But, what may be a bit more surprising—and heartening—is the researchers' finding that those disproportionate-share hospitals that have more-robust electronic health-record systems in use have closed that performance gap.
These findings are the highlights of an 11-page summary report, Evidence of an Emerging Digital Divide Among Hospitals That Care for the Poor. The summary appeared today in the online edition of the policy journal Health Affairs and at the Web site of the Robert Wood Johnson Foundation, which funded the study along with the Office of the National Coordinator for Health Information Technology at HHS.
The full study report will appear as part of the third annual report by the foundation and the ONC on health IT adoption to be released in November.
Ashish Jha, M.D., an associate professor at the Harvard School of Public Health, was the lead author of the report. Jha's team included researchers from Massachusetts General Hospital, Boston, and George Washington University Hospital, Washington, D.C.
The study results will challenge federal policymakers to pay attention to the special needs of those hospitals where services to the poor are concentrated to ensure their IT programs are adequately funded and implemented, Jha said.
“I'm worried about this,” Jha said.
Given the complex funding formulas for the Medicare and Medicaid hospital incentive programs in the American Recovery and Reinvestment Act of 2009, one problem, Jha said, is that it is hard to estimate in advance what an average federal IT subsidy amount for disproportionate-share hospitals will be and whether it will be enough.
“With the docs,” Jha said, the EHR subsidies of up to $44,000 under Medicare (and up to $63,750 under Medicaid), “will cover a good chunk if not all, but for hospital's that's not true.”
“The numbers I hear are in the $5 million to $10 million and $15 million range, and for the larger hospitals, that doesn't even come close,” in terms of what they will need to fund a complete electronic health-record system, he said.
In 2008, with the cooperation of the American Hospital Association, the researchers set out to answer the following four questions about the alleged digital divide:
- Are EHR adoption rates lower in hospitals that disproportionately care for poor patients?
- Are rates of adoption of key underlying EHR functions, such as clinical notes or computerized prescribing, lower in hospitals with a high proportion of poor patients?
- Do such hospitals identify the same barriers to EHR adoption as other hospitals, as well as the same facilitators of adoption?
- And, is there evidence that EHR adoption might play an important role in reducing disparities in the quality of care provided by these hospitals?
Researchers used the CMS' disproportionate-share index, which is based on a combination of its Medicaid-to-Medicare patient mix, as a placeholder for the rates of poor patients each hospital serves. Hospitals were grouped by the index in quartiles. Hospitals in the highest disproportionate-share quartile on average had 40% of their patients covered by Medicare and 27% by Medicaid, compared with 53% Medicare and 9% Medicaid in the lowest quartile.
Blacks made up 18% of the patient mix for hospitals in the highest quartile and Hispanics, 4%; blacks made up 4% of the patient mix of hospitals in the lowest quartile and Hispanics, 1%. Most, 51%, of disproportionate-share hospitals were in the 100- to 399-bed range. Another 20% were large hospitals with 400 or more beds, while 29% were small, with less than 100 beds. Most were in the South, 56%, and West, 25%.
Researchers also collaborated with the AHA during its annual member survey and piggybacked onto it questions about their healthcare IT implementation status. They received 2,368 responses, a response rate of 63%, the report said.
Researchers asked respondents whether they had in place EHR systems with each or all of 31 clinical functions and the degree to which they were in use. As in previous studies by the Harvard research team, they divided the EHR world into two groups, a “basic” EHR with 10 functions in use in one major clinical unit, and a “comprehensive” EHR with 24 functions implemented across all clinical units. In a study released in March, the group found that less than 11% of hospitals had even a basic EHR and just 1.5% of hospitals had a comprehensive EHR
For the digital divide study, because of low adoption rates, researchers combined data on basic and comprehensive EHRs.
To compare EHR adoption to performance, the researchers used 24 Hospital Quality Alliance process measures for acute myocardial infarction, congestive heart failure, pneumonia and surgical complication prevention. The researchers also asked about and identified five of the most cited barriers and “facilitators” to EHR adoption: concerns about return on investment, access to capital to purchase an EHR, the cost of ongoing maintenance, resistance from physicians and concerns about lack of future support.
For disproportionate-share hospitals, as with other hospitals surveyed, funding was reported as the predominant barrier to IT adoption, but funding problems were cited “significantly more often” for the one in four hospitals with higher volumes of poorer patients, according to a summary of the study released in a news release.
According to the report summary, “Among the 24 functions examined, high-(disproportionate-share) hospitals had lower rates of adoption of all 24, compared to low-(disproportionate-share) hospitals, although the magnitude of the gap varied greatly and not all differences were statistically significant.”
The report said, “Statistically significant differences included lower rates of electronic medication lists and electronic discharge summaries. For key functions for which overall adoption levels were low, such as computerized physician medication-order entry, the differences in adoption were smaller and not significant.”
Today, Jha said, it is no longer an issue whether a hospital will adopt clinical IT systems, but it remains most definitely a question of how and when.
“Most people believe that we're going to have to do this, that this is an inevitability and hospitals have started thinking what their strategies are for this,” he said. Current Medicare and Medicaid subsidies, “will not pay for their entire system, but (they) will be helpful,” Jha said. “For high disproportionate-share hospitals it's going to be a big challenge. They're further behind. They have less implemented systems—that's what our survey says—they have less access to capital, and it's going to be a huge challenge for them to use the money in the stimulus bill to make a difference.”
Is there anything else that could and should be done to help these disproportionate-share hospitals close the digital divide?
“Before our study came out, everybody has been worried about this topic and we haven't had any empirical data,” Jha said. “Policymakers were saying, maybe this won't be much of a problem.” The data indicates otherwise, Jha said.
Now, Jha said, “I think to the extent that it is on people's radar screens, that will be helpful.”
Jha said a network of regional IT extension centers proposed under the stimulus bill should be able to track whether disproportionate-share hospitals are keeping pace and whether they need special funding or special help in implementing IT systems.
“We've allocated 30 billion federal dollars and we have God knows how much money flowing into it and we have so little knowledge how these things can be implemented well,” Jha said. The extension centers, “could gain a huge amount of knowledge to see that they do it well.”
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