Lower EHR use in Hospitals that care for the Poor

Hospitals that treat large numbers of poor patients utilize electronic health records (EHRs) less frequently and provide care of lower quality, according to a study by Harvard scientists. However, the scientists also found that when such hospitals do use EHRs, the quality gap disappears.

Ashish Jha and colleagues used the Medicare disproportionate-share hospital (DSH) index as a surrogate for the proportion of poor patients served by each hospital. Using this metric, so-called “high-DSH index” hospitals are the ones caring for the highest percentage of poor people.

To collect information on EHR utilization, the scientists piggybacked a questionnaire onto the 2008 American Hospital Association survey. The questionnaire solicited information regarding the presence and degree of implementation of 32 electronic clinical functions.

To assess quality, Jha’s group used 2008 data from the Hospital Quality Alliance regarding acute myocardial infarction, congestive heart failure, pneumonia and surgical complication prevention.

The group collected information from over 2,300 hospitals, or 63% of those surveyed.

Hospitals in the high-DSH quartile had 40% of their patients covered by Medicare and 27% by Medicaid. Those in the lowest quartile had 53% Medicare and 9% Medicaid.

Jha’s group found that high-DSH hospitals had lower rates of adoption of every single EHR-related function they studied, although not every difference was statistically significant. Significant differences included lower utilization of electronic medication lists, discharge summaries, clinical decision-support, clinical documentation and results viewing.

Disproportionate share hospitals cited inadequate capital as a major barrier to EHR adoption more frequently (77%) than low-DSH hospitals (63%). High-DSH hospitals were also more likely (21% vs. 16%) to report concerns about implementation and future support.

With respect to quality, Jha’s group found a linear relation between DHS status and performance. Thus, for each 10% rise in the DSH index, performance on acute myocardial infarction quality metrics dropped 0.5%. The group noted similar drops in performance for congestive heart failure, pneumonia and surgical complication prevention metrics.

However, the inverse relation between DSH status and quality was not observed among hospitals that reported using an EHR. The findings suggest that EHRs mitigate quality issues associated with high-DSH facilities.

Implications for Health Policy
The American Recovery and Reinvestment Act (ARRA) authorized up to $45 billion, in the form of financial incentives via Medicare and Medicaid, to promote adoption of EHRs by providers. ARRA specifically requires the Office of the National Coordinator for Health Information Technology to assure that the uninsured and other underserved populations benefit from this largesse.

ARRA’s Medicare provisions are crucial for all hospitals, but disproportionate share hospitals will rely more heavily on Medicaid incentives.

Medicaid incentives under ARRA can be used to finance EHR acquisition and implementation costs, in addition to rewarding “meaningful use” of EHRs—which are the sole focus of Medicare incentives—but there is a catch.

Cash-strapped states must pay a healthy chunk of the administrative costs associated with Medicaid-driven EHR adoption programs, and they can opt out of this requirement. If they do, disproportionate share hospitals will likely fall further behind on EHR adoption.

Current Federal financial incentives to adopt EHRs, “will not pay for (an) entire system, but (they) will be helpful,” Jha told Modern Healthcare. “Disproportionate-share hospitals…are further behind. They have less implemented systems, they have less access to capital.”

“Before our study came out, policymakers were saying, maybe this won’t be much of a problem,” Jha added.

His data suggests otherwise.

Glenn Laffel MD, PhD
Sr. Vice President, Clinical Affairs, Practice Fusion

Practice Fusion draws from a community of doctors, medical experts, and digital health influencers that contribute to blog posts.

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