Across the Great Divide
Does a "digital divide" separating health IT "haves" and "have-nots" threaten potential improvements in healthcare delivery and outcomes among minority communities in the United States? The answer is: it's too early to tell, but few organizations are going out of their way to ensure minority and majority communities become equally wired for electronic health record systems.
The term digital divide refers to disparities in the adoption of information and communications technologies generally" and broadband Internet connections specifically"among racial and ethnic groups. Surveys show that whites have adopted broadband in greater proportions than blacks and Hispanics across various geographic and economic categories.
A Department of Commerce study indicates that 69 percent of white households make use of broadband Internet access while less than 50 percent of Hispanic and black households do the same. (See sidebar.)
This digital divide is also reflected in lower adoption rates of health IT among providers that serve minority populations. Complicating the picture is that minority populations tend to be underserved by the healthcare system generally, are disproportionately affected by chronic illnesses, and suffer higher mortality and morbidity rates than the general population.
"Historically, there has been a proportional lack of access to healthcare among minority communities," said Garth Graham, the deputy assistant secretary for minority health at the Department of Health & Human Services. "Many healthcare providers in minority communities are practicing in a challenging environment predating the implementation of electronic health records. That limits what they are able to invest in healthcare technologies."
Graham, along with ONC head Dr. David Blumenthal, recently jumped on the digital divide problem, focusing on the role private industry might play in helping repair the inequity. In an online "letter to the vendor community," they urged suppliers of electronic health record systems to step up to the plate to help right the demographic disparities.
"EHR adoption rates remain lower among providers serving" Hispanic and black patients than those serving whites, Blumenthal and Graham said. "Electronic health records possess the ability to help improve both the quality and efficiency of medical care accessible by minorities, so that perhaps rates of chronic illness, mortality and morbidity decrease within these communities."
While the two acknowledged a federal role in addressing the problem, they also argued that "it is absolutely necessary that the leading EHR vendors work together, continuing to provide EHR adoption opportunities for physicians and other healthcare providers working within underserved communities of color."
The Graham-Blumenthal letter raises a number of issues about the relationship between minority healthcare and health IT.
One is their assertion that the introduction of health IT could improve the quality of healthcare among minority communities. Although the research is sparse, there is evidence to back the claim. A 2009 paper prepared for HHS argued that, "many of the most promising potential improvements in care due to health IT adoption"¦could be of benefit to the underserved," and provided examples of that phenomenon. (See sidebar.)
Another is the letter's emphasis on the role commercial EHR vendors could play to impact the digital divide. Community advocates agree that calling out EHR vendors was the right thing to do, suggesting that they are ignoring disadvantaged neighborhoods.
"At the end of the day, they are always going to pick the bigger and more affluent practices," said Jose Marquez, the president of LISTA, the Latinos in Information Science and Technology Association.
EHR vendors deny that they ignore minority communities. But Marquez also faults a federal approach that, he says, has not done enough to help these communities adopt healthcare technologies. Lost in this discussion is the low adoption rate among providers. A 2009 HHS paper estimated rates of adoption of between 4 percent and 17 percent among physician's practices nationally.
Minority communities suffer from a lack of doctors and nurses to provide healthcare services, the lack of technologists to help set-up EHRs, and the lack of a federal focus on the digital divide, according to Marquez.
"A large percentage of doctors in minority communities deal with Medicare and Medicaid patients," he said. "Penalizing those doctors for failure to use EHRs would make marginal practices that much more difficult to sustain." He is referring to regulations issued by HHS under which providers will suffer reductions in their Medicare and Medicaid payment rates if they fail to make meaningful use of EHRs by 2015. Marquez is concerned that clinics in minority communities might close when faced with the expense of implementing EHRs.
HHS's Office of Minority Health, which Graham heads, has as its mission to, "make sure federal policies and programs take into account the disadvantaged." Yet Marquez said that only two of HHS's regional extension centers" funded under the HITECH Act to support healthcare providers' efforts to become meaningful users"serve minority communities, one in Puerto Rico and one in Atlanta.
Further, he claims, "there are no Spanish speakers at the REC in New York City."
Blumenthal and Graham's approach was designed, "to make sure vendors are part of the solution," said Graham. "We want them to be providing outreach and marketing efforts to folks who care for underserved populations. This is part of the government's strategy and we want it to be part of the vendors' strategies as well."
The core of the government's strategy, Graham said, involves convening educational forums that introduce minority community providers to the benefits of EHRs and emphasizing potential incentive payments for meaningful use of the systems. LISTA also independently runs EHR educational programs in minority communities for providers.
Marquez is gratified that concerns about EHR vendor business strategies are being aired publicly. "Companies look at the bigger picture," he said. "If a company has the opportunity to serve a 25-physician practice in Beverly Hills or a three-man clinic in East L.A., where are they going to go?"
EHR vendors deny that they ignore underserved populations. They say they build software to suit specific needs, provide multilingual materials and ease payment terms when warranted. "We work with a number of organizations that serve minority populations," said Nick Cincotta, an executive with Epic, a leading developer of medical systems and electronic records software, including four federally qualified health centers (FQHC) established to provide primary care to underserved urban and rural communities.
Cincotta also cited Epic's work with OCHIN, a non-profit collaborative headquartered in Portland, Ore., that provides integrated health IT software and services to community health clinics, mental health services and small practices serving the medically underserved.
Epic's software was developed to meet special needs of each of these organizations, Cincotta added, by building in special billing and reporting systems and providing Spanish language menus for MyChart, Epic's patient portal. Epic also delivers educational material in multiple languages.
"On the inpatient side, we work with several safety net hospitals," said Cincotta, which provide care to low-income and uninsured patients.
Siemens Healthcare, another health IT industry giant, also said it was not skirting business with providers in disadvantaged communities. "We are not avoiding low-income areas and I would be surprised if that were the case," said