The external forces driving EHR diffusion have grown in importance since 2004 relative to physicians' internal motivation to adopt such systems. Several national forces are likely contributing to the slowing pace of EHR diffusion.

: Overall, administrators believed that the systems improved care quality and employee satisfaction and were cost effective and that the EHR made a positive return on investment. Electronic documentation led to both increases in charge capture related to resource utilization group documentation, significant savings in pharmacy waste, and reductions in nursing overtime as medical record management became more automated. Quality improvement came from computer-aided monitoring of the certified nurse aide's attendance to residents' activities of daily living.

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