A pair of Boston-area researchers with a penchant for planting proverbial two-by-fours of reality between the eyes of federal healthcare information technology policymakers have landed another whack.
You have to look really hard to find the bright side in the most recent writings of Ashish Jha and Catherine DesRoches. Their article, published online in the policy journal
Health Affairs, declares that roughly 2%—and that's rounding up—of U.S. hospitals in 2009 would have had a chance at passing muster under the new federal criteria for
meaningful use of health IT.
The overriding message is that even after five years of federal health IT cheerleading, about 98% of hospitals would have failed to qualify for federal subsidy payments for the purchase of electronic health-record technology under the American Recovery and Reinvestment Act of 2009.
The researchers also conclude that there is a discernable IT adoption gap between the digital haves and have-nots in this country, that the divide is widening, and that the jury is still out as to whether the IT incentives portion of the federal stimulus law will remediate or exacerbate the problem of IT inequality.
"Larger, nonprofit, urban hospitals made more headway than critical-access hospitals, small and medium-size hospitals, and public and rural hospitals," the authors conclude. Even so, only "a very small proportion" of hospitals could meet the Stage 1 meaningful-use criteria, they said.
This last finding suggests that most hospitals will have to make yeoman efforts to qualify and receive stimulus funds.
The clock starts running Oct. 1 on the first payment year for hospitals under Stage 1 criteria. The criteria are to remain the same for only the first two years of the subsidy program. New, more stringent meaningful-use criteria are expected to be applied to the subsequent, two-year Stage 2 criteria, set to take effect in fiscal 2013.
Jha, a physician, is an associate professor of health policy and management at Harvard Medical School. DesRoches is a survey scientist and assistant professor of medicine at the Mongan Institute for Health Policy at Partners Healthcare. They were joined in producing
"A Progress Report On Electronic Health Records in U.S. Hospitals" by Peter Kralovec, the senior director of the Health Forum, Chicago, and Maulik Joshi, president of the Health Research and Educational Trust and vice president for research for the American Hospital Association, both of Chicago.
Since 2007, Jha and DesRoches have been making grim headlines with research tracking the
snail's pace of EHR adoption, the
cloudy outlook for health information exchanges and the
tepid reception of computerized physician order entry systems.
In their most recent report, the researchers used data from an American Hospital Association survey of 3,101 hospitals conducted last fall but based on IT systems usage and capabilities that hospital executives reported for their organizations as of March 31, 2009.
Although the survey did not include questions specifically about meaningful use—the final rules for meaningful use weren't published by the CMS until July—surveyors did ask hospitals to report on the presence or absence and level of use of 32 clinical functions of an EHR. The researchers matched those functions to nine of 14 "core" criteria in the final meaningful-use requirements and three of the 10 "menu" criteria.
Only 1.6% of U.S. hospitals could meet all of the core and menu objectives, the researchers found. For small, critical-access and rural hospitals, the results were even worse: 1%, 0.9% and 0.6%, respectively.
Using different metrics to express the same IT gap, the researchers noted that between 2008 and 2009, the percentage of hospitals that were using EHR systems that meet the definitions of either a “basic” or a “comprehensive” EHR increased somewhat. But critical-access, small, public and rural hospitals “fell even farther behind.” Critical access, small, public, non-teaching and rural hospitals “had 2% to 10% lower levels of adoption” of electronic hospitals than their larger, urban and teaching hospital counterparts, the authors said.
The stakes of a widening IT gap are greater than one might at first suspect, the authors suggest.
Because IT systems are generally accepted as tools capable of improving coordination of patient care, patient involvement and public health, "If certain types of hospitals fall further behind in adoption and meaningful use, they would be at a serious disadvantage in each of these realms," the authors said. "This potential gap could have important implications for the health of the nearly 60% of Americans who receive care in small or medium-size hospitals and for the sizable proportion who receive care in public or rural hospitals."
To address the situation, the authors suggest the government provide additional IT assistance to critical-access, smaller and rural hospitals through the regional IT extension service program, which is currently focused on office-based primary-care physicians.
"Another option might be to offer additional incentive payments or to lend money to smaller, public or rural hospitals to offset the costs of purchasing or upgrading a certified electronic health record system," they said. "There is precedent for this approach: Congress has already allocated extra incentive payments for providers that care for a large proportion of Medicaid patients."
"If we wait until after 2011 to identify the early recipients of meaningful-use incentives, it may be too late to reverse these trends in a timely fashion," they warn.
Jha said he takes no pleasure in reporting bad but important news.
"It's painful," Jha said in a telephone interview. "The issue is, having good, credible and transparent data is in some ways the lifeblood of making good policy."
He added: "The message I've taken away is this transformation from paper-based to electronic records is difficult and slow. We just have to, in some ways, recalibrate our expectations."
Presidents George W. Bush and Barack Obama have endorsed the goal of giving most Americans access to an electronic medical record by 2014. But Congress followed up only last year with the stimulus law that has an incentive program to help drive the country toward that goal. The stimulus-law incentive payments for the largest chunk of providers are set to end in 2015, and penalties in the form of Medicare deductions are scheduled to start the following year.
For office-based physicians, the incentive payments of $44,000 from Medicare and $63,750 from Medicaid, although probably not enough to cover the entire cost of EHR conversion, are "pretty decent," Jha said. But for hospitals well down the road to IT adoption the incentive payments will be at best just a bonus toward deploying a complete EHR system.
For the IT have-nots, however, additional federal interventions—perhaps special regional extension center programs targeting the most IT-needy hospitals—and higher levels of financial help may be required, Jha said. Otherwise, he said, we face the specter of a healthcare system with two tiers of technology.
"For hospitals that are struggling, the incentives are going to be inadequate, and I think a number of them are just going to sit it out and hope the penalties never set in."
