Hospitals That Care for Poor Patients Face Digital Divide Without Federal Help

First national look at electronic health records in hospitals that serve the poor shows effect of lagging adoption rates on quality.

    • October 26, 2009

Hospitals that serve a disproportionately large share of poor patients are lagging behind other hospitals in adopting electronic health records (EHR), leading to a digital divide that could exacerbate health care disparities, researchers report today in the Web exclusive edition of the journal Health Affairs. Using data from the first national survey to examine EHR adoption among hospitals, the authors focused on hospitals with a large portion of poor patients. They found that lack of capital remains a large barrier to embracing digital recordkeeping, and that unless enough federal dollars flow to these institutions, they will have a difficult time catching up.

"Health information technology (HIT) is central to improving the quality and efficiency of health care in America. HIT is woefully inadequate throughout the health care system, but institutions that treat the most vulnerable patients have much less of it and this leads to worse care," says lead study author Ashish Jha, M.D., M.P.H., associate professor at the Harvard School of Public Health. "This is not an isolated issue. We are talking about one in every four hospitals—and they treat millions of patients. These hospitals will need a concerted effort from both national and state policymakers to avert a serious digital divide from emerging," says Jha.

The study, supported by the Robert Wood Johnson Foundation and the federal government’s Office of the National Coordinator for Health Information Technology, was conducted by Jha and colleagues at the Harvard School of Public Health, Massachusetts General Hospital and George Washington University. This study will appear in the third annual report on HIT adoption trends in hospitals, also funded by RWJF and ONC, to be released in November.

The findings come as the federal government determines how to target HIT dollars under the American Recovery and Reinvestment Act. Highlights of what the researchers found:

  • Hospitals with higher rates of poor patients had lower levels of adoption of electronic clinical decision support tools, electronic medication lists and electronic discharge summaries.
  • Among hospitals without an EHR system, inadequate capital was cited significantly more often as a barrier to adoption by hospitals caring for a greater number of poor patients than other hospitals or so called disproportionate share (DSH) hospitals.
  • Hospitals caring for more poor patients were significantly more likely than those with fewer poor patients to report concerns about future support.

The authors also found that EHR adoption has the potential to eliminate the gaps in disparities in care for patients. Among hospitals without EHR systems, hospitals caring for more poor patients provided a lower standard of care than others. However, among hospitals that had adopted EHR systems, there was no disparity in the care between the two types of institutions. Researchers looked at treatment for myocardial infarction, congestive heart failure, pneumonia and prevention of surgical complications.

"Our study shows that EHRs have the potential for eliminating disparities between hospitals that care for greater numbers of poor patients and those that don’t," says Jha. "Without HIT, it will be much harder for hospitals that primarily serve the poor to catch up."

The federal stimulus package authorized $30 billion to establish an HIT infrastructure that uses financial incentives via Medicare and Medicaid to promote adoption of EHRs by hospitals and physicians. The law requires the federal government to make sure that uninsured and medically underserved patients benefit from HIT. But Jha and his research colleagues worry that hospitals serving the poor may be disadvantaged because of the way the law is interpreted and bonus payments are allocated.

How Medicaid funds HIT will be a key indicator since DSH hospitals rely more on that program than Medicare. If cash-strapped states opt out of participating in funding their portion of Medicaid HIT efforts, hospitals disproportionately serving poor patients will likely fall further behind in adoption, the authors warn. In addition, how Medicare and state Medicaid programs set up the incentive program will be a key step to spurring more adoption.

"We have to find a way to close this digital divide and make sure these hospitals get the capital they need. If we don’t, we risk widening gaps in care that will lead to higher costs and more inefficiency," says John Lumpkin, M.D., senior vice president of RWJF’s Health Care Group.

The authors examined EHR use in 2,368 acute care hospitals. The authors found that hospitals providing care for more Medicaid patients also served a disproportionately larger share of elderly black patients, and elderly Hispanic patients than other hospitals. While some of these hospitals were large, urban teaching hospitals, many were also smaller, for-profit institutions located in the South.

Copies of the article, "Evidence of an Emerging Digital Divide Among Hospitals that Care for the Poor," appear in the October 26 Web edition of Health Affairs.


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The Institute for Health Policy (IHP) at Massachusetts General Hospital (MGH) and Partners Health System is dedicated to conducting world-class research on the central health care issues of our time. The mission of the IHP is to improve the health and health care of the American people through conducting health policy and health services research, translating new healthcare knowledge into practice, informing and influencing public policy, and training scholars and practitioners of health policy.