Why the Digital Divide is Likely to Expand under ARRA

Recently, a study funded by the Robert Wood Johnson Foundation and the Office of the National Coordinator for HIT found that hospitals that serve a disproportionate share of poor patients are lagging behind other hospitals in adopting Electronic Health Records.

According to the study:

“Data from a national survey indicate early evidence of an emerging digital divide: U.S. hospitals that provide care to large numbers of poor patients also had minimal use of EHRs. These same hospitals lagged others in quality performance as well, but those with EHR systems seemed to have eliminated the quality gap. These findings suggest that adopting EHRs should be a major policy goal of health reform measures targeting hospitals that serve large populations of poor patients.”[1]

These disproportionate-share hospitals (DSHs) now join the ranks of rural and critical access hospitals (CAHs), which have also been shown to have major EHR adoption disparities compared to other hospitals.[2]

John Glaser, Advisor to the National Coordinator for HIT, responded to the study’s release with the following commentary:

“The president’s goal is to have everyone in this country benefit from the improvements in care that can result from the meaningful use of electronic health records. Everyone.

“EHR adoption data has indicated the potential formation of a digital divide between the providers that have and the providers that have not. A primary goal of the federal EHR strategy is ensuring that that divide does not form and that all providers (and all patients) realize the value of the technology.

“Medicare and Medicaid incentive funds provided need capital. Extension center activities to support providers are targeted to critical access hospitals and physicians in small practices. The grants directed to the states carry with them the obligation of state government to help ensure that no providers and no patients are left behind.

“An EHR digital divide is something that none of us will accept.”[3]

While I applaud the imperative articulated in Mr. Glaser’s last line, it seems clear that unless action is taken, ARRA and its associated regulations will in fact significantly expand the already prominent digital divide. It will do so for the following reasons:

1. ARRA provides Critical Access Hospitals, which have the lowest EMR adoption rates of any hospitals surveyed by HIMSS Analytics, with a fraction of the incentives that Prospective Payment System hospitals will receive.  (See Chapters 2 & 3 in ARRA History section for more information)

2. The “meaningful EHR use” standards (as recommended by the HIT Policy Committee) have been designed for hospitals already far along with their EHR adoption efforts. Many experts believe that if the standards are implemented as written, hospitals at early stages of adoption will simply not have a reasonable amount of time to become meaningful users and attain incentives.  (See Chapter 4 in ARRA History section for more information)

3. Contrary to Mr. Glaser’s assertion, Regional Extension Center activities are not targeted to critical access hospitals or, indeed, any hospitals.  In its REC grant guidance, ONC redefined the term “prioritized provider” to exclude hospitals, even though ARRA language originally included them.  So hospitals in need of technical assistance will not be able to receive it, at least through the REC program.  (See Chapter 5 in ARRA History section for more information)

4. A key EHR implementation barrier for providers on the wrong end of the digital divide is access to capital. The one ARRA provision that might have helped was a loan program through the states.  It currently appears that ONC will not act to establish this much needed program.  The Small Business Financing and Investment Act contains an HIT loan program, but it has no provisions to help hospitals.

In the coming months, this blog will be assessing emerging ARRA-related news and regulatory language, with an eye toward how it will impact rural and underserved providers, and how it will affect the currently widening digital divide.

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[1] Ashish K. Jha, et al [Health Aff (Millwood). 2009;28(6):w1160–70 (published online 26 October 2009;10.1377/hlthaff.28.6.w1160)]

[2] HIMSS Analytics:  http://www.himssanalytics.org/hc_providers/emr_adoption.asp

[3] John Glaser, CHIME’s Healthcare CIO SmartBrief, 10-30-2009

Tagged as: ARRA, Rural