The digital divide is alive and well when it comes to health care technology.
Although President Barack Obama has made it a priority to have medical facilities deploy electronic health records (EHR) over the next four years, the people most likely to benefit — those in poor and minority communities — are unlikely to see them anytime soon.
Physicians’ practices and small clinics, where most doctors work, don’t have the money to implement the technology, which can cost tens of thousands of dollars.
In an open letter to IT vendors, David Blumenthal, National Coordinator for Health IT, asked that they do what they can to improve health care for low-income and minority communities to prevent health disparities caused by a “digital divide.”
EHRs, which can help ensure that medical best practices are followed and aid in tracking illnesses by geographic regions, can mean the difference between life and death.
“It is absolutely necessary that the leading EHR vendors work together, continuing to provide EHR adoption opportunities for physicians and other health care providers working within underserved communities of color,” Blumenthal wrote. “Despite our best efforts, data from the National Ambulatory Medical Care Survey indicates that EHR adoption rates remain lower among providers serving Hispanic or Latino patients who are uninsured or relied upon Medicaid.”
EHR adoption rates among health facilities that offer care to uninsured African-Americans are lower than they are among providers of care to privately insured white patients, Blumenthal said in his letter. At the same time, racial and ethnic minorities remain disproportionately affected by chronic illnesses, a contributing factor to high mortality and morbidity rates.
Ruth Perot, managing director of the National Health IT Collaborative for the Underserved, said there is surprisingly little data on the overall adoption of EHRs by health care facilities. But recent statistics show that only about 8% of community-based health clinics are using the technology.
“Among health providers in underserved communities, the percentages are considerably lower,” she said. “African-American and Latino consumers are much less likely to be served by a physician with an EHR.”
Cost is a barrier
Perot said the biggest barrier is cost. Most of the clinics in underprivileged areas serve patients who rely on Medicaid and Medicare for health insurance, so the providers have less money to install EHRs, hire IT specialists or train staff to maintain the systems.
“This is a transformation of your practice. We’re talking about moving from paper to electronic records. That doesn’t happen overnight. Many of these providers simply can’t afford the downtime required,” Perot said.
Another barrier to adoption is education. Health care practices in rural or underserved communities don’t always have information about what EHRs are available, how to migrate to them and what needs to be done in preparation for that, Perot said.
Even at larger hospitals, where EHR costs can quickly rise into the millions of dollars, adoption rates remain relatively low.
Overall, only 20% of physicians and 10% of hospitals use even the most basic EHR technology, according to the U.S. Department of Health and Human Resources (HHS). The HHS Centers for Medicare and Medicaid Services, which created the so-called meaningful-use rules for EHRs, estimates that between 66% to 92% of hospitals and between 21% and 53% of private practices will implement EHRs by 2015, the deadline for receiving reimbursements from the federal government to defray the cost of EHR deployments. But the HHS doesn’t break those numbers down by demographics.
For physicians and hospitals that do roll out EHRs and prove that they are engaged in “meaningful use” of the systems, billions of dollars in reimbursements are available over the next decade. But they must pay upfront for the systems before receiving the reimbursements.
EHRs improve health care
Electronic records not only allow general practitioners and specialists to document and easily share patient information; they also help support “evidence-based” medicine. That allows physicians to treat patients using best practices derived from the systematic, scientific study of standard treatments. For example, it’s been known for years that patients should be prescribed aspirin after a heart attack, but there is currently no way to make sure that happens.
A sepsis alert system that Methodist North Hospital (MNH) implemented more than two years ago in conjunction with its EHR database has helped save as many as 4,000 lives. The Memphis hospital’s EHR system alerts doctors and nurses to patients suffering from sepsis, an often deadly infection that can be difficult to diagnose in its early stages. The hospital’s system includes three adult-care facilities that also use the sepsis alert system.
Paula Jacobs, director of quality and performance improvement at MNH, said the early detection technology has reduced sepsis deaths by 17% year over year, or by about six patients every month at the 280-bed facility.
“You’re talking about having access to up-to-date protocols so that the right procedures are followed. The other thing is informing the consumer [through access to personal health records and electronic alerts] so that he or she knows what’s being done so they can ask more questions and more likely follow the right treatment regimen,” Perot said.
By 2014, the federal government wants more than half of all health care facilities to use EHRs. Physicians who implement EHR systems can get as much as $44,000 to help defray technology costs; a typical 275-bed hospital would be eligible for approximately $6 million. But clinicians and facilities must show they’re using EHRs in a meaningful way beginning in the government’s 2012 fiscal year in order to qualify for a full incentive payment. Hospitals that do not meet federal guidelines by 2015 face Medicare reimbursement cuts.
EHR systems would also improve the lives of physicians by allowing them to access and share patient records, including radiological images, from remote locations and through mobile devices. EHRs would also free them up from administrative tasks.
“It’s complicated, but at the same time we feel so strongly that our communities benefit from this technology, and that’s why we’re pushing so hard,” Perot said.
The federal government would also be able to better track who has health insurance to get a better view of what’s needed in terms of federal supplemental medical coverage under the Affordable Care Act, which took effect last month.
Perhaps most important, by mining data from EHRs, the government and physician groups can more quickly and accurately pinpoint health issues associated with poor and minority populations — as well as the treatments that are most effective, according to Craig Le Clair, an analyst at Forrester Research.
The SaaS option
Le Clair said that he believes a software-as-a-service (SaaS) EHR model would be the most cost-effective and least complicated deployment for medical practices, clinics and hospitals unable to afford in-house IT equipment. He said government efforts to spur adoption in rural and underprivileged areas should focus on funding SaaS-based deployments.
“They tend to have no IT infrastructure. They tend to be undercapitalized. They tend to not have the percentage of insurance-based patients, the so-called ‘Cadillac plans,'” Le Clair said. “Basically, they’re dealing with the 38 [million] to 40 million of uninsured Americans.”
Under a SaaS model, EHR applications such as physician-order-entry systems are hosted on servers in a vendor facility and hospitals would access those systems through a secure Internet portal or via a virtual private network. That way, the health care facility would not need to deploy hardware and software in its data center or hire the IT staffers needed to support and maintain an EHR system.
Le Clair said that even large, highly-profitable hospitals today are struggling with EHR adoption because they face other challenges. For example, health care facilities face a 2013 deadline to implement the ICD-10 standard, a diagnostic coding system used for insurance processing and reimbursement and gathering statistical data.
“My solution is to take the SaaS offerings coming to market, many of which are from start-up companies that need help, and select a few of those and invest in them so they can have lower-cost services for these areas,” he said. “That’s short money for the efficiency that will accrue to the administrative costs.”
Among the EHR service providers Le Clair cited are large companies like Allscripts, with its EMR Workforce offering; McKesson, which has a system called Horizon Practice Plus; and Sage, which offers Intergy OnDemand. He also cited smaller companies like eClinicalWorks and Greenway Medical Technologies.
Prices vary by vendor, but basic SaaS-based EHR offerings — hosted by the vendor in a data center — cost around $350 a month.
Federal help for EHRs
HHS has spent $62 million on the creation of 62 regional extension centers (REC) throughout the country. Their mission is to help rural medical facilities roll out EHRs.
The federal government also issued $144 million in grants to create college courses to train people and help fill an estimated 50,000 jobs needed to assist doctors and hospitals as they roll out EHRs. However, none of the government money covers the cost of EHR hardware and software — the most basic costs associated with health IT.
Dr. Garth Graham, deputy assistant secretary for Minority Health in the Office of Minority Health at HHS, said the government is looking at “a number of different models” for improving infrastructure at community health centers. For one, HHS formed the National Health Information Technology Collaborative for the Underserved, which aims to help rural and nonprofit facilities figure out how to deploy EHRs.
But Graham said his office is just now getting “abreast of the landscape” and investigating different models for deploying EHRs.
“There’s no simplifying it,” Graham said. “There are certainly a number of challenges, from cost to physician behavior and doctors’ attitudes toward EHRs.
“You’ve got to reach folks and educate them in terms of the different strategies they can move forward,” he added. “It’s not going to be easy. Certainly we know that providers who take care of rural and underserved community face many challenges.”
Lucas Mearian covers storage, disaster recovery and business continuity, financial services infrastructure and health care IT for Computerworld. Follow Lucas on Twitter at @lucasmearian, or subscribe to Lucas’s RSS feed . His e-mail address is email@example.com.