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HEALTH REFORM: The Great Digital Divide

"In a health-care debate characterized by partisan bickering," Alexi Mostrous of the Washington Post writes, "most lawmakers agree on one thing: American medicine needs to go digital." But how how we make sure it goes digital -- evenly?  In other words, how can we use technology to eliminate health disparities -- not enlarge them?

As we have written before, there is significant evidence that the widespread (and smart) adoption of health information technology will help improve the safety, efficiency and effectiveness of the U.S. health care system. It can also eventually save money or "bend the cost curve." As such, Obama's American Recovery and Reinvestment Act of 2009 (the stimulus bill) made a roughly $30 billion net investment toward Health IT adoption by physicians and hospitals.

But the administration also wants to make sure that health IT reduces -- not deepens -- health disparities. That means making sure the health IT funds benefit the rural, uninsured and underserved populations. 

A study released this week by Health Affairs, Evidence of An Emerging Digital Divide Among Hospitals That Care For The Poor, funded by the Office of the National Coordinator for Health Information Technology and the Robert Wood Johnson Foundation, examines the adoption of electronic health records in hospitals nationally. They surveyed 3,747 acute care non-federal hospitals and received responses from 2,368 -- a response rate of 63.1 percent.

While the study is only an early indicator of EHR use in U.S. hospitals, it has some interesting conclusions:

  • EHR adoption rates are low overall; hospitals with higher rates of poor patients have lower adoption rates of electronic decision support tools, electronic medication lists and electronic discharge summaries
  • Hospitals that serve high numbers of poor patients more often cite money as a major barrier to adoption
  • There are modest differences in the quality of care provided at hospitals disproportionately caring for the poor versus hospitals that are not

Hospitals with high numbers of poor patients (Disproportionate Share Hospitals) rely on Medicaid funds significantly more than other hospitals. As states that have "cash strapped" Medicaid programs may choose not to contribute to health IT initiatives, these hospitals will have less money available to launch EHR systems.

The researchers are concerned that a "digital divide" is emerging between hospitals treating high numbers of poor patients -- and those that are not. They worry that as hospitals adopt electronic health records, hospitals that serve a disproportionate number of poor patients will fall even further behind in their ability to provide quality care. So despite the great potential of health IT, the impending "digital divide" and insufficient financial capital may well continue to exacerbate, not end, health disparities throughout the country. 

"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," explains Dr. Ashish Jha, the lead researcher.

For example, the research reveals that there is no disparity between the care provided by hospitals caring for more poor patients than those that do not -- but this is among hospitals with EHR systems. "Without HIT," Dr. Jha continues, "it will be much harder for hospitals that primarily serve the poor to catch up. 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." (To learn about one safety net hospital that has used Health IT extensively and effectively, read about Denver Health here.

Another study conducted by Esther Hing and Catherine Burty illustrates that uninsured Black and Hispanic or Latino patients, as well as Hispanic or Latino Medicaid patients, are less likely to have primary care physicians that use EHRs than privately-insured white patients.

As policymakers decide what measures they will take to make lasting improvements in the U.S. health care system, it is critical that they address the "digital divide" and ensure that hospitals are given equal opportunity to adopt EHRs. "This is not an isolated issue," Dr Jha explains, "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."

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