Will HITECH exacerbate differences in quality and outcomes?

 In an open letter to the vendor community National Coordinator for Health IT Dr. David Blumenthal appealed for assistance in overcoming the digital divide, asking health IT vendors to "include providers who serve minority communities in their sales and marketing efforts".

"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. 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. Moreover, this data also identifies that EHR adoption rates among providers of uninsured non-Hispanic Black patients are lower than for providers of privately insured non-Hispanic White patients."

Blumenthal's letter goes on to acknowledge the critical roles played by the administration and REC's in addition to the IT vendors to "work together and focus substantial efforts on these priority populations."

Properly applied, electronic health records will raise the quality of care and outcomes wherever they are deployed.  However, will EHR's, unequally deployed, heighten the appalling differences in care quality and outcomes that exist today among races and regions in the U.S.?

To address this question, its helpful to understand these baseline differences.  The Dartmouth Atlas Project has released its Primary Care Report, examining disparities in health care quality and outcomes.

The report found that primary care access and the probability of hospitalization varied dramatically by region and race. "Although blacks were as little as half as likely to see a primary care clinician and up to 84% more likely to be hospitalized than whites within areas, these racial disparities were less pronounced than the differences across locations...

"Blacks had much higher rates of leg amputation, a grave consequence of poorly controlled diabetes and peripheral vascular disease. Amputation rates were 4.7 times greater in blacks than in whites nationally during the study period from 2003 to 2007. Among U.S. hospital referral regions (HRRs), rates of amputation for all Medicare beneficiaries differed by a factor of 10, an extraordinary degree. In a closer look at the 44 hospital service areas (HSAs) within a single HRR, Atlanta, Georgia, there was almost a fourfold variation in leg amputation rates."

For evidence-based, recommended services, such as appropriate testing for diabetes and mammography, variations across the nation’s HRRs were substantially greater than the disparities by race within a given region. We found similar results across the smaller HSAs, and we demonstrate this with data from the HSAs within the Atlanta, Georgia HRR. In other words, where patients live has a greater influence on the care they receive than the color of their skin. Indeed, in a few locations, blacks received equal or better care than did whites, but care for all patients was less than ideal."

To address these disparities, The Dartmouth Atlas Project properly highlighted the need for focus on the "full spectrum of health determinants, ranging from lower levels of schooling and limited health literacy, to inadequate housing and lack of transportation, as well as lack of access to high-quality primary care that is well-coordinated with specialty care."

Implications for Meaningful Use

Meaningful use will raise the level of provider capability to proactively manage the health of patient populations.  There's the real possibility that Stage 1 Meaningful Use can uplift the level of care and outcomes for millions, giving  providers systematic visibility to quality measures that matter for better managing chronic conditions that drive 75% of the national health care costs.  This can, over time reduce the number of amputations as an example.

Perhaps it will be Health Information Technology combined with health-care-reform-fueled accountable care organizations that will finally overcome some of the intractable problems of care coordination that Dartmouth Atlas suggests may be behind these stats.

Even as HITECH raises the potential for better health outcomes nationally, might it also cause increasing disparities at the same time?

There are signs that smaller physicians are now starting to invest in EHR's in larger numbers.  This will be a great equalizer to be sure, as primary care practices are enabled with the tools that heretofore have been thought to be beyond the reach of most small practices.  Other equalizers include the special incentives for rural providers and federally qualified health centers.  David Blumenthal's efforts to focus all parties on underserved populations should be lauded and supported.

There is reason for concern.  Meaningful use is incentive-based and voluntary.  So while meaningful use will raise the levels where it's applied, might that investment occur unequally?  Might the regions that are already achieving better health outcomes be the ones most likely to become meaningful users of EHR's?  Will supplemental hospital (Stark relaxation) incentives be unequally and similarly applied by area?  Might this actually exacerbate the differences in care and outcomes across regions and races?