A decade post-HITECH: Critical access hospitals have electronic health records but struggle to keep up with other advanced functions

Abstract

Objective: Despite broad electronic health record (EHR) adoption in U.S. hospitals, there is concern that an "advanced use" digital divide exists between critical access hospitals (CAHs) and non-CAHs. We measured EHR adoption and advanced use over time to analyzed changes in the divide.

Materials and methods: We used 2008 to 2018 American Hospital Association Information Technology survey data to update national EHR adoption statistics. We stratified EHR adoption by CAH status and measured advanced use for both patient engagement (PE) and clinical data analytics (CDA) domains. We used a linear probability regression for each domain with year-CAH interactions to measure temporal changes in the relationship between CAH status and advanced use.

Results: In 2018, 98.3% of hospitals had adopted EHRs; there were no differences by CAH status. A total of 58.7% and 55.6% of hospitals adopted advanced PE and CDA functions, respectively. In both domains, CAHs were less likely to be advanced users: 46.6% demonstrated advanced use for PE and 32.0% for CDA. Since 2015, the advanced use divide has persisted for PE and widened for CDA.

Discussion: EHR adoption among hospitals is essentially ubiquitous; however, CAHs still lag behind in advanced use functions critical to improving care quality. This may be rooted in different advanced use needs among CAH patients and lack of access to technical expertise.

Conclusions: The advanced use divide prevents CAH patients from benefitting from a fully digitized healthcare system. To close the widening gap in CDA, policymakers should consider partnering with vendors to develop implementation guides and standards for functions like dashboards and high-risk patient identification algorithms to better support CAH adoption.

Keywords: EHR adoption; critical access hospitals; data analytics; digital divide; hospitals.

Figure 1.

Electronic health record (EHR) adoption and advanced EHR functions by critical access status. Plots show adoption of EHRs, patient engagement functions, and clinical data analytics functions over time for critical access hospitals and noncritical access hospitals. The differences between these lines are plotted in Figure 2. Data Source: Authors’ analysis of the American Hospital Association Annual Survey IT Supplement.

Figure 2.

Gap between critical access hospital (CAH) and non-CAH electronic health record (EHR) and advanced functionality adoption over time. The plot shows the difference between CAH and non-CAH adoption rates of EHRs (gray), patient engagement functions (blue), and clinical data analytics functions (orange) over time. Stars indicate statistical significance of adoption gap between CAHs and non-CAHs from 2-sided t tests with unequal variances. *P < .05; **P < .01; ***P < .001. Data Source: Authors’ analysis of the American Hospital Association Annual Survey IT Supplement.

Figure 3.

Patient engagement functions adoption, critical access hospitals (CAHs) and non-CAHs in 2018. The plot shows the difference between CAH (orange) and non-CAH (blue) adoption rates of individual patient engagement functions as of 2018. Stars indicate statistical significance of adoption gap between CAHs and non-CAHs from chi-square tests. Rates of adoption for CAHs and non-CAHs are reported in Supplementary Table 4. *P < .05; **P < .01; ***P < .001. Data Source: Authors’ analysis of the American Hospital Association Annual Survey IT Supplement. EHR: electronic health record.

Figure 4.

Clinical data analytics functions adoption, critical access hospitals (CAHs) and non-CAHs in 2018. The plot shows the difference between CAH (orange) and non-CAH (blue) adoption rates of individual clinical data analytics functions as of 2018. Stars indicate statistical significance of adoption gap between CAHs and non-CAHs from chi-square tests. Rates of adoption for CAHs and non-CAHs are reported in Supplementary Table 4. *P < .05; **P < .01; ***P < .001. Data Source: Authors’ analysis of the American Hospital Association Annual Survey IT Supplement.