Study: EHR adoption encouraged for providers serving the poor

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According to a study published online Oct. 26 in Health Affairs, EHR adoption by hospitals that serve a large population of poor patients should be a major policy goal of health reform measures.

The authors also found that poorer hospitals lagged behind other healthcare facilities in quality performance as well, but those with EHR systems seemed to have eliminated the quality gap.

Ashish K. Jha, PhD, associate professer of health policy at Harvard University in Cambridge, Mass., and colleagues noted that there is a worry that the American Recovery and Reinvestment Act of 2009 and the push for meaningful use might “exacerbate existing disparities in care by creating a new healthcare ‘digital divide’ between providers that disproportionately care for the poor and those that do not.”

There are no national data on the proportion of patients served by a given hospital who are poor, the authors wrote. They used a hospital's Medicare disproportionate-share hospital (DSH) index as a surrogate measure. Each hospital was assigned an index by the Centers for Medicare & Medicaid Services (CMS) based on a combination of its fraction of elderly Medicare patients eligible for Supplemental Security Income and its fraction of nonelderly patients with Medicaid coverage. CMS uses this formula to identify hospitals eligible for additional Medicare payments for caring for the poor. The study used the 2007 Impact File compiled by the CMS to obtain each organization's DSH index.

The researchers, supported by the Office of the National Coordinator for Health IT and the Robert Wood Johnson Foundation, partnered with the American Hospital Association to administer a hospital IT survey to 3,747 acute-care member hospitals in 2008 as a supplement to the association's annual survey. The survey achieved a response rate of 63.1 percent.

The study did not examine how EHR systems are used within hospitals nor did it have a direct measure of the number of poor patients in any given hospital.

Among the 24 EHR functions examined, high-DSH hospitals had lower rates of adoption of all 24 compared with low-DSH hospitals, although the magnitude of the gap varied greatly and not all differences were statistically significant, Jha and colleagues wrote. Statistically significant differences included lower rates of electronic medication lists and electronic discharge summaries.

According to the results, among hospitals without an EHR system, inadequate capital was cited significantly more often as a major barrier to adoption by high-DSH hospitals (77 percent) than low-DSH hospitals (63 percent).

The authors assessed whether the proportion of poor patients in a given hospital was related to the quality of care provided. They found a highly statistically significant association in all four examined conditions: a 10 percent increase in DSH index was associated with a 0.5 percent lower performance on acute heart attack quality metrics; a 1 percent lower performance on congestive heart failure metrics; a 0.9 percent lower performance on pneumonia metrics; and a 1.5 percent lower performance on surgical complication prevention metrics.

Jha and colleagues concluded that for many of the EHR functions examined, hospitals that served a higher proportion of poor patients had modestly lower levels of adoption of health IT. Their results suggest that EHR systems may be helpful in reducing the disparities in care between high- and low-DSH hospitals.