,  medication  management,  support   for  patient  access  to  their  health  information,  transitions  in  care,  quality   measurement  and  research,  and  bi-­‐directional  communication  with  public  health   agencies.    Stage  3  focuses  on  achieving  improvements  in  quality,  safety  and   efficiency,  focusing  on  decision  support  for  national  high  priority  conditions,  patient   access  to  self  management  tools,  access  to  comprehensive  patient  data,  and   improving  population  health  outcomes  (US  Department  of  Health  and  Human   Services,  2010).     Page 4  
  5. 5. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     Each  module  within  the  meaningful  use  definition  contains  a  specific  objective  and   measurable  goal  that  must  be  met  for  disbursement  of  the  associated  financial   incentive.    Sample  hospital  objectives/measures  include:   1. Objective:  Use  of  computerized  physician  order  entry  (CPOE)  for  orders  (any   type)  directly  entered  by  authorizing  provider  (for  example,  MD,  DO,  RN,  PA,   NP)     Measure:  CPOE  is  used  for  at  least  10  percent  of  all  orders   2. Objective:  Implement  drug-­‐drug,  drug-­‐allergy,  drug-­‐  formulary  checks   Measure:  The  eligible  hospital  has  enabled  this  functionality   3. Objective:  Maintain  active  medication  list.   Measure:  At  least  80  percent  of  all  unique  patients  admitted  by  the  eligible   hospital  have  at  least  one  entry  (or  an  indication  of  “none”  if  the  patient  is   not  currently  prescribed  any  medication)  recorded  as  structured  data.   4. Objective:  Record  demographics.   Measure:  At  least  80  percent  of  all  unique  patients  admitted  to  the  eligible   hospital  have  demographics  recorded  as  structured  data   5. Objective:  Generate  lists  of  patients  by  specific  conditions  to  use  for  quality   improvement,  reduction  of  disparities,  research,  and  outreach   Measure:  Generate  at  least  one  report  listing  patients  of  the  eligible  hospital   with  a  specific  condition.     Similar  measures  and  objectives  have  been  created  for  providers  who  do  not  work   within  a  hospital  system  (Beaudoin,  2009a,  2009b).    On  its  face,  each  module   appears  relatively  straightforward.    However,  as  evidenced  by  the  lack  of  EHR   adoption  within  the  US  and  the  lively  discussion  that  is  taking  place  with  the  initial   definition  released,  it  is  clear  that  there  is  room  for  debate  on  the  viability  of  the   current  federal  strategy.   Page 5  
  6. 6. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010       One  would  be  hard  pressed  to  find  a  provider  who  is  not  interested  in  providing   quality  (however  they  define  the  word)  care.    At  the  same  time,  a  wide  range  of   studies  have  suggested  that  EHRs  are  an  important  factor  of  quality  improvement   strategies  (Chen,  Garrido,  Chock,  Okawa,  &  Liang,  2009;  MW  Friedberg,  et  al.,  2009;   M  Friedberg,  et  al.,  2009;  Orszag,  2008).    With  this  in  mind,  it  is  reasonable  to   inquire  why  all  health  care  providers  have  not  already  embraced  meaningful  use  of   EHRs  as  an  automatic  member  of  the  overall  care  approach.     Research  to  date,  as  well  as  comments  from  experts  in  the  field,  consistently   underscore  that  it  is  not  the  mere  presence  of  an  EHR  that  makes  a  difference,  but   rather  the  use  of  the  information  contained  as  a  decision  support  device  that   improves  quality  (Dexheimer,  Talbot,  Sanders,  Rosenbloom,  &  Aronsky,  2008;  Ford,   Menachemi,  Peterson,  &  Huerta,  2009;  M  Friedberg,  et  al.,  2009;  Poon,  et  al.,  2010;   Sequist,  et  al.,  2005).      This  distinction  is  at  the  heart  of  the  challenge  of  universal   EHR  adoption;  crossing  the  divide  between  the  presence  of  an  EHR  and  the  proactive   use  of  an  EHR  is  where  strategy,  creativity,  and  technological  savvy  meet.     This  paper  does  attempt  to  tackle  the  myriad  facets  of  EHR  creation  and  adoption;  to   do  so  would  require  volumes  as  an  entire  industry  is  devoted  to  this  pursuit.     Instead,  focus  is  placed  specific  elements  underlying  the  possibility  of  adoption  and   widespread  use  of  such  tools,  with  an  eye  towards  the  overarching  question  of   Page 6  
  7. 7. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     whether  or  not  EHRs  will  in  fact  impact  the  quality  of  health  care  in  the  United   States.    These  elements  include  design,  interoperability,  and  patient  access  to  data.     The  three  elements  named  are  at  the  heart  of  moving  from  EHRs  being  viewed  as   impediments  to  EHRs  being  seen  as  tools  to  positively  impact  quality  of  care  for  all   patients,  regardless  of  geographic  location  or  health  status.    Justification  for  slow   adoption  rates  are  complex,  involving  cost,  variability  in  EHR  platforms,  culture   within  each  practice,  a  lack  of  incentives,  and  a  lack  of  resources  to  install,  train,  and   maintain  such  systems.       While  the  current  meaningful  use  standards  and  incentives  are  limited  to  Medicare   and  Medicaid  patients,  it  is  important  to  remember  that  providers  for  these  patients   are  situated  within  the  larger  context  of  the  American  health  care  system,  which  at   its  core  is  based  in  a  competitive  business  model.    The  business  of  EHRs  is  a  part  of   this,  with  a  number  of  individual  vendors  vying  to  gain  market  share.      This  has  only   increased  with  the  possibility  of  financial  incentives  from  the  federal  government.     For  evidence  of  this,  one  needs  to  look  no  further  than  the  most  recent  Healthcare   Information  and  Management  Systems  Society  (HIMSS)  conference  that  took  place   in  early  March  of  this  year.    Per  feedback  from  attendees,  there  was  a  surge  in   attendance  from  EMR  and  EHR  vendors,  and  everyone  was  talking  about  meaningful   use  (Dillon,  2010;  Halamka,  2010a).           Page 7  
  8. 8. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     At  present,  there  is  no  industry  standard  on  core  elements  that  should  be  included   within  an  EMR,  and  many  EHR  providers  are  striving  to  set  the  standard  (or  have   enough  market  share  that  they  are  by  default  the  standard).      This  means  there  is  a   long  list  of  EHR  providers  to  choose  from  –  a  quick  web  search  resulted  in  over  200   distinct  vendors,  each  offering  variations  on  the  general  idea  of  an  EHR  ("EMR  and   EHR  Matrix,"  2010;  John,  2006).  For  smaller  offices,  most  of  who  do  not  have  IT  staff   knowledgeable  about  EHRs,  the  task  can  seem  overwhelming  to  the  point  of  being   impossible.     It  is  here  that  design  and  interoperability  must  be  carefully  considered,  as  they  play   a  critical  role  in  the  ability  to  effectively  use  an  EHR.    With  each  company  striving  to   stand  out  from  the  pack,  there  is  a  lack  of  uniformity  within  current  systems.    Each   has  a  unique  user  interface,  meaning  there  is  a  learning  curve  for  providers   switching  from  one  vendor  to  another.    Even  within  vendors,  there  is  variability  of   design,  as  each  individual  implementation  is  generally  customized  based  on  the   purchaser’s  needs.    Thus,  if  a  provider  has  worked  with  a  particular  vendor’s  system   at  Hospital  A,  there  is  no  guarantee  that  the  same  vendor’s  EHR  will  look  similar  if   the  provider  takes  on  a  new  job  at  Hospital  B.    This  can  be  frustrating,  and  a   deterrent  for  adoption  of  the  technology.     A  frequent  concern  voiced  by  physicians  is  that  EHRs  are  designed  to  suit  the  needs   of  administrators,  rather  than  reflecting  the  flow  of  clinical  interactions  (Loomis,   Page 8  
  9. 9. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     Ries,  Saywell,  &  Thakker,  2002;  McDonald,  1997;  Smith  &  Zastrow,  1994).      As  a   result,  the  user  interface  is  not  well  suited  for  efficient  entry  from  a  clinical   perspective.    Similar  to  the  learning  curve  encountered  when  learning  a  new  system,   the  inability  to  enter  data  in  an  intuitive  fashion  is  seen  largely  as  a  deterrent  and   inefficient  use  of  time,  as  opposed  to  being  helpful  for  patient  care.     Customization,  while  reasonable  from  an  individual  practice  perspective,  also  leads   to  interoperability  challenges,  as  there  is  generally  more  focus  on  tailoring  the   interface  than  forethought  on  core  elements  that  should  be  carried  through  to  other   practices.    What  is  often  neglected  along  the  way  is  attention  put  towards  having  a   patient’s  medical  record  live  anywhere  but  the  place  in  which  it  originates.    Thus,   using  the  same  Hospital  A/Hospital  B/same  vendor  scenario  above,  it  is  possible   that  a  patient  can  change  providers  and  not  have  their  record  travel  electronically   with  them,  even  if  both  systems  utilize  an  EHR  from  the  same  company.         Interoperability  is  not  only  of  concern  for  providers,  but  patients  as  well.    Patients   are  increasingly  interested  in  the  ability  to  access  their  own  medical  information  on   an  on  demand  basis.    Personal  health  records  (PHRs)  are  patient-­‐facing  interfaces   designed  to  handle  this  task,  and,  like  EHRs,  come  in  many  different  forms.    Ideally   PHRs  are  a  subset  of  EHR  data,  with  the  capability  of  being  augmented  by  the   patient  and/or  multiple  data  sources  to  create  a  more  complete  health  picture.     Large  organizations  such  as  Kaiser  Permanente  have  invested  heavily  in  this  type  of   Page 9  
  10. 10. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     tool,  most  recently  partnering  with  Microsoft  to  transfer  data  between  internal   systems  and  Microsoft’s  HealthVault,  and  online  data  platform  (Press  Release,   2008a,  2008b).    Kaiser  is  unique,  however,  in  having  the  resources  and  willingness   to  adopt  this  type  of  approach.     The  ability  of  patients  to  access  their  information  from  EHRs  as  an  element  of   improving  quality  of  care  was  a  topic  covered  within  the  public  comments  on  the   meaningful  use  proposed  definition.    Notably,  Google,  Microsoft,  and  Dossia  (a   consortium  of  Fortune  500  companies  striving  to  aggregate  health  information  into   a  web-­‐based  platform)  submitted  joint  testimony  highlighting  the  significance  of   including  PHRs  in  meaningful  use  criteria.    In  their  joint  comments,  they  requested   that  HHS  “clarify  that  patients  have  the  right  to  direct  EPs  and  eligible  hospitals  to   electronically  transmit  such  information  to  a  destination  of  their  choice  and…   require  that  at  least  80%  of  all  unique  patients  seen  by  the  EP  are  provided  timely   electronic  access  to  their  health  information”  (Dossia,  Google,  &  Microsoft,  2010).     Even  with  the  aforementioned  concerns  in  mind,  there  is  a  strong  case  to  be  made   for  the  federal  government’s  efforts  to  define  meaningful  use  and  promote  adoption   of  EHRs  via  the  use  of  financial  incentives.      The  staged  approach  was  established   intentionally  to  allow  time  for  debate  and  development,  and  incentives  are  not  tied   to  quality  improvement  until  the  final  stage.    Still,  without  establishing  core   Page 10  
  11. 11. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     principles  early  on,  it  is  possible  that  the  efforts  will  fail  to  meet  the  ultimate  goal  of   quality  improvement.     One  of  the  central  principles  that  should  be  established  is  the  creation  of  a  core  set   of  data  points  should  be  determined  for  all  EHRs,  and  structured  such  that  these   data  elements  can  be  transferred  between  all  EHRs  eligible  for  meaningful  use   certification.    These  data  elements  could  include  aspects  such  as  demographics,   allergies,  immunizations,  and  medication  lists.         A  second,  and  more  controversial,  consideration  is  to  allow  EHRs  utilizing  the  use  of   an  open  application  programming  interface  (Open  API)  to  qualify  for  certification   (only  EHRs  certified  by  the  Certification  Commission  for  Health  Information   Technology  (CCHIT)  are  eligible  for  financial  incentives  as  proposed  in  the  stimulus   package).    An  Open  API  entails  a  set  of  technologies  that  enable  websites  to  interact   with  one  another  in  a  more  seamless  fashion.    This  generally  presumes  web-­‐based   applications  (in  contrast  to  software  installed  on  a  local  hard  drive),  although  that  is   not  required.    The  benefit  of  such  systems  is  that  it  allows  for  a  vast  and  vibrant   ecosystem  of  smaller  programs  to  develop  and  work  together  to  deliver  a  more   robust  overall  product.    For  example,  a  design  specialist  could  work  on  a  malleable   user  interface,  while  an  engineer  can  implement  the  back  end  data  elements  into   software.    It  would  not  be  necessary  that  these  two  workers  be  with  the  same   company.      Alternatively,  a  small  company  could  create  a  solution  to  store  and  track   Page 11  
  12. 12. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010     data  related  to  a  unique  set  of  conditions,  which  could  then  be  read  within  the   patient’s  EHR.     At  present  this  approach  is  highly  uncommon,  and  there  is  some  debate  over   whether  this  is  due  simply  to  a  lack  of  lobbying  power  (Blankenhorn,  2009;  Douglas,   2009).    However,  with  cloud  computing  becoming  more  prevalent,  and  with  an   increasing  shift  towards  democratizing  application  development  (see  the  success  of   Firefox’s  add-­‐ons  as  a  challenger  to  Microsoft  Internet  Explorer  for  an  example  of   this  approach)  it  is  likely  that  certification  will  have  to  address  the  possibility  of   Open  API  in  the  future.     Overall,  the  development  of  meaningful  use  standards  is  a  step  in  the  right  direction.     EHRs,  when  utilized  in  a  systematic  and  purposeful  fashion,  can  have  a  tremendous   impact  on  quality  measures.    At  present  the  possibilities  are  tempered  by  consensus   on  how  to  best  define  meaningful  use,  a  lack  of  core  standards  across  all  EHRs,  and  a   general  hesitancy  within  the  provider  community.    By  coupling  a  transparent  and   open  process  with  financial  incentives,  however,  large-­‐scale  change  should  be  seen   over  the  next  five  years.    Tremendous  opportunity  for  quality  improvement  exists  if   people  can  remain  patient  and  persistent  throughout  the  process.     Page 12  
  13. 13. Jodi  Sperber   Quality  and  Performance  Measurement  in  Health  Care   March  31,  2010       References  cited   Beaudoin,  J.  (2009a).  Eligible  Hospital  "Meaningful  Use"  Criteria.  Retrieved  March   15,  2010,  from  HIMSS:  http://is.gd/b8oQ0   Beaudoin,  J.  (2009b).  Eligible  Provider  "Meaningful  Use"  Criteria.  Retrieved  March   15,  2010,  from  HIMSS:  http://is.gd/b8p0Q   Blankenhorn,  D.  (2009,  March  15).  Open  source  to  meet  with  CCHIT  at  HIMSS.   http://is.gd/b99JZ.   Blumenthal,  D.  (2010).  Launching  HITECH.  The  New  England  journal  of  medicine,   362(5),  382.   Centers  for  Medicare  and  Medicaid  (2006).  Strategic  Action  Plan  for  2006  -­  2009:   Achieving  A  Transformed  And  Modernized  Health-­care  System  For  The  21st   Century.  Baltimore,  MD:  US  Department  of  Health  and  Human  Services.   Chen,  C.,  Garrido,  T.,  Chock,  D.,  Okawa,  G.,  &  Liang,  L.  (2009).  The  Kaiser  Permanente   Electronic  Health  Record:  transforming  and  streamlining  modalities  of  care.   Health  Affairs,  28(2),  323.   Department  of  Health  &  Human  Services  (2009).  Health  Information  Technology.   CMS  Information  Related  to  the  Economic  Recovery  Act  of  2009.    Retrieved   March  13,  2010,  from  http://is.gd/aDZbL   DesRoches,  C.,  Campbell,  E.,  Rao,  S.,  Donelan,  K.,  Ferris,  T.,  Jha,  A.,  et  al.  (2008).   Electronic  health  records  in  ambulatory  care-­‐-­‐a  national  survey  of   physicians.  The  New  England  journal  of  medicine,  359(1),  50.   Dexheimer,  J.,  Talbot,  T.,  Sanders,  D.,  Rosenbloom,  S.,  &  Aronsky,  D.  (2008).   Prompting  clinicians  about  preventive  care  measures:  a  systematic  review  of   randomized  controlled  trials.  Journal  of  the  American  Medical  Informatics   Association,  15(3),  311-­‐320.   Dillon,  B.  (2010,  March  16).  HIMSS  2010  Wrap  Up.  http://is.gd/b920z.   Dossia,  Google,  &  Microsoft  (2010).  Re:  CMS-­‐0033-­‐P;  Medicare  &  Medicaid   Programs;  Electronic  Health  Record  Incentive   Program  Proposed  Rule.  Unpublished  Public  Comment.   Douglas,  M.  (2009,  March  15).  US  Market:  Open  Source  EHR  and  CCHIT  certification.   http://is.gd/b99Fh.   EMR  and  EHR  Matrix  (2010).    Retrieved  March  20,  2010,  from  http://is.gd/b8DYS   Ford,  E.,  Menachemi,  N.,  Peterson,  L.,  &  Huerta,  T.  (2009).  Resistance  is  futile:  but  it   is  slowing  the  pace  of  EHR  adoption  nonetheless.  Journal  of  the  American   Medical  Informatics  Association,  16(3),  274-­‐281.   Friedberg,  M.,  Coltin,  K.,  Safran,  D.,  Dresser,  M.,  Zaslavsky,  A.,  &  Schneider,  E.  (2009).   Associations  Between  Structural  Capabilities  of  Primary  Care  Practices  and   Performance  on  Selected  Quality  Measures.  Annals  of  Internal  Medicine,   151(7),  456.   Page 13  
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