Pennsylvania rural hospitals: FHIR endpoint publication and EHR concentration
All 187 hospitals CMS lists in Pennsylvania, joined to the certified-EHR service-base-URL bundles their vendors publish under HTI-1. The join answers two questions at once: whether a hospital is reachable by FHIR, and which EHR it runs. Result: 137 of 187 (73%) appear in a vendor bundle. Rural hospitals are not behind. 81% of hospitals in nonmetro counties appear, and 65% of Critical Access hospitals. The EHR market is concentrated: Epic 86, athenahealth 24, MEDITECH 8, TruBridge 7, Oracle Health 5. The sharper finding is structural: only 51 of the 137 have an Organization record that cross-links to an Endpoint resource, and the gap is almost entirely Epic, which publishes 4,445 Pennsylvania organizations and cross-links 49. Software that traverses Organization to Endpoint finds nothing for most Pennsylvania hospitals even though the endpoint exists.
What this means
Startups + integrators
Do not resolve a Pennsylvania hospital by walking Organization to Endpoint. Epic cross-links 49 of its 4,445 published PA organizations, so the traversal fails for most hospitals whose endpoint is live. Resolve through the vendor bundle instead.
CMS publishing the data
Bundle completeness varies by vendor in a way that changes what downstream software can do. Every vendor except Epic cross-links essentially all published organizations to an endpoint. A conformance expectation on that cross-reference would make the bundles traversable.
State Medicaid PI offices
The 50 hospitals with no vendor-bundle match are the list to check first, not a list of hospitals without endpoints. Some publish under a parent system name and federal facilities publish differently. Every row carries its match tier.
Researchers
Rural disadvantage does not show up in endpoint publication here, which is worth stating because the opposite is usually assumed. Nonmetro PA counties do carry lower median household income ($59,743 against $71,832) and an older population (23.5% aged 65+ against 20.9%), so the demand-side gap is real even where the connectivity gap is not.
Methodology readers
Hospital-to-vendor matching is by name and city because most bundles omit the NPI, so results are tiered: 114 exact, 23 by token overlap, 50 unmatched. Per-hospital Health Information Organization and TEFCA participation are deliberately absent because no machine-readable participant list exists.
Null hypothesis
Hospitals in nonmetro Pennsylvania counties and Critical Access hospitals publish FHIR endpoints at a materially lower rate than metro hospitals, and published organization records reliably resolve to an endpoint. Both halves rejected: rural publication runs above the statewide rate, and organization-to-endpoint resolution fails for the majority because of one vendor.
Denominator
The 187 hospitals with a Pennsylvania address in CMS Hospital General Information. County rural status is the USDA ERS Rural-Urban Continuum Code 2023 (4-9 nonmetro), covering 34 of 67 counties. Critical Access is the CMS facility-level federal rural designation, 17 hospitals. The endpoint denominator is the set of Pennsylvania organizations published in certified-EHR bundles (10,177 at the pinned snapshot).
Data source
Five public sources, no BigQuery and no paid API: CMS Hospital General Information; USDA ERS Rural-Urban Continuum Codes 2023; USDA ERS county median household income; Census Population Estimates vintage 2023 for median age and share 65+; and ftrotter-gov/npd_slurp_cehrt_clientfhir_cache, the CMS directory team's cache of ONC Lantern certified-EHR bundles. Compute script: `analysis/pa_rural_health.py`.
Pre-registered: results not yet published.
This finding is listed here before results drop. That is the project's trust contract: the null hypothesis and the computation are public first, and numbers follow. Methodology: /methodology.
Get the next finding in your inbox. One email per release, no filler.