Association of hospital and market characteristics with 30-day readmission rates from 2009 to 2015.

Objectives: The US government implemented the Hospital Readmission Reduction Program on 1 October 2012 to reduce readmission rates through financial penalties to hospitals with excessive readmissions. We conducted a pooled cross-sectional analysis of US hospitals from 2009 to 2015 to determine the association of the Hospital Readmission Reduction Program with 30-day readmissions. Methods: We utilized multivariable linear regression with year and state fixed effects. The model was adjusted for hospital and market characteristics lagged by 1 year. Interaction effects of hospital and market characteristics with the Hospital Readmission Reduction Program indicator variable was also included to assess whether associations of Hospital Readmission Reduction Program with 30-day readmissions differed by these characteristics. Results: In multivariable adjusted analysis, the main effect of the Hospital Readmission Reduction Program was a 3.80 percentage point (p < 0.001) decrease in readmission rates in 2013-2015 relative to 2009-2012. Hospitals with lower readmission rates overall included not-for-profit and government hospitals, medium and large hospitals, those in markets with a larger percentage of Hispanic residents, and population 65 years and older. Higher hospital readmission rates were observed among those with higher licensed practical nurse staffing ratio, larger Medicare and Medicaid share, and less competition. Statistically significant interaction effects between hospital/market characteristics and the Hospital Readmission Reduction Program on the outcome of 30-day readmission rates were present. Teaching hospitals, rural hospitals, and hospitals in markets with a higher percentage of residents who were Black experienced larger decreases in readmission rates. Hospitals with larger registered nurse staffing ratios and in markets with higher uninsured rate and percentage of residents with a high school education or greater experienced smaller decreases in readmission rates. Conclusion: Findings of the current study support the effectiveness of the Hospital Readmission Reduction Program but also point to the need to consider the ability of hospitals to respond to penalties and incentives based on their characteristics during policy development.

International and Interprofessional Collaboration: An Innovative Week of Learning Across Three Professions, Three Universities, and One Ocean.

ABSTRACT: As the COVID-19 pandemic prevented planned international travel opportunities for students and faculty, faculty at three universities from three professions created a four-day innovative, online learning experience. Each session included presentations from each country, small-group discussions, and evaluation. The topics appealed to students regardless of profession or nationality. Daily evaluations showed attendees valued the experience. The benefits of international and interprofessional learning were evident; students gained better understanding of other professions and health care systems through sessions that expanded their thinking. International appreciation and learning can be prioritized without physical travel.

Examining Medical Office Owners and Clinicians Perceptions on Patient Safety Climate.

OBJECTIVE: An essential element of effective medical practice management is having a shared set of beliefs among members regarding patient safety climate. Recognizing the need for improving patient safety, the Agency for Healthcare Research and Quality began a series of surveys to assess medical practice members' attitudes and beliefs on patient safety climate. The aim of the study was to examine owners and clinicians perceptions of their medical practice's patient safety climate. METHODS: We used the 2010-2011 Medical Office Survey on Patient Safety Culture collected by the Agency for Healthcare Research and Quality. We used hierarchical linear modeling to examine owners' and clinicians' perceptions of practice's patient safety climate while controlling for the nested nature of individuals within practices. RESULTS: Managers with ownership responsibility, clinicians with ownership responsibility, and staff clinicians have different perceptions of the practice's patient safety climate. In particular, managers with ownership responsibility have more positive perceptions of the patient safety climate, as compared with non-owners. Clinicians with ownership responsibility had less favorable views than managers in a similar role. Finally, staff clinicians have the most negative perceptions of patient safety climate as compared with individuals in the ownership positions. CONCLUSIONS: There is a statistically significant lack of agreement among medical office team members depending on their backgrounds and roles. Increasing the communication among organizational members about their practice's patient safety climate is a principal aim whether improvements in care quality are to be achieved.

How Differences Between Manager and Clinician Perceptions of Safety Culture Impact Hospital Processes of Care.

OBJECTIVE: Evidenced-based processes of care improve patient outcomes, yet universal compliance is lacking, and perceptions of the quality of care are highly variable. The purpose of this study is to examine how differences in clinician and management perceptions on teamwork and communication relate to adherence to hospital processes of care. METHODS: Hospitals submitted identifiable data for the 2012 Hospital Survey on Patient Safety Culture and the Centers for Medicare and Medicaid Services' Hospital Compare. The dependent variable was a composite, developed from the scores on adherence to acute myocardial infarction, heart failure, and pneumonia process of care measures. The primary independent variables reflected 4 safety culture domains: communication openness, feedback about errors, teamwork within units, and teamwork between units. We assigned each hospital into one of 4 groups based on agreement between managers and clinicians on each domain. Each hospital was categorized as "high" (above the median) or "low" (below) for clinicians and managers in communication and teamwork. RESULTS: We found a positive relationship between perceived teamwork and communication climate and processes of care measures. If managers and clinicians perceived the communication openness as high, the hospital was more likely to adhere with processes of care. Similarly, if clinicians perceived teamwork across units as high, the hospital was more likely to adhere to processes of care. CONCLUSIONS: Manager and staff perceptions about teamwork and communications impact adherence to processes of care. Policies should recognize the importance of perceptions of both clinicians and managers on teamwork and communication and seek to improve organizational climate and practices. Clinician perceptions of teamwork across units are more closely linked to processes of care, so managers should be cognizant and try to improve their perceptions.

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

PURPOSE: The aim of this study was to explore the relationship between managers and clinicians' agreement on deeming the patient safety climate as high or low and the patients' satisfaction with those organizations. DATA SOURCES/STUDY SETTING: We used two secondary data sets: the Hospital Survey on Patient Safety Culture (2012) and the Hospital Consumer Assessment of Healthcare Providers and Systems (2012). METHODOLOGY/APPROACH: We used ordinary least squares regressions to analyze the relationship between the extent of agreement between managers and clinicians' perceptions of safety climate in relationship to patient satisfaction. The dependent variables were four Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores: communication with nurses, communication with doctors, communication about medicines, and discharge information. The main independent variables were four groups that were formed based on the extent of managers and clinicians' agreement on four patient safety climate domains: communication openness, feedback and communication about errors, teamwork within units, and teamwork across units. FINDINGS: After controlling for hospital and market-level characteristics, we found that patient satisfaction was significantly higher if managers and clinicians reported that patient safety climate is high or if only clinicians perceived the climate as high. Specifically, manager and clinician agreement on high levels of communication openness (ß = 2.25, p = .01; ß = 2.46, p = .05), feedback and communication about errors (ß = 3.0, p = .001; ß = 2.89, p = .01), and teamwork across units (ß = 2.91, p = .001; ß = 3.34, p = .01) was positively and significantly associated with patient satisfaction with discharge information and communication about medication. In addition, more favorable perceptions about patient safety climate by clinicians only yielded similar findings. PRACTICE IMPLICATIONS: Organizations should measure and examine patient safety climate from multiple perspectives and be aware that individuals may have varying opinions about safety climate. Hospitals should encourage multidisciplinary collaboration given that staff perceptions about patient safety climate may be associated with patient satisfaction.

Development and Validation of the Activities of Daily Living Short Form for Community-Dwelling Korean Stroke Survivors.

This study developed and validated a short form (SF) using activities of daily living (ADL) outcome measures from the Korea National Health and Nutrition Examination Survey (KNHANES) that can minimize survey administration burden for clinicians. This study utilized secondary data from the 2005 KNHANES with 422 community-dwelling stroke survivors. The KNHANES data were collected from April to June 2005 in South Korea. We created a 7-item SF from the 17 ADL questions in the survey using item response theory (IRT) methodologies. The precision and validity of the SF were compared to the full questionnaire of ADL items and the EuroQol-5D total score. Among the 17 ADL questions, 14 questions demonstrated unidimensional construct validity. Using IRT methodologies, a set of 7 items were selected from the full bank. The 7-item SF demonstrated good psychometric properties: high correlation with the full bank ( r = .975, p < .001), good internal consistency (Cronbach's α = .93), and a high correlation with the EuroQol-5D total score ( r = .678, p < .001). These findings indicate that a well-developed SF can precisely measure ADL performance capacity for stroke survivors compared to the full item bank, which is expected to reduce the administration burden of the KNHANES.

Social Media Use Among Living Kidney Donors and Recipients: Survey on Current Practice and Potential.

BACKGROUND: In the United States, there is a national shortage of organs donated for transplant. Among the solid organs, most often kidneys are donated by living donors, but the lack of information and complicated processes limit the number of individuals who serve as living kidney donors. Social media can be a tool for advocacy, educating the public about the need, process, and outcomes of live kidney donors, yet little is known about social media use by kidney transplant patients. OBJECTIVE: The purpose of this study was to examine the social media use of potential kidney transplant patients and their willingness to use social media and their networks to advocate and educate about living kidney donation. METHODS: Using a validated survey, we modified the instrument to apply to the patient population of interest attending the Medical University of South Carolina, Charleston, SC, USA. The questions on the survey inquired about current social media use, sites visited, frequency and duration of social media use, and willingness to use social media to share the need for living kidney donors. We asked patients who had received a transplant and those awaiting a transplant to complete the survey during an office visit. Participation was voluntary. RESULTS: A total of 199 patients completed the survey. Approximately half of all kidney transplant patients surveyed used social media (104/199, 52.3%), and approximately one-third (66/199, 33.2%) had more than 100 friends in their social media network. Facebook was the most popular site, and 51% (102/199) reported that they would be willing to post information about living kidney donation on their social networks. More than a quarter of the sample (75/199, 37.7%) had posted about their health status in the past. CONCLUSIONS: Social media holds great promise for health-related education and awareness. Our study shows the current social media use of kidney transplant patients. In turn, such information can be used to design interventions to ensure appropriate decision making about live kidney donation. Transplant programs can help increase the number of living donors by providing guidance to kidney transplant patients in how to use social media, to be advocates, and to provide information about living kidney donation to their social network.

Do hospitals that do the right thing have more satisfied patients?

BACKGROUND: Hospital incentive payments are increasingly becoming tied to quality. However, the U.S. health care system continues to face rising health care costs and scarce workforce resources, making improving quality a challenge. Patient satisfaction and process quality are two areas of quality tied to reimbursement. Both are associated with positive health outcomes, but little is known about the relationship between the two. PURPOSES: The purpose of this study is to determine if there is an association between process quality and patient satisfaction in a representative sample of U.S. hospitals. METHODOLOGY/APPROACH: We utilize a pooled cross-sectional study design with year fixed effects from 2009 to 2011. We linked the Hospital Compare data set and the American Hospital Association Annual Survey of Hospitals (AHA) data set. We use a method prescribed by the Joint Commission to determine hospital-level process quality in three areas: heart failure, acute myocardial infarction, and pneumonia treatment. We then use regression models to measure the relationship between process quality and two measures of overall hospital patient satisfaction. FINDINGS: After we control for hospital-level characteristics and year, we find that patient satisfaction is positively associated with all three areas of hospital process quality (p < .01). For example, acute myocardial infarction process quality was positively associated with whether patients "would definitely recommend the hospital" (B = 0.75, p < .01). Process quality areas were moderately and positively correlated (p < .01), and on average, patient satisfaction scores have increased over time (p < .01). PRACTICE IMPLICATIONS: Our findings of an association between process quality and patient satisfaction suggest that focusing on process quality does not have negative implications for patient satisfaction. As performance in different process quality areas is only moderately correlated, managers should continually monitor all areas. The trend of increased patient satisfaction over time, perhaps because of industry pressures, should be investigated further.

Living Donor Kidney Transplantation: Overcoming Disparities in Live Kidney Donation in the US--Recommendations from a Consensus Conference.

Despite its superior outcomes relative to chronic dialysis and deceased donor kidney transplantation, live donor kidney transplantation (LDKT) is less likely to occur in minorities, older adults, and poor patients than in those who are white, younger, and have higher household income. In addition, there is considerable geographic variability in LDKT rates. Concomitantly, in recent years, the rate of living kidney donation (LKD) has stopped increasing and is declining, after decades of consistent growth. Particularly noteworthy is the decline in LKD among black, younger, male, and lower-income adults. The Live Donor Community of Practice within the American Society of Transplantation, with financial support from 10 other organizations, held a Consensus Conference on Best Practices in Live Kidney Donation in June 2014. The purpose of this meeting was to identify LKD best practices and knowledge gaps that might influence LDKT, with a focus on patient and donor education, evaluation efficiencies, disparities, and systemic barriers to LKD. In this article, we discuss trends in LDKT/LKD and emerging novel strategies for attenuating disparities, and we offer specific recommendations for future clinical practice, education, research, and policy from the Consensus Conference Workgroup focused on disparities.

Early treatment withdrawal from evidence-based psychotherapy for PTSD: telemedicine and in-person parameters.

OBJECTIVE: To determine differences in reported barriers to treatment completion associated with telemedicine vs. in-person delivery of evidence-based treatment for PTSD in combat veterans. METHOD: The present study was derived from two ongoing randomized controlled trials (RCTs) comparing in-person vs. telemedicine delivery of exposure therapy for PTSD. A one-time telephone assessment of participants who dropped out from the treatment phase of these two studies was conducted, with measures focusing on reported reasons for dropout, and perceived comfort and efficacy of the treatment modality. Dichotomous data were analyzed via chi-square and logistic regression; continuous data via ANOVA. RESULTS: Forty-seven of 69 total dropouts participated. There was no difference in rate of dropout between modalities. A greater proportion of participants receiving in-person exposure therapy reported difficulties with logistical aspects of care (e.g., parking), whereas a greater proportion of participants receiving telemedicine therapy reported difficulty tolerating certain stressful aspects of treatment; however, those receiving telemedicine delivered treatment completed more sessions before dropping out. Participants in both conditions reported that they liked and were confident in their therapist Conclusions: Dropout reasons varied according to type of treatment delivery. Recommendations for future research are given in terms of modification of treatment protocol according to delivery modality.

Association of electronic health records with cost savings in a national sample.

OBJECTIVES: To determine whether advanced electronic health record (EHR) use in hospitals is associated with lower cost of providing inpatient care. STUDY DESIGN: National Inpatient Sample (NIS) and the Health Information Management Systems Society (HIMSS) Annual Survey are combined in the restrospective, cross-sectional analysis. We study patients who are 18 years or older and discharged from a general acute care hospital. METHODS: Using 2009 data and a cross-sectional design with a gamma distributed generalized linear model, a patient-level analysis is conducted with propensity scores to control for selection bias. Patient- and organizational-level variables are included as controls. The main outcome measure is total cost per patient admission and represents the amount that it costs the hospital to provide services based on the adjusted charges for an admission. RESULTS: We include 5,047,089 individuals treated at 550 hospitals in the United States and represent a population-based sample. There are 104 (18.9%) hospitals included that use advanced EHRs. Patients treated in hospitals with advanced EHRs cost, on average, $731, or 9.66%, less than patients admitted to hospitals without advanced EHRs, after controlling for patient and hospital characteristics. CONCLUSIONS: Hospitals that use advanced EHRs have lower cost per patient admission than comparable hospitals with similar case mix.

Development and testing of a disease-specific health literacy measure in kidney transplant patients.

CONTEXT: Health literacy affects a patient's ability to navigate through the system of care for late-stage kidney disease, including evaluation, waiting, and recovering from kidney transplant. OBJECTIVES: To develop and provide a preliminary evaluation of a knowledge and decision-making capacity tool, which is a component of health literacy. DESIGN: Cross-sectional design with purposive sampling. SETTING: Vascular access, dialysis, and outpatient transplant clinics. METHODS: A Decision-Making Capacity Assessment Tool (DMCAT) was developed and administered to 127 adults at different stages in the kidney care process. RESULTS: The DMCAT tool is positively and significantly correlated to the other 2 previously validated instruments and accounts for more variance than the other 2 tools in the regression models. We found significant differences in patients' health literacy and decision-making capacity related to their stage of care. Decision-making capacity appeared to be an important component of health literacy and should be considered as health care providers tailor care to meet patients' needs.

Lower rates of EMR use in rural hospitals represent a previously unexplored child health disparity.

OBJECTIVES: Rural hospitals face significant barriers to adoption of advanced-stage electronic medical records (EMRs), which may translate to an unexplored disparity for children in rural hospitals. Our objective was to determine whether children hospitalized in rural settings are less likely to be cared for using advanced-stage EMRs. METHODS: We merged the 2009 Healthcare Cost and Utilization Project Kids Inpatient Dataset with the 2009 Healthcare Information and Management Systems Society database. Logistic regression determined the independent relationship between receiving care in a rural hospital and advanced-stage EMRs. RESULTS: A total of 430 055 (9.3%) of the 4 605 454 pediatric discharges were rural. Logistic regression analysis determined that even when an extensive list of various patient and hospital characteristics are accounted for, rurality continues to be a strong predictor of a child's care without advanced-stage EMRs (odds ratio 0.3; 95% confidence interval, 0.2-0.5). CONCLUSIONS: Children hospitalized in a rural hospital are less than half as likely to be treated using advanced-stage EMRs. A focus of government and hospital policies to expand the use of EMRs among rural hospitals may reduce this child health care disparity.

Patient satisfaction scores and their relationship to hospital website quality measures.

Hospitals and health systems are using web-based and social media tools to market themselves to consumers with increasingly sophisticated strategies. These efforts are designed to shape the consumers' expectations, influence their purchase decisions, and build a positive reputation in the marketplace. Little is known about how these web-based marketing efforts are taking form and if they have any relationship to consumers' satisfaction with the services they receive. The purpose of this study is to assess if a relationship exists between the quality of hospitals' public websites and their aggregated patient satisfaction ratings. Based on analyses of 1,952 U.S. hospitals, our results show that website quality is significantly and positively related to patients' overall rating of the hospital and their intention to recommend the facility to others. The potential for web-based information sources to influence consumer behavior has important implications for policymakers, third-party payers, health care providers, and consumers.

Electronic medical record adoption in hospitals that care for children.

OBJECTIVE: Hospitals that care for children face unique barriers in electronic medical records (EMR) use that may affect their ability to meaningfully use EMR. The purpose of this study was to investigate hospitals that care for children, both freestanding and adult hospitals with children's services, to determine progress toward advanced stages of EMR use. METHODS: The American Hospital Association survey described hospitals across the United States. Healthcare Information and Management Systems Society 2006 and 2010 databases identified hospitals' EMR use. EMR stage was classified according to previous studies. Multivariable analysis was used to determine independent predictors of EMR use. RESULTS: The analysis included 2794 hospitals. During the study time frame, a significant increase occurred for hospitals moving into any stage of EMR in adult hospitals with children's services (47% to 75%; P < .001), while improvements for freestanding children's hospitals were modest at best (46% to 59%; P = .3). Conversely, freestanding children's hospitals had the largest gain in advance stage 3 adoption (6% to 39%; P < .001) compared to adult hospitals with children's services (6% to 23%; P < .001). Freestanding children's hospitals were less likely to use pharmacy information systems but more likely to use computerized provider order entry. CONCLUSIONS: In 2010, freestanding children's hospitals had the highest percentage use of advanced stage EMR (39%), but the lowest improvements in percentage of hospitals entering into any stage of adoption over the study period. This trend created a digital divide among freestanding children's hospitals that may improve with pediatric-specific electronic medication management products.

Optimizing the Economic Impact of rtPA Use in a Stroke Belt State: The Case of South Carolina.

BACKGROUND: Stroke is the fourth leading cause of death in the United States, and its incidence is especially high in South Carolina. Recombinant tissue plasminogen activator (rtPA) has been given to patients with acute ischemic stroke since 1996 and has shown overall improved outcomes relative to patients who are not treated with rtPA. OBJECTIVE: A 1998 study by Fagan and colleagues reported the economic impact of the use of rtPA. The purpose of this current article is to present an updated economic analysis of the impact of rtPA. METHODS: In the current analysis, an updated estimate of the economic and health benefits of treatment with rtPA in South Carolina was provided using estimates of cost, incidence, and course of treatment from several data sources. The Markov model in the 1998 study was used as a guide in this current study; we sought to replicate the methodology, while providing updated economic figures and applying it to the state of South Carolina. We estimated the costs per 1000 patients who are eligible for treatment with rtPA compared with 1000 untreated patients, as well as routine medical practice and outcomes of quality-adjusted life-years (QALYs) and economic costs based on whether a patient was treated with rtPA or not. We calculated the number of stroke cases that would be treated with rtPA if the rate were to increase from 3% to 20%, using the most recent number of strokes in South Carolina and prorating for 5 years to estimate the total expected cost-savings with increased rtPA use. RESULTS: The results indicate that the use of rtPA in South Carolina accounts for a cost-savings of $3454 per treated patient over a 6-year period. The model estimates an increase of 0.425 QALYs (or 5.1 quality-adjusted months) of survival per patient treated with rtPA. Over the lifetime of a treated patient, the estimated cost-savings are $4084, with an accrued health benefit of 0.692 QALYs (or 8.3 quality-adjusted months). For every 100 patients treated with rtPA, there is a gain of 69.17 QALYs and of $408,419 over the lifetime of 100 treated patients with acute ischemic stroke. We calculated that the cost-savings gained by increasing the rtPA treatment rate in a state with a high incidence of stroke from the current 3% rate to an achievable 20% rate over a 5-year period would be $16,615,723. CONCLUSIONS: This new analysis demonstrates a significant savings associated with the use of rtPA for patients with stroke and provides great support for the increased systematic use of rtPA in the state of South Carolina for patients with acute ischemic stroke. For every additional 100 patients who are treated with rtPA in South Carolina, a robust savings supports the wider economic benefit that would be gained with an increased use of rtPA.

Telemedicine in an international context: definition, use, and future.

PURPOSE: Use of telemedicine is increasingly prevalent in order to provide better access to expert care, and we examine telemedicine use internationally. DESIGN/METHODOLOGY: Using Donabedian's structure, process outcome framework, we conduct an analysis of published studies in the United States, Europe, and Asia to examine the uses, conditions treated, barriers, and future of telemedicine. FINDINGS: We identify several similarities and challenges to telemedicine use in each region. We find use of videoconferencing between providers or providers and patients for the treatment of acute and chronic conditions. Studies in the United States are more likely to identify applications for the use of chronic conditions, whereas studies in Europe or Asia are more likely to use them for acute access to expertise. Each region reported comparable challenges in reimbursement, liability, technology, and provider licensing. RESEARCH LIMITATIONS: We compare available research articles from three diverse regions, and many of the articles were merely descriptive in nature. Furthermore, the number of articles per region varied. PRACTICAL IMPLICATIONS: Barriers to telemedicine use include a lack of reimbursement, language commonality, technological availability, physician licensure or credentialing, trained support staff and patient privacy, and security assurances. Practitioners and policy makers should work to address these barriers. ORIGINALITY/VALUE: Through this work, a summary of the research to date describes telemedicine use in the United States, Asia, and Europe. Identification of use and barriers may provide impetus for improving access to care by finding ways to increase telemedicine use through standardization.

Hospital electronic medical record use and cost of inpatient pediatric care.

OBJECTIVE: Electronic medical record (EMR) systems are costly for hospitals to implement and maintain, and the effects of EMR on the cost of care for inpatient pediatrics remain unknown. Our objective was to determine whether delivering care with advanced-stage EMR was associated with a decreased cost per case in a national sample of hospitalized children. METHODS: The Healthcare Cost and Utilization Project Kids Inpatient Dataset 2009 identified pediatric discharges. The Healthcare Information and Management Systems Society 2009 database identified hospitals' EMR use. EMR was classified into 3 stages, with advanced-stage 3 EMR including automation of ancillary services, automation of nursing workflow, computerized provider order entry, and clinical decision support. Multivariable linear regression was used to determine the independent effect of advanced-stage EMR on cost per case. Propensity score adjustment was included to control for nonrandom assignment of EMR use. RESULTS: This analysis included 4,605,454 weighted discharges. EMR use by hospitals that care for children was common: 24% for stage 1, 23% stage 2, and 32% advanced stage 3. The multivariable model demonstrated that advanced stage EMR was associated with an average 7% greater cost per case ($146 per discharge). CONCLUSIONS: The care of children across the United States with EMRs may create a safer health care system but is not associated with inpatient cost savings. In fact our primary analysis shows a 7% additional cost per case. This finding is contrary to predicted savings and may represent an added barrier in the adoption of EMR for inpatient pediatrics.

Hospital characteristics related to the intention to apply for meaningful use incentive payments.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides incentives for hospitals to fully adopt and use electronic health records (EHRs). We used data from the 2009 American Hospital Association (AHA) Annual Survey Information Technology Supplement and the Centers for Medicare and Medicaid Services (CMS) 2008 Hospital Cost Reports to examine how various hospital characteristics are associated with the intention to pursue meaningful use incentives. Overall, 86 percent of hospitals indicated an intent to pursue HITECH incentives. However, hospitals that already have an EHR system, are larger, and are located in urban areas are more likely to indicate an intention to pursue incentives. Despite a high interest in HITECH incentives, certain hospital characteristics, including current EHR use, increase the proclivity for some hospitals to pursue meaningful use. Given these differences, there is the potential for the HITECH Act to inadvertently increase the digital divide between hospitals with certain characteristics and their counterparts without those characteristics. Policy makers should consider ways to alleviate barriers, especially for nonusers of EHRs, to realize the maximum benefits of the HITECH Act.