Trending in the right direction: critical access hospitals increased adoption of advanced electronic health record functions from 2018 to 2023

Abstract

Objectives

We analyzed trends in adoption of advanced patient engagement and clinical data analytics functionalities among critical access hospitals (CAHs) and non-CAHs to assess how historical gaps have changed.

Materials and Methods

We used 2014, 2018, and 2023 data from the American Hospital Association Annual Survey IT Supplement to measure differences in adoption rates (ie, the “adoption gap”) of patient engagement and clinical data analytics functionalities across CAHs and non-CAHs. We measured changes over time in CAH and non-CAH adoption of 6 “core” clinical data analytics functionalities, 5 “core” patient engagement functionalities, 5 new patient engagement functionalities, and 3 bulk data export use cases. We constructed 2 composite measures for core functionalities and analyzed adoption for other functionalities individually.

Results

Core functionality adoption increased from 21% of CAHs in 2014 to 56% in 2023 for clinical data analytics and 18% to 49% for patient engagement. The CAH adoption gap in both domains narrowed from 2018 to 2023 (both P < .01). More than 90% of all hospitals had adopted viewing and downloading electronic data and clinical notes by 2023. The largest CAH adoption gaps in 2023 were for Fast Healthcare Interoperability Resources (FHIR) bulk export use cases (eg, analytics and reporting: 63% of CAHs, 81% of non-CAHs, P < .001).

Discussion

Adoption of advanced electronic health record functionalities has increased for CAHs and non-CAHs, and some adoption gaps have been closed since 2018. However, CAHs may continue to struggle with clinical data analytics and FHIR-based functionalities.

Conclusion

Some crucial patient engagement functionalities have reached near-universal adoption; however, policymakers should consider programs to support CAHs in closing remaining adoption gaps.

Introduction

Background and significance

While electronic health record (EHR) systems are now widely adopted across hospitals,^1,2 previous studies have found widening gaps in advanced EHR functionalities between critical access hospitals (CAHs) and other hospitals.^2–5 These advanced functionalities include, for example, using the EHR to identify patient care gaps, track adherence to clinical practice guidelines, and facilitate patient access to their health information. Specifically, previous work has categorized these functionalities into: (1) advanced analytics capabilities and (2) patient engagement functionalities, and found that both categories have historically lagged among CAHs as of 2018.² These gaps prevent CAHs and their patients from realizing the full potential of a digitized health care system. It is therefore important to continue to track uptake of these functionalities and assess the degree to which the “digital divide” between CAHs and other hospitals has widened or closed.

Further, the COVID-19 pandemic likely impacted these gaps, but how CAH technology adoption has evolved since the pandemic is difficult to predict given the complex dynamics underlying advanced technology use among hospitals. For example, the value of digital patient engagement functionalities rose dramatically following the onset of the pandemic because they facilitated the use of telemedicine (both synchronous and asynchronous) via patient portals.^6–8 Critical access hospitals may have invested in these tools independently or taken advantage of federal policy supports and waivers during the pandemic period,⁹ and allocated these resources toward strategic investments in increasing their advanced capabilities.¹⁰ If this occurred, we would observe a narrowing of the advanced functionality gap. On the other hand, it is also possible that the extreme strain placed on the US health care system during the pandemic further constrained the limited resources of CAHs and crowded out these hospitals’ ability to adopt advanced EHR functionalities.^11,12 Under this potential scenario, gaps would have persisted or even widened. These examples capture just a few of the numerous forces underlying CAH adoption of advanced technology in the pandemic era. If CAHs continue to lag non-CAHs in advanced use, additional programmatic support may be required from states and/or federal agencies that have historically provided technical assistance in the adoption of EHRs after the 2009 HITECH Act.^13–15 If past gaps have closed, however, policymakers should shift to focus on persistent or newly emerging gaps.

Understanding the trajectory and current magnitude of advanced functionality gaps is directly relevant to ongoing policymaking and rulemaking from the health IT provisions of the 21st Century Cures Act (Cures Act), which had requirements related to patients’ access to their electronic health information through EHR support for modern application programming interfaces (APIs) based on the openly available Fast Healthcare Interoperability Resources (FHIR) data standard. These requirements are intended to: (1) support easy access to EHR data for applications used by patients and clinicians and (2) ensure that the ability to export information from the EHR in bulk is available to support data analytics, artificial intelligence, and population health management.^16,17 Functionality gaps in domains pertinent to Cures Act regulatory requirements, as measured by gaps in capabilities to provide patients’ access to their patient health information and clinical notes via these standard-based APIs, have not yet been assessed nationally.

Objective

Our study assesses the CAH vs non-CAH advanced use functionality gap, focusing on how gaps have evolved in recent years following the onset of the COVID-19 pandemic and on newly assessed functionalities relevant to the Cures Act. We used national hospital survey data from 2014, 2018, and 2023 to capture both historical trends and the current state of CAH advanced use to address 3 research questions. First, how has the adoption gap of “core” patient engagement and data analytics functionalities changed from 2014 to 2023? Second, how has the adoption of individual functionalities that compose these aggregate measures changed from 2018 to 2023? And finally, are there current gaps (in 2023) between CAHs and non-CAHs for new functionalities that reflect Cures Act policy goals? Our findings have important implications for prioritizing ongoing efforts to ensure that all patients can maximally benefit from digitized health records, regardless of where they receive care.¹⁸

Materials and methods

Data and sample

We analyzed 3 years of survey data from the American Hospital Association (AHA) Annual Survey IT Supplement, which captures information about a large set of clinical and operational technologies in place at US hospitals. The Annual Survey is sent to all US hospitals, and the IT Supplement is typically completed by the Chief Information Officer, Chief Medical Informatics Officer, or an appropriate delegate. Respondents can complete the survey either online or via mail, and the survey administrator conducts follow-up calls and mailings to ensure high response rates. The 2023 survey was fielded from March to August and had a 58% response rate. We also used IT Supplement data from 2014 and 2018 and included all nonfederal acute care hospitals that responded to the survey in any of the 3 survey years. We chose 2014 and 2018 as reference years to match prior studies reporting CAH vs non-CAH differences in advanced EHR functionalities.^2,3 We categorize the measures of advanced EHR functionalities into 4 groups, delineated by domain (clinical data analytics or patient engagement) and whether they have been assessed in prior studies,^2,3 with “core” indicating past assessment and “new” indicating measures that we are the first to report.

Measures: core clinical data analytics and patient engagement functions

Clinical data analytics

We measured adoption of 6 functionalities for the clinical data analytics domain, which represent the items that were assessed in all 3 survey years (“core”). These functions included (1) create an approach for clinicians to query EHR data; (2) assess adherence to clinical practice guidelines; (3) identify care gaps for specific patient populations; (4) support a continuous quality improvement process; (5) monitor patient safety (eg, adverse drug events); and (6) identify high-risk patients for follow-up care using algorithms or other tools. For each of these items, hospital respondents indicated “yes” or “no” with respect to whether the hospital used electronic clinical data from the EHR or other electronic system in the hospital. To measure overall adoption of advanced clinical data analytics in aggregate that is consistent with prior literature^2,3 and avoids underestimating adoption due to the use of too strict criteria,¹⁹ we created a binary variable set to 1 if a hospital reported adoption of at least 5 of the 6 functions.

Patient engagement

For advanced patient engagement functionalities, the 5 items assessed across all 3 survey years (“core”) were patient ability to (1) view health and medical data online; (2) download information from their medical record; (3) send electronic versions of their health information to a third party; (4) submit patient-generated health data (eg, blood glucose, weight) to their medical record; and (5) message providers via secure messaging tools, all assessed via “yes” or “no” response. To measure overall adoption of patient engagement functionalities in aggregate, we created a binary variable set to 1 if a hospital reported adoption of all 5 functions.

Measures: new patient engagement and clinical data analytics functions

Patient engagement

We also measured the adoption of 5 new patient engagement functionalities that were not assessed in 2014. Three new patient engagement functions were measured in 2018 and 2023: (1) import of medical records from other organizations via patient portal; (2) viewing clinical notes; (3) patient access to their health/medical information using applications (apps) configured to meet the API specifications in your EHR. Two additional patient engagement functions were newly assessed in 2023: (4) patient access to their health/medical information using apps configured to meet FHIR specifications; and (5) patients’ ability to submit patient-generated data through apps configured to meet FHIR specifications. Because these functions were added to the survey in different years, we analyzed these functions individually rather than in aggregate. For the 3 items assessed in both 2018 and 2023 (items 1-3), we analyzed changes over time.

Clinical data analytics (bulk FHIR export)

We measured the adoption of 3 new advanced clinical data analytics functions related specifically to Cures Act requirements regarding FHIR-enabled data export. These items assessed via “yes” or “no” response hospital use cases for “bulk export” to export multiple records from the primary inpatient EHR to support (1) analytics and reporting; (2) population health management; and (3) switching EHR systems. We report 2023 rates for these 3 individual measures, as they were not included in 2014 or 2018 AHA IT Supplements.

Analytic approach

For our first research question, we calculated adoption rates of core clinical data analytics and patient engagement functions in 2014, 2018, and 2023 using the binary measures, stratified by hospital CAH status. We then calculated the adoption gap as the difference between CAH and non-CAH adoption rates of core functions. To assess statistical differences in adoption rates, we used Rao-Scott corrected chi-square tests. To analyze changes in CAH vs non-CAH aggregate adoption of core functionalities (ie, gap closure), we used logistic regression models that included CAH status, year, and interaction term for CAH × Survey Year to test for the significance of changes in the gap over time.

For our second research question, we calculated CAH and non-CAH adoption rates and adoption gaps for each of the 11 core functionalities included on the IT Supplement in 2018 and 2023. For our third research question, we calculated CAH and non-CAH adoption rates and adoption gaps for the study years in which each functionality was assessed (2023 only or 2018 and 2023).

All analyses integrated nonresponse weights to adjust all estimates to reflect the population of nonfederal acute care hospitals in the United States, consistent with prior studies.^2,3 Specifically, we used a logistic regression to predict the likelihood that a hospital in the full AHA Annual Survey responded to the IT survey based on the hospital’s size, ownership, teaching status, system membership, and availability of a cardiac intensive care unit, urban status, and region. Hospital weights were then the inverse of these response probabilities. This study was exempt from Institutional Review Board review as it uses hospital-level survey data from the AHA. We used Stata 15 SE for all statistical analyses and a cutoff of P = .05 to determine statistical significance.

Results

Overall adoption of core functions, 2014-2023

From 2014 to 2023, CAH adoption of core advanced functions in both clinical data analytics and patient engagement domains increased from 21% of CAHs in 2014 to 56% in 2023 for clinical data analytics and 18% to 49% for patient engagement (Figure 1). The aggregate adoption gap initially widened between 2014 and 2018, followed by a decrease between 2018 and 2023 where the advanced analytics gap narrowed from 31 percentage points to 13 percentage points for clinical data analytics. During this time period, the gap narrowed from 16 percentage points to 7 percentage points for patient engagement (Figure 1). In 2023, non-CAHs remained ahead of CAHs in both domains with 69% of non-CAHs adopting core analytics functions and 56% adopting core patient engagement functions. Overall, core function adoption gaps between CAHs and non-CAHs remained significant in 2023 (Clinical Data Analytics Relative Likelihood: 0.81, P < .001; Patient Engagement Relative Likelihood: 0.88, P < .001), and the change in the adoption gap between 2018 and 2023 was statistically significant for both domains, indicating a decreasing CAH adoption gap (P < .001 for Clinical Data Analytics and P = .004 for Patient Engagement).

Figure 1.

Advanced use function adoption and CAH adoption gap by hospital type, 2014-2023. Bars illustrate adoption rates among CAHs and non-CAHs of composite measures of advanced use function adoption across 2 domains, patient engagement and clinical data analytics, in 2014, 2018, and 2023. For patient engagement, a hospital is considered an “adopter” if the hospital reports adoption of at least 5 of 5 advanced patient engagement functionalities. For clinical data analytics, a hospital is considered an “adopter” if the hospital reports adoption of at least 5 of 6 advanced clinical data analytics functionalities. The red line (secondary y-axis) illustrates the trend in the adoption gap over time, measured as the difference between CAH and non-CAH adoption rates for each advanced use domain in each year. AHA, American Hospital Association; CAH, critical access hospital. Data Source: AHA Annual Survey IT Supplement.

Composition of core functionality gaps, 2018-2023

Five of six core clinical data analytics functionalities exhibited persistent adoption gaps in 2023 (Table 1), with “monitoring patient safety” as the only individual functionality exhibiting statistical equivalence in adoption across CAHs (81%) and non-CAHs (84%, P = .12). However, CAH adoption rates increased for all 6 functions from 2018 to 2023, and functionalities with relatively low CAH adoption in 2018 exhibited the largest percentage-point gains. Creating an approach for clinicians to query data rose from 36% adoption in 2018 to 60% of CAHs in 2023; identifying high-risk patients for follow-up care using algorithms rose from 52% to 73% of CAHs; and identifying care gaps for specific patient populations rose from 49% to 68% of CAHs. Assessing adherence to clinical practice guidelines also rose from 44% to 61%—across all 6 functions, at least 60% of CAHs indicated adoption in 2023 (Table 1).

Table 1.

Adoption of individual advanced functions by hospital type, 2018 and 2023.

	2018				2023
	Critical access hospitals (%)	Noncritical access hospitals (%)	Difference	P-value of difference	Critical access hospitals (%)	Noncritical access hospitals (%)	Difference	P-value of difference
Core clinical data analytics functions
Create an approach for clinicians to query the data	36	61	25pp	< .001	60	79	19pp	< .001
Assess adherence to clinical practice guidelines	44	71	27pp	< .001	61	73	12pp	< .001
Identify care gaps for specific patient populations	49	71	22pp	< .001	68	85	17pp	< .001
Support a continuous quality improvement process	75	87	12pp	< .001	82	92	10pp	< .001
Monitor patient safety (eg, adverse drug events)	72	89	17pp	< .001	81	84	3pp	= .12
Identify high-risk patients for follow-up care using algorithms	52	79	27pp	< .001	73	85	12pp	< .001
Core patient engagement functions
Patient ability to view electronic data	97	96	−1pp	= .001	99	99	0pp	= .77
Download electronic data from portal	88	92	4pp	= .001	96	98	2pp	= .02
Send electronic versions of their health information	60	78	18pp	< .001	77	89	12pp	< .001
Submit patient-generated health data to their medical record	44	56	12pp	< .001	59	62	3pp	= .09
Message providers via secure messaging tools	74	76	2pp	= .52	91	93	2pp	= .18
New patient engagement functions
Import records from other organizations to your portal	35	36	1pp	= .39	52	58	6pp	= .003
View clinical notes	53	58	5pp	= .01	91	96	5pp	< .001
Access their health information via apps configured to meet the API specifications in your EHR	46	46	0pp	= .90	76	88	12pp	< .001
Access their health information via apps configured to meet FHIR API specifications	N/A	N/A	N/A	N/A	65	72	7pp	< .001
Submit patient-generated data via apps configured to meet FHIR specifications	N/A	N/A	N/A	N/A	45	50	5pp	= .03
New bulk FHIR export functions (use capability to export multiple records to support…)
Analytics and reporting	N/A	N/A	N/A	N/A	63	81	18pp	< .001
Population health management	N/A	N/A	N/A	N/A	47	63	16pp	< .001
Switching EHR systems	N/A	N/A	N/A	N/A	21	35	14pp	< .001

The “difference” column for each function illustrates the CAH vs non-CAH gap in adoption of a given function. Comparing the 2023 difference to the 2018 difference indicates how the CAH vs non-CAH gap has changed since 2018. N/A indicates that a measure was not assessed in the AHA IT Supplement in that year.

Abbreviations: API, application programming interface; EHR, electronic health record; FHIR, Fast Healthcare Interoperability Resources; pp, percentage points.

Two of five core patient engagement functionalities had relatively high adoption but persistent gaps in 2023: sending electronic versions of patient health information to third parties (77% of CAHs vs 89% of non-CAHs, P < .001) and downloading electronic data from the patient portal (96% of CAHs vs 98% of non-CAHs, P = .02) (Table 1). Submitting patient-generated health data had the lowest levels of adoption of any patient engagement function (59% of CAHs and 62% of non-CAHs, P = .09), while the ability to communicate directly with providers via secure messaging tools exhibited high adoption for both hospital types (91% of CAHs and 93% of non-CAHs, P = .18). Patient ability to view electronic data via patient portals has achieved essentially universal adoption, with 99% of CAHs and non-CAHs reporting this functionality (P = .77).

New patient engagement functionalities

Among newly assessed patient engagement functionalities, both CAHs and non-CAHs increased adoption of clinical note viewing from 2018 to 2023, with CAHs increasing from 53% to 91% and non-CAHs from 58% to 96% (2023 difference P < .001) (Figure 2). Access to patient records via API-enabled applications has also increased from 46% for both CAHs and non-CAHs in 2018 to 76% and 88%, respectively (P < .001). Import of outside records to the patient portal has exhibited a similar trend, with 35% of CAHs and 36% of non-CAHs indicating adoption in 2018 and 52% and 58% in 2023, respectively (P = .003). Finally, for the 2 functionalities specific to FHIR APIs that were only assessed in 2023, CAHs lag non-CAHs in adoption rates (Figure 3). However, 65% of CAHs and 72% of non-CAHs indicated access to records via FHIR apps (P < .001), 45% of CAHs and 50% of non-CAHs indicated the ability for patients to submit patient-generated data via FHIR-enabled app (P = .03).

Figure 2.

New advanced patient engagement function adoption by hospital type, 2018-2023. Bars illustrate adoption rates among CAHs and non-CAHs of individual patient engagement functionalities assessed by the AHA survey in 2018 and 2023. AHA, American Hospital Association; CAH, critical access hospital. Data Source: AHA Annual Survey IT Supplement.

Figure 3.

FHIR functionality and use case adoption among CAHs and non-CAHs, 2023. Bars illustrate adoption rates among CAHs and non-CAHs of individual FHIR-enabled patient engagement functionalities and bulk FHIR export use cases assessed by the AHA survey in 2018 and 2023. AHA, American Hospital Association; CAH, critical access hospital; FHIR, Fast Healthcare Interoperability Resources. Data Source: AHA Annual Survey IT Supplement.

New clinical data analytics (bulk FHIR export) use cases

CAHs demonstrated significant adoption gaps in all bulk FHIR export use cases in 2023 (Figure 3), with 63% using bulk export for analytics and reporting compared to 81% of non-CAHs (P < .001) and 47% using bulk export for population health management compared to 63% of non-CAHs (P < .001). Use of bulk export for switching EHR systems was the least common use case across both hospital types, with only 21% of CAHs and 35% of non-CAHs reporting it.

Discussion

Substantial and growing differences between critical access and noncritical access hospitals in adoption of patient engagement and clinical data analytics capabilities in 2018 led to concern that CAHs could increasingly fall behind other hospitals in realizing the benefits of EHRs. We analyzed the adoption of patient engagement and clinical data analytics capabilities among CAHs and non-CAHs and found that for “core” functionalities, the historical adoption gap has narrowed substantially from 2018 to 2023 These trends indicate that CAHs were broadly able to continue to implement and upgrade health IT, including functionalities whose adoption by health IT developers was incentivized by federal policy, even in the absence of targeted incentives or technical support directly aimed at CAHs.

Increased adoption and decreasing differences between CAHs and non-CAHs occurred across several functionalities. Some patient engagement functionalities have reached near-ubiquity as of 2023: patients’ ability to view their own clinical data, download data from patient portals, message providers, and view clinical notes. Three of these (all except messaging providers) have been directly supported by federal policy including Stage 2 of the EHR Incentive Program and the Cures Act prohibition on information blocking. Two specific provisions of the 21st Century Cures Act and subsequent regulation related to viewing clinical notes and the use of APIs to support patient engagement apps increased dramatically between 2018 and 2023 with little difference between CAHs and non-CAHs. Simultaneously, clinical data analytics functionality adoption increased for CAHs and non-CAHs from 2018 to 2023.

While these domains of increased adoption among hospitals suggest progress toward policy goals, we are not able to separate the impact of policy from secular trends. It is possible that these functionalities would have exhibited this adoption trend absent explicit federal incentives,¹⁹ as they are frequently demanded by patients for care coordination needs.²⁰ This is certainly the case for messaging providers, which has increased dramatically since the COVID-19 pandemic and is now well established as a key tool for patients and providers.^21–23 Nevertheless, the fact that the adoption gap narrowed during the COVID-19 pandemic suggests that CAHs were able to adopt certified EHR technology with these capabilities to increase patients’ use of these critical tools (eg, secure messaging and viewing electronic data) and that the COVID-19 pandemic did not stall technological advancement among CAHs.

Despite this progress, some gaps in individual “core” functionalities in both domains persisted in 2023. Specifically, CAHs still lag in sending electronic version of health information in the patient engagement domain (12 percentage-point gap); clinician querying of EHR data (19 percentage-point gap); and identifying care gaps (17 percentage-point gap) in clinical data analytics. These 3 “core” functionalities represent potential opportunities for CAHs to leapfrog the core version of these, which often use proprietary APIs and thus require substantial local resources and capacity, in favor of analogous functionalities facilitated by standardized FHIR APIs, which may reduce some localization costs for CAHs. This potential to leapfrog nonstandardized technologies may explain why the gap between CAHs and non-CAHs in the use of vendor-specific APIs for patient engagement apps is larger (12 percentage points) than the gap between CAHs and non-CAHs in the adoption of FHIR APIs for patient engagement apps (7 percentage points). That is, CAHs may be bypassing vendor-specific APIs in favor of open standards in the patient engagement domain. However, we see less evidence of CAH leapfrogging in the use of bulk FHIR to support analytics and population health, where CAHs lag non-CAHs at greater rates (Figure 3). As of January 1, 2023, Bulk FHIR is a required functionality of a Base EHR defined by federal policy; our findings suggest that CAHs may be well positioned to take advantage of open standards for patient engagement but will likely require targeted support in the form of implementation and analytic guidance and technical assistance to make full use of FHIR in the data and analytics domains. However, CAHs may lack the resources to support these tools long term, so ongoing assessment will be important.

Our findings have important policy implications for the implementation of the Cures Act requirements and how federal programs can support CAHs in their technological advancement. First, our results affirm the implementation of mandated APIs as a part of the Cures Act,² to support patient engagement functionalities in particular. Fast Healthcare Interoperability Resources-based patient engagement functionalities demonstrated relatively small gaps between CAHs and non-CAHs as of 2023, suggesting that these technologies are not prohibitively onerous for CAHs to adopt. Second, the ability of CAHs to adopt many functions incentivized or required by policymakers through the 21st Century Cures Act indicates that CAHs may be better positioned to implement and benefit from new technologies than indicated by trends in 2018, which may provide some support for federal policymakers to continue to implement meaningful requirements on developers of certified health IT and hospitals. Finally, new CAH adoption gaps in bulk FHIR use cases and persistent gaps in some core clinical data analytics functionalities illustrate that CAHs may continue to struggle with functionalities in this domain. These tools require substantial technical expertise to implement and maintain as well as organizational capacity—2 things that CAHs commonly lack due to staffing constraints and lack of access to technical talent pools relative to other hospitals.^12,13,24,25 In turn, this leads to less experience with clinical analytics and population health services. This puts CAHs at a potential disadvantage in adoption of forthcoming technologies built atop bulk FHIR exports, including applications using predictive models, machine learning, and artificial intelligence, which appear poised to impact health care. To our knowledge, no CAH-specific workforce development programs or programs to provide technical assistance with implementation and maintenance of advanced data analytics tools have been rolled out in the Cures Act era and therefore are a policy strategy worth consideration.

Limitations

Our study has several limitations to consider. First, we use measures of patient engagement and clinical data analytics functionalities to be as consistent as possible with prior literature tracking CAH adoption gaps.^2,3 Use of different measures or aggregation methodologies may yield slightly different estimates of the adoption gap and changes over time. Second, our choice of measures necessitated the use of 2014, 2018, and 2023 AHA IT Supplement Survey data since these were the years in which the items appeared consistently and thus were comparable. This limits our ability to track, for example, annual adoption rates and draw more precise conclusions about how adoption trends did or did not change during the initial years of the COVID-19 pandemic. Third, measures of functionality adoption that we study here do not reflect local usage of the relevant tools. It is likely that hospitals vary widely in whether they use these functionalities and the intensity of their use; however, we are unable to observe that variation in survey data. Fourth, all analyses are associational and do not imply causal relationships between CAH status and individual functionality adoption. Finally, the data used in our study is self-reported survey data from AHA survey respondents and may be subject to bias from social desirability and/or nonresponse, especially as CAHs responded to these surveys at lower rates than non-CAHs (54% of surveyed CAHs responded in 2023 compared to 60% of non-CAHs). However, the AHA survey has been shown to have high reliability²⁶ and our nonresponse weights allow us to generate nationally representative estimates.

Conclusion

Trends toward larger gaps between CAHs and non-CAHs from 2014 to 2018 reversed between 2018 and 2023, leading to diminishing gaps in the adoption of patient engagement and clinical data analytics functionalities. In some cases, crucial functionalities have reached near-universal adoption. Critical access hospitals continue to advance their technological capabilities but also continue to lag non-CAHs in their capabilities for clinical data analytics in support of population health and quality improvement efforts. This may systematically hinder efforts to improve population health for the communities that CAHs serve. However, opportunities exist for CAHs to leapfrog via the adoption and use of standardized FHIR APIs that can provide infrastructure while reducing localization and implementation costs to support a variety of advanced patient engagement and analytics use cases. Cost, staff expertise, and organizational capacity likely remain key barriers to CAH technological advancement, so policymakers should consider program development specifically to support CAHs in this endeavor.

Author contributions

Nate C. Apathy Performed conceptualization; Writing—original draft; Writing—review & editing visualization. A. Jay Holmgren Performed conceptualization; Writing—review & editing. Paige Nong Performed conceptualization; Writing—review & editing. Julia Adler-Milstein Performed conceptualization; Writing—review & editing; Supervision; Project administration. Jordan Everson Performed conceptualization; Writing—review & editing; Methodology; Formal analysis; Data curation; Visualization; Project administration.

Funding

None declared.

Conflicts of interest

None declared.

Data availability

Interested researchers may acquire the data from the AHA; however, we cannot release the data per conditions of the data use agreement.