Meaningful Use Attestations among US Hospitals: The Growing Rural-Urban Divide

摘要

The purpose of this study was to assess EHR Incentive Program attestations of eligible US hospitals across geography and hospital type. The proportions of attestations were compared between metropolitan, micropolitan, and rural hospitals and by whether a hospital was critical access or prospective payment system. From 2011 until December 2013, rural and critical access hospitals were attesting to meaningful use and receiving federal incentive payments at a significantly lower proportion than their urban counterparts. The data suggest that the digital divide between urban and rural hospitals that are adopting electronic health records and using the technology effectively is widening. These findings illustrate that the needs of rural hospitals currently and into the future are different than urban hospitals, and the meaningful use program does not appear to provide the resources needed to propel these rural hospitals forward. Keywords: Meaningful use, critical access hospitals, rural, urbanIntroductionElectronic health records (EHRs) are touted to have the ability to improve the quality of healthcare and reduce its cost. Recent studies have demonstrated the potential for EHRs to improve caregiver decisions and patient outcomes.~(~(1)) Given the potential benefits of health information technology (IT) adoption and use, EHR proponents passed the Health Information Technology for Economic and Clinical Health (HITECH) Act to address the obstacles to the adoption of EHRs. The barriers to EHR adoption include “substantial cost, the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about the privacy and security of electronic health information.”~(~(2)) Additionally, there are cultural and organizational barriers to EHR adoption.~(~(3),~(4)) Prior to the adoption of the HITECH Act, there was low adoption of EHRs among office-based physicians and hospitals. In 2009, between 17 and 22 percent of office-based physicians had adopted EHRs.~(~(5),~(6)) Similarly, hospitals had an adoption rate between 9 and 10 percent.~(~(7),~(8))BackgroundThe HITECH Act incentivizes providers and hospitals to adopt EHRs. Enacted under the HITECH Act is the EHR Incentive Program. Monetary incentives are provided to providers and hospitals that are able to demonstrate that they use certified EHRs to complete specific functional and process-related objectives, also known as “meaningful use.” The program does not increase the reimbursement rates from payers, but rather provides an incentive payment based on overall Medicare and/or Medicaid claims. This program has two components. The first component of the program provides Medicaid-only financial incentives to hospitals and eligible professionals for adopting, implementing, or upgrading (AIU) their EHR software, that is, for providers and hospitals not yet able to demonstrate the functional and process requirements of the meaningful use program. The second component provides Medicare and/or Medicaid financial incentive payments to eligible professionals and hospitals for effectively using certified EHR technology. Eligible hospitals are able to receive both Medicare and Medicaid payments, while eligible professionals must choose either Medicare or Medicaid as their source of payment. The program has a total investment of more than $27 billion dollars over a decade.~(~(9)) The program includes specific standards, implementation specifications, and EHR certification criteria.~(~(10))The EHR Incentive Program has drastically affected the adoption of EHRs among hospitals. As of March 2014, a total of 347,230 payments have been made to Medicare/Medicaid eligible professionals, and 4,477 payments have been made to eligible hospitals. These payments have resulted in a total of $20,937,048,827 in incentive payments for meaningful use of EHRs.~(~(11))Not only has the overall rate of EHR adoption increased as a result of the EHR Incentive Program, but the sophistication of the adopted technology has increased as well. Between 2008 and 2012, the adoption of basic EHRs increased from 9.4 to 44.4 percent among nonfederal acute care hospitals. Moreover, the adoption of comprehensive EHRs increased from 1.6 to 16.9 percent in the same period.~(~(12))While adoption of EHRs has increased significantly since 2009, there have been concerns that hospitals and providers in urban areas are achieving meaningful use at disproportionately higher rates than their nonurban counterparts. The gaps in adoption of EHRs based on size, location, and teaching status may leave hospitals at risk of penalties in 2015.~(~(11),~(14)) Prior to the launch of the EHR Incentive Program, the American Hospital Association reported that 66 percent of critical access hospitals (CAHs) and 56 percent of rural hospitals did not expect to meet meaningful use standards.~(~(15)) According to one study,