Digital divide emerges at hospitals serving poor patients

Hospitals that disproportionately care for poor patients are less likely than other hospitals to have adopted health information technology, says a new study. The research finds the digital divide is associated with differences in how well hospitals address racial and ethnic disparities in care and highlights the importance of helping hospitals go electronic.

Researchers surveyed 2,368 hospitals about their use of electronic systems for 24 functions such as physician notes, discharge summaries, test results viewing, order entries and decision support. The hospitals that served the most Medicaid, black and Hispanic patients, according to a Medicare measure known as the disproportionate-share hospital index, had lower rates of adoption than hospitals that served the fewest such patients, said the Health Affairs study published online Oct. 26.

"People have talked a lot about whether electronic medical records will make disparities better or worse," said study lead author Ashish K. Jha, MD, MPH. "Among people who worry that the push for electronic records will create a digital divide, this study says it is certainly possible, we are starting to see it already, and this could end up ... making disparities even worse."

Yet there is hope that health IT adoption could help hospitals caring for the greatest number of poor patients improve quality and combat racial and ethnic disparities, said Dr. Jha, associate professor of health policy in the Harvard School of Public Health's Dept. of Health Policy and Management in Massachusetts.

"Among hospitals that had electronic records, there was no gap" in care quality, regardless of the proportion of poor patients they served, he said. "But among hospitals that did not have electronic records, there was a big gap."

About two-thirds of hospitals are on their way to fully adopting electronic medical records systems, according to the American Hospital Assn. The American Recovery and Reinvestment Act includes about $19 billion in Medicare and Medicaid incentives for doctors and hospitals to adopt health IT.

Less capital, less IT

Experts said the Health Affairs study shows there is a risk that the health IT push could leave behind hospitals caring for the underserved.

"Hospitals with a high proportion of Medicaid patients or uninsured patients are less financially viable than hospitals with a higher-paying patient mix," said Romana Hasnain-Wynia, PhD, director of the Center for Healthcare Equity at Northwestern University's Feinberg School of Medicine in Illinois. "This study shows that financial factors play a big role in hospitals being either resource-constrained or resource-rich and that this does in fact have an outcome that relates to the quality of care."

When researchers asked about barriers to adopting health IT, hospitals caring for the greatest number of poor patients were 22% more likely to mention lack of capital than hospitals caring for the fewest poor patients.

To qualify for stimulus funds starting in 2011, hospitals must demonstrate "meaningful use" of the technology in providing care. The Centers for Medicare & Medicaid Services is expected to propose regulations governing the incentive program "in late 2009," according to the Dept. of Health and Human Services' Office of the National Coordinator for Health Information Technology.

While the stimulus package's Medicare incentives will apply equally to all hospitals, Medicaid programs can create their own rules, and it is unclear whether they will follow federal policy, Dr. Jha said.

In response to questions, a spokeswoman for the Office of the National Coordinator cited the agency's Web site, which says the stimulus package "clearly prioritizes access to health information technology for historically underserved and other special-needs populations, and use of that technology to achieve reduction in health disparities."

Hoangmai H. Pham, MD, MPH, was pleased that the digital divide wasn't deep. She noted that while hospitals serving the most poor patients trailed in adopting health IT, they did not trail by very much.

"It could have been a lot worse," said Dr. Pham, senior health researcher at the Center for Studying Health System Change, a nonpartisan Washington, D.C., research organization. "There doesn't seem to be the really stark differences between these two populations of hospitals that you'd be afraid of finding."