The digital divide in adoption and advanced use of electronic health records among US hospitals: rural versus urban disparities from 2008 to 2023

OBJECTIVE: Using 15 years of hospital survey data (2008-2023), we examined rural-urban trends in electronic health records (EHR) adoption and advanced capabilities for data sharing, public health reporting, and care improvements. MATERIALS AND METHODS: We conducted a repeated cross-sectional study using the American Hospital Association Annual Survey Information Technology Supplement (2008-2018, 2020-2023). We constructed hospital-year measures of basic and comprehensive EHR capability, certified EHR technology (CEHRT) adoption, and advanced functions in patient engagement, interoperability, public health reporting, and social determinants of health (SDOH). We compared rural and urban adoption using descriptive analyses, Cochran-Armitage trend tests, and logistic regression with clustered standard errors, adjusted for bed size, ownership, and census division. RESULTS: The cohort included 41 838 hospital-years (45% rural). Comprehensive capability rose from 2% in 2008 to 75% in 2020, and CEHRT was nearly universal by 2023. Rural hospitals lagged urban hospitals in adopting basic and comprehensive EHRs, with the gap peaking at 25% in 2016. By 2021-2023, most hospitals reported patient portals, interoperability, public health reporting, and SDOH capabilities. Rural hospitals remained 4%-15% behind urban peers in advanced functions, particularly interoperability, public health reporting, and SDOH data collection and use. DISCUSSION: Persistent rural-urban gaps in advanced EHR use may limit interoperability, data-driven care, and public health reporting in rural settings. CONCLUSION: EHR adoption is widespread, but substantial rural-urban gaps persist in advanced EHR use. Support for advanced capabilities that enable data sharing, reporting, and data-driven improvement is needed to ensure that rural hospitals and communities benefit from digital transformation beyond adoption.