Acknowledgements

In its 2010 report Future Directions for the National Healthcare Quality and Disparities Reports, the Institute of Medicine (IOM, 2010) recommended that future editions of the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) include data on the health care system's infrastructure capabilities. According to the IOM:

[T]hese components are not necessarily health care aims/attributes in themselves, but are a means to those aims since they are elements of the health care system that better enable the provision of quality care... health systems infrastructure are of interest to the extent that they improve effectiveness, safety, timeliness, patient-centeredness, access, or efficiency.

Acknowledging that the measures and data to assess the strength and capabilities of the health care infrastructure have not been well developed, the IOM identified structural elements that may affect quality improvement. Key elements include:

• Information systems for data collection, quality improvement analysis, and clinical communication support.
• An adequate and well-distributed workforce.
• Organizational capacity to support emerging models of care, cultural competence services, and ongoing improvement efforts.

Of significance, inadequacies in health system infrastructure may limit access and contribute to poor quality of care and outcomes, particularly among vulnerable population groups that include racial and ethnic minority groups and people residing in areas with health professional shortages.

This chapter presents data to understand the strength of the U.S. health system infrastructure and how this infrastructure may influence quality of care. This chapter is divided into three sections, health information technology, workforce distribution, and care management processes, each addressing a unique aspect of the health care system. The chapter begins with data to describe the adoption and use of health information technology (IT). Use of health IT can be an effective way to manage health care costs and improve the quality of care.

Since the publication of the IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,ⁱ which emphasized the need for standardized collection and reporting of racial and ethnic data, the need for more granular detail on racial and ethnic subgroups has become apparent. This is an area where the adoption and use of health IT can be beneficial.

Another area of patient care that could be improved with the adoption and use of health IT is care coordination. A Commonwealth Fund study found that health IT can facilitate care coordination within a practice, but a lack of interoperability makes exchange of information between health care facilities difficult (Shih, et al., 2008).

Evidence has also shown that the adoption and effective use of health IT can help reduce medical errors and adverse events, enable better documentation and file organization, provide patients with information that assists their adherence to medication regimens and scheduled appointments, and assist doctors in tracking their treatment protocols (IOM, 2010).

Following presentation of measures of the use of health IT, data on health care workforce diversity are presented. An adequate supply of health care providers is an important indicator of health care quality. Aside from a provider-to-population ratio that effectively meets demand for care, it is important that the workforce be appropriately distributed.

In previous quality and disparities reports, data have been presented on diversity in the physician, nursing, dental, and pharmacy workforce. This year, the NHQR and NHDR present data on the geographic and racial/ethnic distribution of allied health professionals that include occupational and physical therapists, as well as speech-language pathologists.

The distribution and availability of a culturally competent health care workforce has significant repercussions for access to care, particularly among the Nation's most vulnerable populations—racial and ethnic minorities, low-income populations, and uninsured or underinsured people. People who cannot access health care services, either because of financial considerations or inadequacy in the local health care infrastructure, often rely on safety net providers for essential health care services. The final section presents measures related to the performance of safety net providers, including people served, characteristics of selected safety net providers, and patient outcomes.

Measures

The IOM acknowledges that health system infrastructure measures such as adoption and effective use of health IT are likely to be in the developmental stage, and evidence of the impact on quality improvement has not yet been strongly established. The IOM highlighted three infrastructure capabilities that should be further evaluated for reporting. These capabilities include adoption and use of health IT, workforce distribution and its relevance to minority and other underserved populations, and care management processes.

Findings

Health Information Technology: Focus on Electronic Health Records

According to the Office of the National Coordinator for Health IT, an electronic health record (EHR) is a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decisionmaking. The EHR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.

The IOM report Future Directions for the National Healthcare Quality and Disparities Reports highlights the adoption and use of health IT as a tool to manage cost and improve the quality of care delivered (IOM, 2010). Meaningful use of an EHR, for instance, is increasingly viewed as essential to improving both the efficiency of service delivery and health care quality (Resnick & Alwan, 2010). The potential benefits of EHRs are not limited to hospitals and ambulatory care settings but are also valuable tools in hospice and home health agencies.

As the proportion of the population represented by older adults continues to increase, so does the need for home health and hospice care. These organizations can improve their service delivery by implementing EHRs. One area in which these benefits are evident is in the home setting, where EHRs can improve accuracy and timeliness of care documentation and facilitate preventive interventions (Resnick & Alwan, 2010).

Health providers using EHRs have reported improvement in clinical decisionmaking and communication with other providers and patients, as well as faster and more accurate access to medical records and avoidance of medical errors (Romano & Stafford, 2011). Components of EHRs, such as computerized provider order entry (CPOE) and clinical decision support (CDS), have been found to be associated with significant reductions in medication errors (Devine, et al., 2010).

CPOE systems are computer applications that allow direct electronic entry of orders for medications, laboratory tests, radiology services, referrals, and procedures. CDS encompasses a wide range of computerized tools directed at improving patient care, including computerized reminders and advice regarding drug selection, dosage, interactions, allergies, and need for subsequent orders (Kaushal, et al., 2003).

New! Electronic Health Records in Hospitals

EHRs can improve the quality and safety of care in all types of hospitals and in departments within hospitals. In emergency departments, for instance, electronic clinical documentation and decision support can help mitigate problems of treating new patients with complicated medical histories and gaps in their medical records. EHRs can also provide effective decision support and clinical reminders to facilitate a seamless transition of care by reducing communication breakdown between different providers. The 2010 NHQR reported on medication management in hospitals, but this year's report tracks overall EHR use in hospitals.

Figure 8.1. Electronic medical record use in hospitals, by geographic region and hospital size, 2009

     
 


[D] Select for Text Description.

Key: CPOE = computerized provider order entry.
Source: American Hospital Association, 2009 Information Technology Supplement.

• Electronic Clinical Documentation:
  • In 2009, 12% of hospitals had an electronic system that supports clinical documentation, which includes patient demographics, physician notes, nursing notes, problem lists, medication lists, discharge summaries, and advance directives (Figure 8.1).
  • Hospitals in the Midwest had the highest percentage of electronic systems that support clinical documentation (14%). In the West and the South, 13% and 11% of hospitals, respectively, had an electronic system that supports clinical documentation. In the Northeast, only 9% of hospitals had an electronic system that supports clinical documentation.
  • Hospitals with 400 beds or more had a higher percentage of electronic systems that support clinical documentation (18%) compared with hospitals with 100-399 beds (14%) and hospitals with fewer than 100 beds (9%).
• Decision Support:
  • In 2009, 17% of hospitals had a fully implemented electronic system for decision support, including clinical guidelines, clinical reminders, drug allergy alerts, drug-drug interaction alerts, drug lab interaction alerts, and drug dosing support.
  • The largest difference in implementation was observed between large and small hospitals. About 30% of hospitals with 400 beds or more had a fully implemented electronic system for decision support, but only 10% of hospitals with fewer than 100 beds had a fully implemented system. About 21% of hospitals with 100-399 beds had a fully implemented electronic system for decision support.
  • The Northeast had the highest percentage of hospitals with a fully implemented electronic system for decision support (19%). In the South, 17% of hospitals had a fully implemented electronic system for decision support. In the Midwest, 17%, and in the West, 13%, of hospitals had a fully implemented electronic system for decision support.
• Computerized Provider Order Entry:
  • In 2009, 17% of hospitals had fully implemented CPOE systems that allowed providers to directly enter their own orders for laboratory tests, radiology tests, medications, consultation requests, and nursing orders.
  • The Northeast had the highest percentage of hospitals with a fully implemented CPOE system (25%). The West had 17%, the Midwest had 16%, and the South had 14%.
  • There was also a large discrepancy in implementation between small and large hospitals. Only 10% of hospitals with fewer than 100 beds had a fully implemented CPOE system while 36% of hospitals with 400 beds or more had a fully implemented CPOE system.
• Results Viewing:
  • In 2009, 36% of hospitals had a fully implemented results viewing system for laboratory reports, radiology reports, radiology images, diagnostic test results, and diagnostic test images.
  • In the South, 35% of hospitals had fully implemented results viewing systems; in the Midwest, 36%; in the Northeast, 41%; and in the West, 33%.
  • The largest difference in implementation was observed between large and small hospitals. While 55% of hospitals with 400 beds or more had a fully implemented results viewing system, only 22% of hospitals with fewer than 100 beds had a fully implemented system. Nearly 47% of hospitals with 100-399 beds had a fully implemented results viewing system.

Also, in the NHDR:

• Hospitals run by the Federal Government had a much higher percentage of electronic systems that support clinical documentation, decision support, CPOE, and results viewing than non-Federal, not-for-profit, and for-profit hospitals.
• Children's general hospitals had a higher percentage of electronic systems that support clinical documentation, decision support, CPOE, and results viewing than general medical and surgical hospitals, psychiatric hospitals, rehabilitation hospitals, and acute long-term care hospitals.

New! Electronic Health Records in Home Health and Hospice Agencies

One of the challenges of providing home health and hospice care is that patients are often located in a wide geographic area and require services that have to be coordinated among several different providers. EHRs can be very beneficial to home health and hospice agencies by improving the agency's ability to effectively coordinate care between multiple providers from different health disciplines.

EHRs can provide home health and hospice staff with consistent and thorough documentation, leading to improved outcomes for patients due to awareness of potential risks noted in the documentation. EHR adoption holds tremendous promise for improving health care quality and increasing patient safety, as well as reducing the costs of providing home health and hospice care. This is the first year data for home health and hospice agencies are included in the reports

Figure 8.2. Electronic medical record use by home health and hospice agencies, by type of service and number of patients, 2007

    
 


[D] Select for Text Description.

Key: CPOE = computerized provider order entry.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, 2007 National Home and Hospice Care Survey, 2007.
Note: Data were statistically unreliable for clinical decision support systems and CPOE in agencies with 101-150 current patients.

• Overall Computerized System Adoption:
  • In 2007, agencies that provided both home health and hospice care had a significantly higher percentage of organizations with EHRs than agencies that provided home health care only (Figure 8.2). Agencies with 151 or more current patients had a significantly higher percentage of EHR use than agencies with 150 or fewer current patients.
• Patient Demographics:
  • In 2007, 99% of home health-only agencies and more than 99% of hospice-only agencies that had an EHR system had a component for patient demographics. Nearly all agencies that provide both home health and hospice care that had an EHR system had a component for patient demographics.
  • In 2007, agencies with 101-150 current patients had the lowest percentage of providers of home health or hospice care whose EHRs included patient demographics (96%). Of the agencies that had an EHR system, 99% of agencies with 151 or more current patients, 99.2% of agencies with 50 or fewer current patients, and 99.7% of agencies with 51-100 current patients had organizations with EHR systems that had a component for patient demographics.
• Clinical Notes:
  • In 2007, 94% of agencies with an EHR system that provide both home health and hospice care, 81% that provide home health only, and 79% of hospice-only providers had a component for clinical notes.
  • In 2007, of those agencies with an EHR system, more than 91% of agencies with 151 or more current patients, 89% of agencies with 51-100 current patients, and 79% of agencies with 50 or fewer current patients had EHRs with a component for clinical notes. Only about two-thirds of agencies with 101-150 current patients had EHRs with a component for clinical notes.
• Clinical Decision Support:
  • In 2007, 61% of agencies providing both home health and hospice care, 59% of providers of home health care only, and 49% of providers of hospice care only that had an EHR system had an electronic system with a CDS component.
  • In 2007, of those agencies that had an EHR system, three-quarters of providers of home health or hospice care with 151 or more current patients, and 67% of providers with 51-100 current patients had EHRs with a CDS component. Only 31% of providers with 50 or fewer current patients had EHRs with a CDS component.
• Computerized Provider Order Entry:
  • In 2007, of those agencies that had an EHR system, nearly half of both home health and hospice and hospice-only providers had EHRs with a CPOE component. More than half (54%) of home health-only providers had EHRs with a CPOE component.
  • Nearly 63% of organizations that had an EHR system and 51-100 current patients, 53% of organizations with 151 or more current patients, and 38% of organizations with 50 or fewer current patients had EHRs with a CPOE component.

Also, in the NHDR:

• All government-owned agencies that had an EHR system had EHRs with a patient demographic component. Ninety-nine percent of private, not-for-profit agencies and 98% of for-profit agencies that had an EHR system had EHRs with a patient demographic component.
• More than 95% of private, not-for-profit agencies, 80% of government-owned agencies, and 70% of for-profit agencies that had an EHR system had EHRs with a component for clinical notes.
• In 2007, of those agencies that had EHRs, 51% of providers in the Midwest, and 42% of providers in the South had EHRs with a CPOE component.

New! Workforce Distribution

According to the U.S. Census Bureau, adults age 65 and over accounted for 13% (40.3 million) of the U.S. population in 2010 (Howden & Meyer, 2011). By 2050, that number will more than double to 88.5 million (20%). In 2010, the number of people age 100 and over reached 71,991 and this population is projected to grow to 601,000 by 2050 (U.S. Census Bureau, 2011).

Older adults are at increased risk of accidental falls, which are associated with reduced levels of independence, poorer quality of life, and high levels of anxiety (Hanley, et al., 2011). In 2009, 2.2 million nonfatal fall injuries among older adults were treated in emergency departments and more than 523,000 of these patients were hospitalized (Centers for Disease Control and Prevention [CDC], 2011). Occupational and physical therapy can help patients recover from injury and can prevent falls.

Occupational therapists provide treatment to help individuals recover from injuries and regain physical function that might be lost due to injury. They also explore factors that contributed to the injury and create prevention plans tailored to each patient. Physical therapists' expertise includes screening high-risk populations such as older adults; assessing physical functions such as balance, gait, and strength; and implementing risk reduction strategies. These strategies can include development of exercise programs, selection and training in the use of assistive devices, patient education, and identification of potential risks and barriers in the patient's home.

According to CDC, three-quarters of strokes occur in people age 65 and over. Between 15% and 30% of stroke survivors are permanently disabled and suffer from paralysis and movement difficulties, sensory disturbances, language problems, thinking and memory problems, and emotional disturbances. The primary objective of speech and language pathologists is to improve quality of life by optimizing individuals' ability to communicate and swallow. Speech and language pathologists address typical and atypical areas of communication and swallowing, such as speech sound production, cognition, feeding and swallowing, and oral-motor functions. The work of speech and language pathologists is essential in helping temporarily disabled and older patients have a better quality of life.

This year, the NHQR presents the geographic distribution of occupational therapists, physical therapists, and speech-language pathologists to examine access to these vital health care services in various areas.

Figure 8.3. U.S. occupational therapy, physical therapy, and speech-language pathology professionals, by geographic region, 2005-2009

   
 




[D] Select for Text Description.

Source: U.S. Census Bureau, American Community Survey, 2005-2009.

• From 2005 to 2009, the Northeast had a higher rate of occupational therapists than the South and the West (Figure 8.3).
• During this same period, the Northeast had a significantly higher rate of physical therapists than all other regions.
• The Northeast also had a significantly higher rate of speech and language pathologists than the West in all years and the South in 4 out of 5 years.

Also, in the NHDR:

• From 2005 to 2009, Whites had a significantly higher rate of physical therapists than Blacks, AI/ANs, and people of other and multiple races. Asians, however, had a higher rate of physical therapists than Whites. Non-Hispanic Whites had a significantly higher rate than Hispanics.

Care Management Processes: Focus on the Health Care Safety Net

Concern about growing physician and health workforce shortages has increased over the past decade. According to the Health Resources and Services Administration, by 2020, the United States will experience a shortage of about 100,000 physicians and 1 million nurses.ⁱⁱ In his seminal work on health care quality, Donabedian (1980) describes a robust health care "structure"—the setting or infrastructure supporting the delivery of care (e.g., hospitals, providers)—as necessary to ensure that processes of care contribute to good outcomes. Structural deficiencies in the United States health care delivery system resulting from shortages of providers, growing demand, and a high rate of uninsurance and underinsurance have contributed to unmet need and could result in increased morbidity and health care costs.

Safety net providers play an integral role in relieving unmet needs. As defined in a report sponsored by HRSA, the U.S. health care safety net is composed of "[t]hose providers that organize and deliver a significant level of health care and other health-related services to the uninsured, Medicaid, and other vulnerable populations" (IOM, 2010). Safety net providers act as a default system, or providers "of last resort," by ensuring access to care for millions of Americans lacking medical coverage or provider access, regardless of education, social status, language competency, or ability to pay.

The safety net includes many different types of providers, including public health departments, hospitals, and federally funded health centers (FFHCs). For the 50 million uninsured people and individuals with low income, safety net providers serve an essential function, eliminating financial barriers to care and enhancing access to services. As workforce shortages escalate, demand for safety net services is likely to increase.

This section includes measures that highlight the magnitude of health workforce shortages and, specifically, the magnitude of underserved populations located in designated primary care, mental health, and dental health professional shortage areas (HPSAs). Designation of an area as an HPSA and estimates of the underserved population in these areas were derived by HRSA. An HPSA consists of a geographic area, low-income population, or facility that does not meet designated standards of provider coverage.

This section also highlights the role of FFHCs as safety net providers by describing (1) the characteristics of people with an FFHC visit in 2010 and (2) the quality of care rendered to patients with hypertension and diabetes who are treated at these facilities.

New! Underserved Population in Health Professional Shortage Areas

HRSA estimates the underserved population, those who may not have adequate access to provider services, as follows:

(Underserved population residing in HPSA / State population) × 100; where the underserved population is computed by multiplying the number of practitioners in the area by target population-to-practitioner ratios ⁱⁱⁱ and subtracting this figure from the area population.

Estimated separately for primary care, mental health, and dental HPSAs, these measures provide insight into the availability of providers to meet the needs of the population in each State.

Figure 8.4 groups States by quartile, based on the percentage of underserved population in HPSAs. Separate estimates were generated for primary care, mental health, and dental HPSAs. As shown in these figures, the magnitude of underserved population in HPSAs varied substantially across States. States highlighted in small dots had among the highest percentages of underserved population and those highlighted in green had among the lowest percentages.^iv

Figure 8.4. Underserved populations in primary care, mental health, and dental health professional shortage areas, 2011

[D] Select for Text Description.

Key: Worst quartile indicates States with the highest percentages of underserved people. Best quartile indicates States with the lowest percentages.
Source: Health Resource and Services Administration, Bureau of Health Professions, Office of Shortage Designation, Designated Health Professional Shortage Area Statistics, May 15, 2011.

• The percentage of State population underserved by primary care providers was highest in Alaska (69%), Washington (65%), and Idaho (59%) (Figure 8.4). States with the lowest percentage of underserved population include New Jersey (2%), Vermont (3%), and Hawaii (3%).^v
• In addition to the territories, several Mountain and North Central States have large populations underserved by mental health professionals. States and territories with the highest percentage include the Virgin Islands (76%), Wyoming (75%), Puerto Rico (70%), and Idaho (69%). States with the lowest percentage include Delaware (0%), New Jersey (1%), and New Hampshire (4%).
• Overall, the percentage of underserved population in dental HPSAs was highest in the territories and the southern States. States and territories with the highest percentage include the Virgin Islands (97%), Puerto Rico (35%), Mississippi (34%), and Louisiana (32%). States with the lowest percentage include New Jersey (1%), Nebraska (2%), New Hampshire (2%), and Vermont (3%).
• Five States and territories were in the worst quartile for all three types of services: Idaho, Louisiana, Montana, New Mexico, and Puerto Rico; three States were in the best quartile for each service: New Hampshire, New Jersey, and Vermont.

New! Patients Using Federally Funded Health Centers

FFHCs include health care organizations that receive a grant under Section 330 of the Public Health Service Act, including community health centers, migrant health centers, Health Care for the Homeless programs, and Public Housing Primary Care programs. These organizations typically render services to low-income populations, uninsured people, people with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and public housing residents.

To obtain Federal grant funding, these public and nonprofit organizations agree to provide a minimum set of services, including primary and preventive care, mental health, and dental services. Access to care is available to all persons, regardless of ability to pay. Charges for services rendered are based on a sliding scale linked to patients' family income. More than 19 million people visited an FFHC in 2010.

Figure 8.5. Characteristics of FFHC patients, by age, gender, and insurance status, 2010

[D] Select for Text Description.

Source: ASource: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2010.
Note: Data were obtained from 1,124 Section 330g grantees.

• In 2010, the largest group of FFHC patients comprised adults ages 20-64 (58%; Figure 8.5), whereas adults age 65 and over made up only a small proportion of FFHC patients (7%).
• In 2010, a substantially larger percentage of females (59%) than males (41%) received treatment at an FFHC.
• Nearly 40% of patients seen at an FFHC were uninsured and nearly 40% had Medicaid.

Also, in the NHDR:

• Approximately 64% of patients seen at an FFHC were non-Hispanic White, and one-quarter were non-Hispanic Black.
• Almost three-quarters of patients seen in an FFHC in 2010 had income at or below the Federal poverty level.

New! Control of Hypertension and Diabetes in FFHC Patients

Nearly 2.4 million adults treated at an FFHC in 2010 had a hypertension diagnosis, and almost 1.3 million had either Type I or Type II diabetes. The population with hypertension and diabetes may overlap, so the two numbers should not be added together. Control of hypertension and diabetes can help indicate quality of care at FFHCs since people with these conditions require frequent monitoring.

Figure 8.6. FFHC patients with hypertension or diabetes whose symptoms are controlled, 2010

[D] Select for Text Description.

Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2010.
Note: Data were obtained from 1,124 Section 330g grantees. Patients with hypertension include those ages 18-85. Hypertension is determined to be controlled if the patient's last blood pressure reading was less than 140/90 mm Hg. Patients with diabetes include those ages 18-75. Diabetes is determined to be controlled if the patient's most recent hemoglobin A1c level was 7% or less.

• In 2010, about 63% of FFHC patients with hypertension had controlled blood pressure at the time of their last blood pressure reading (Figure 8.6).
• Almost 40 percent of FFHC patients with diabetes were found to have a hemoglobin A1C (HbA1c) level below 7% at the time of their most recent test.
• Although the measure is based on a 3-year average for 2005-2008, the National Health and Nutrition Examination Survey estimates suggest that across the Nation, 54% of people with diabetes have symptoms under control (data not shown; for information, go to http://www.healthindicators.gov).

Also, in the NHDR:

• More than two-thirds of non-Hispanic White patients had their hypertension under control. Subgroups of patients with the lowest proportion of controlled hypertension were Native Hawaiians, Pacific Islanders, and American Indians and Alaska Natives; only about one-half of patients in these racial groups had their blood pressure under control.
• Among Hispanic FFHC patients with hypertension, two-thirds had controlled blood pressure; one-third of Hispanics with diabetes had their HbA1c under control.

References

Centers for Disease Control and Prevention. WISQARS [Web-based Injury Statistics Query and Reporting System] nonfatal injury death reports. Available at: http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html. 2011.

Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med Inform Assoc 2010 Jan-Feb;17(1):78-84.

Donabedian A. The definition of quality and approaches to its assessment. Chicago: Health Administration Press; 1980.

Facts for Features. Older Americans Month: May 2011. Suitland, MD: U.S. Census Bureau; March 23, 2011. Publication No. CB11-FF.08. Available at: http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb11-ff08.html.

Hanley A, Silke C, Murphy J. Community-based health efforts for the prevention of falls in the elderly. Clin Interv Aging 2011;6:19-25. Epub 2010 Dec 20.

Howden LM, Meyer JA. Age and sex composition: 2010. 2010 Census Briefs. Suitland, MD: U.S. Census Bureau; May 2011. Publication No. C2010BR-03. Available at: http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf [Plugin Software Help]. Accessed August 16, 2011.

Institute of Medicine, Board of Health Care Services. Future directions for the National Healthcare Quality and Disparities Reports. Washington, DC: National Academies Press; 2010.

Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003 Jun 23;163(12):1409-16.

Resnick HE, Alwan M. Use of health information technology in home health and hospice agencies: United States, 2007. J Am Med Inform Assoc 2010;17:389-95.

Romano MJ, Stafford RS. Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Arch Intern Med 2011;171(10):897-903.

Shih A, Davis K, Schoenbaum S, et al. Organizing the U.S. health care delivery system for high performance, 2008. New York, NY: The Commonwealth Fund Commission on a High Performance Health System. Available at: http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf [Plugin Software Help].

^i. Available at the National Academies Press Web site at http://www.nap.edu/openbook.php?isbn=030908265X .
^ii. National Center for Health Workforce Analysis, http://bhpr.hrsa.gov/healthworkforce/index.html. Accessed August 15, 2011.
^iii. Target ratios are 2,000:1 for primary care; 3,000:1 for dental; and 10,000:1 for mental health.
^iv. Of particular importance in understanding these data, State efforts drive the number of designated HPSAs. States vary in the degree to which they respond to requests for HPSA designation. As such, these data do not reflect a universal capture of all areas that meet the criteria.
^v. State data are available at HRSA's Web site, http://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/BCD_HPSA_State_Summary&rs:Format=HTML3.2.