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Digital Divide Threatens Health Care

Jan 11, 2011

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Two years ago, the Ethio American Health Center opened its doors in the nation's capital, promising the country's largest community of Ethiopian immigrants a place where doctors spoke their language and understood their culture.

Many of the community's poorest quickly flocked to the center. But for all the specialized services the center offers patients, there's one area where it's fallen short: moving from paper files to electronic health records. They don't even have a website.

"It would be great, but we can't afford it," said Dawit Gizaw, the center's administrator.

The center is not alone. Although the federal government is directing billions of dollars in economic stimulus money to get electronic health record technology into hospitals and clinics nationwide, some doctors and small clinics indicate they're unlikely to meet the Obama administration's goal of going digital in the next five years.

That possibility is raising concern among health care specialists both inside and outside the federal government, who worry that the benefit of the technology may disproportionately fall to top health care facilities, potentially increasing the so-called digital divide — and as a result, health disparities between rich and poor and between different races.

Electronic medical record systems not only give doctors digital access to a patient's medical history but can allow them to check what medications and treatment best fit the patient. Many people believe that electronic medical records will help improve the quality of health care by giving doctors more detailed data on their patients wherever they seek care, and by allowing those physicians to better analyze data to understand what treatments work.

"On the one hand the potential for IT [information technology] helping is enormous," said Ruth Perot, head of the National Health IT Collaborative for the Underserved, a nonprofit public-private partnership focusing on using this technology to reduce health disparities. "The flip side is, if it's available in communities that are doing better than others, and communities of color aren’t getting access, it doesn't take a rocket scientist to see that gaps are going to increase."

The biggest problem: cost. Although the federal government is offering individual doctors approximately $44,000 apiece in economic stimulus money for using electronic health records to improve patient care, many doctors in small practices say that amount won't cover the purchase costs of the necessary equipment — and even if it did, they do not have the cash to pay for the systems up front.

The Ethio American Health Center, above, cannot afford to purchase electronic medical record systems, which the Obama administration is encouraging doctors to use. The $44,000 payments were pledged as part of the massive economic stimulus legislation passed a month after President Obama took office. That bill allocated more than $27 billion to help doctors and hospitals who have purchased electronic health record systems. The money will be paid out over several years as doctors meet government benchmarks for demonstrating that the technology is improving patient care. Little of the money has yet been given out.

There's no single figure for the use of electronic medical records among low-income providers, but several surveys suggest that fewer than the national average have gone digital. For instance, a survey of 2,368 hospitals published in Health Affairs in October 2009 found that, though overall adoption of digital systems wasn't high, those serving a greater proportion of low-income patients were even less likely to adopt electronic medical records — and that those without digital systems tended to have an inferior quality of care.

The National Association for Community Health Centers, which serves about one in three low-income patients, appears the most advanced technologically, with about 30 percent of its clinics using some sort of digital system, higher than the national average.

Still, many low-income patients go to doctors in small, one- or two-doctor clinics, like the Ethio American Health Center. A December report by the President's Council of Advisors on Science and Technology found that such clinics often "lack even rudimentary digital records."

As it is, the Ethio American facility draws most of its patients from Medicaid, which reimburses doctors at rates less than many private insurers. With that sort of business model, the center can barely cover rent and its two part-time doctors on an annual budget of $400,000, the administrator Gizaw said.

The problem has not gone unnoticed. This fall, the federal government's e-health czar, David Blumenthal, publicly encouraged the industry to do more to ensure "we are not creating a new form of 'digital divide,'" urging digital medical records vendors to market their products more to lower income and minority doctors. In response, several companies are now creating loan and financing programs, government officials said.

To that end, the federal government has also doled out nearly $300 million in additional stimulus money to hospitals and clinics serving low-income patients to purchase electronic health record systems. It has established 62 outreach centers across the country, including one in Washington, D.C., to aid smaller medical practices in figuring out how to go digital. And a spokesperson for Blumenthal's office, the Department of Health and Human Services' Office of the National Coordinator for Health Information Technology, said officials are also working closely with HHS's Office of Minority Health to develop a "comprehensive strategy" for getting more low-income and minority doctors to go digital.

HHS spokesperson Nancy Szemraj acknowledged in a written response to questions that there are "critical issues that impede adoption of health IT" among low-income providers. Still, she said, HHS believes that the "use of health information technology will play a critical role in eliminating health disparities," and is "confident" that will happen.

Whether these efforts will be enough to lessen disparities in care remains uncertain. Research shows that poor health has a strong correlation with lower income levels, but even within similar economic brackets, minorities still receive worse care and have higher rates of most chronic diseases than whites, according to the 2009 report on health care disparities by the HHS Agency for Healthcare Research and Quality.

Health care researchers say that no single effort will eliminate the disparities between different classes and different races. Certainly, increasing peoples’ access to health care may go a long way — and many are betting health care reform will help address these disparities.

But some also believe that electronic health record technology can help improve care for the poorest. The reason? Studies show that many uninsured and minority patients routinely receive poorer care, in part because they often bounce between hospitals and clinics. They also have higher rates of chronic illnesses like diabetes and hypertension, conditions that some research has shown digital technology can help address. Government officials hope that having electronic data will allow health care providers to access those patients' information at any location — and to figure out who needs care and intervene.

If electronic health records are broadly adopted, "that really is going to be transformative because … we'll have a much better understanding of the health experiences of a much broader group of Americans," said Adolph Falcón, senior vice president of the National Alliance for Hispanic Health, an advocacy group.

Dawit Gizaw helped start the Ethio American Health Center in Washington, D.C., to provide the Ethiopian immigrant community with doctors who understood their language and culture. Research showing that this digital technology reduces disparities in health care is still quite limited. Most researchers point to anecdotal examples of clinics serving low-income patients, where the rates of vaccinations and patients whose chronic illnesses are medically controlled have gone up since the clinics went digital.

One such example is the Open Door Family Medical Centers. The low-income clinic operation, which has several locations in Westchester County, N.Y., began installing an electronic health record system in 2007, before the federal government put out any money to help low-income clinics. The center had begun saving for a system years before and was lucky enough to get a grant from its nonprofit health insurer to cover much of the approximate $1.2 million cost.

Now, at the Westchester clinics, a specialist mines patient data to figure out who is due for checkups and screenings — and then clinic staff reach out to those patients, who might otherwise have failed to come in to the doctor.

Because of these efforts, the clinic has seen a jump from 41 percent to 65 percent in the proportion of its 2,200 patients with hypertension who have stabilized their blood pressure in the last two years. It has also seen strides among its 1,200 diabetic patients—the percentage whose conditions were medically controlled rose from 36 percent to 47 percent.

"The role that technology plays is just giving you a much better hold on your patients so patients aren’t falling through the cracks," said Lindsey Farrell, president of the Open Door centers.

There's also a hope that new electronic data may help the medical profession better understand how diseases impact minority communities.

For instance, at Morehouse School of Medicine in Atlanta, researchers are starting to pull together data on African-Americans, culled from electronic medical records in the South. The goal: to analyze causes and rates of hypertension, a chronic condition found more prominently among blacks. Because the data draws from blacks of all socio-economic conditions, researchers hope to track whether there are significant differences in the severity and treatment of hypertension within the black community. Researchers will also be surveying patients and getting biological specimens to trace how much of the problem is genetic.

"The hope is, of course, that this then puts us in a position to address the issues that affect these communities," said Gary Gibbons, lead researcher on the project.

But getting that kind of data from across the country is hardly certain. Though federal aid per patient to community health centers has increased slightly over the past decade, many low-income clinics have faced other cutbacks because of cash-strapped state budgets. The National Association for Community Health Centers said that health centers have seen an average 20 percent decline in state funding for 2011, a five-year low. Some specific allocations for electronic health records have been cut too, such as in New York state, where a $2.7 million fund recently got slashed.

What's more, the association said, centers' reimbursements for seeing patients, the largest chunk of their budgets, have dropped as the number of uninsured patients they see has gone up. For instance, between 2008 and 2009, the centers saw a 21 percent increase in the number of uninsured patients.

Some have called for more funds to reach lower income physicians, including the President's Council of Advisors on Science and Technology. In a December report the council also urged the government to create companies through the Small Business Administration to aid these doctors in going digital.

Money is not the only factor slowing down the adoption of digital records. Marcia Thomas-Brown, who works with the National Health IT Collaborative for the Underserved, said many minority groups are more skeptical of government efforts and need more outreach to be convinced of the program's benefits.

"Providers in certain communities of color need to have trust to begin a conversation in most issues, but specifically EHRs [electronic health records]," she said. "You're comfortable with what looks like you and feels like you."

To bridge that gap, the collaborative has launched government-funded pilot programs with three regional outreach centers to target doctors in minority communities, making the extra effort to explain how the technology might help.

"We didn’t think providers in those communities were going to adopt because they receive a brochure from ONC [the Office of the National Coordinator] that says so," Thomas-Brown said.

Instead, the collaborative is working with community activists to go out to doctors "so we can deliver the message and cultural nuances that the community respects and trusts," she said.

Yet, said David Adamson, director of a low-income health clinic in Colorado, Mountain Family Health Center, the focus on technology may overshadow other means of tackling health disparities. Though his clinic has gone digital and seen improvements similar to the Westchester centers, he's seen cuts in other programs he believes have made a difference in reducing health disparities in his community.

One of those has been run by the center's outreach worker Sharla Gallegos. For the past three years, she has stood outside pharmacies, shopping malls, gas stations — anywhere they will let her — to test peoples' blood sugars and cholesterol. Most of the more than 5,000 people she's checked are uninsured, and many learn for the first time they have hypertension or diabetes. "It makes a difference to put money in prevention than waiting until people get sick," she said.

But the state funding for the program has been cut back so much that they've dropped the number of people they can test by more than 60 percent. Now, Adamson, the director, is uncertain how much longer they can keep funding it.

"Everything's a tradeoff. In some instances you always wonder would we be better off taking all the money that goes into technology, if right across the street we put in a wellness center that did exercise and training?" Adamson said. "In the long run that might be more effective. We'll never know."

At the Ethio American Health Center, Gizaw would still like to have an electronic health system so he can better connect and coordinate the clinic's patients to other hospitals and specialists they may need to see. He even had a company show his staff a demo last year, but hasn't been able to raise any funds or secure grants to cover up front costs.

What that means for patients like Mokonnen Jimma is that he still has to cart records back and forth between the clinic and hospital. Jimma, 47, moved to the United States ten months ago from his native Ethiopia, leaving behind a wife and five children. "I came to this country and I was hoping just to work and help my family," he said through a translator.

Just three months later, he found himself unusually tired, with intense back pain and unable to walk even short distances. That's how he ended up at the Ethio American Health Center, where he was diagnosed with hepatitis B.

To get treatment, he's had to go to the local hospital with an interpreter, bringing along paper copies of his record.

But when he can, he prefers coming to the center, where he can navigate the system on his own. "The doctor understands my language and my culture," he said.

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