Some challenges they face are unique to their markets’ economic, social and geographic factors. Other threats are universal — felt by hospitals small and large, in town and country — but especially daunting for rural hospitals, considering their thin margins and limited resources.
While they may not have the largest footprint, small to midsized community and critical access hospitals play a crucial role in the U.S. healthcare system. Fourteen percent of Americans, or approximately 46 million people, live in rural counties, according to the Pew Research Center. The U.S. population is aging nationwide, but rural areas have a higher share of adults age 65 and older than urban or suburban counties, meaning they also see higher prevalence of chronic disease, a higher disability rate, lower prevalence of healthy behaviors and a growing gap in life expectancy compared to the nation as a whole, according to population health researchers.
“Just because you’re a rural, small- to medium-sized hospital doesn’t mean you don’t have people who are as sick as can be,” said Paul Black, CEO of Allscripts. “They have dietary problems, anxiety problems, cardiac problems — people with those health issues don’t just live in big cities.”
Since 2012, Mr. Black has led Allscripts, a trusted partner to many leading healthcare organizations and thousands of clinicians around the world for its EHR, population health, patient engagement and revenue cycle management services.
In October 2019, Allscripts hosted a private summit in Chicago at the Becker’s Hospital Review 5th Annual Health IT + Revenue Cycle Conference for leaders from hospitals with 100 or fewer beds across the country to discuss opportunities and challenges in the rural healthcare landscape, including innovation, clinician burden, population health and variation in clinical care and practice. What follows is an abbreviated summary of that gathering.
‘You are their last hope’
Small to midsized community hospitals in smalltown America face distinctive economic, social and geographic disparities that can challenge healthcare delivery and limit access to care. People who live in small or rural communities are less likely to receive the basic healthcare they need, and physical distance from care is a primary reason. Consider rural residents who live on farms and must travel long distances to reach a healthcare provider. The time they must take off work to make an initial or follow-up appointment causes many to delay or forgo care. This dynamic can make rural hospitals’ population health efforts especially difficult.
“We can talk about precision medicine, consumerism, telemedicine and all those wonderful things,” said Mr. Black. “But I think about what you do day in, day out, 99 percent of the time when people come to your emergency room or your critical access hospital. You are their last hope. They don’t want to go to the big city.”
To complicate things, small and midsized community hospitals are encountering another major threat on a regular basis that counters their very mission: cyberattacks. All hospitals make attractive targets for cybercriminals due to the increasingly interconnected nature of their operations and IT, but smaller hospitals are more susceptible to cyberthreats like ransomware since they are less likely to possess robust cybersecurity policies and resources and more vulnerable to the financial impact, according to Moody’s.
“There’s a hot place in hell for people doing cybersecurity attacks on hospitals, and a lot of you are vulnerable to that,” said Mr. Black. “You didn’t do anything to deserve it, but it’s a real, live issue in this world today. Having an infrastructure in place with a shield against that is not impenetrable, but more effective than what’s probably happening each and every day at your hospitals.”
Many rural hospitals have minimal operating margins with little room for financial loss. In fact, 21 percent of U.S. rural hospitals are at high risk of closing unless their finances improve, according to a 2019 analysis from management consultancy firm Navigant, which assessed hospitals’ operating margin, days cash on hand and debt-to-capitalization ratio. One determinant Navigant specifically cited for at-risk hospitals is their lack of capital to invest in updated, innovative technology.
Innovation to transform healthcare: It takes a village
Thousands of hospitals, health systems, community practices and pharmaceutical companies rely on Allscripts to build open, connected communities of health through its EHR, financial management tools and population health systems. The Chicago-based company is consistently expanding its offerings through its longstanding relationship with a major multinational technology company to complement its software products and operating systems. That company is Microsoft.
Allscripts made its community care EHR platform available through the cloud via Microsoft Azure. This single-platform solution is an end-to-end offering with clinical, financial and ambulatory content to reinforce organizations’ operational and financial health. The cloud solution offers the same capabilities as the on-premise version of the EHR, but the subscription model enables faster implementation and includes upgrades.
Sunrise™ Community Care is hosted on Microsoft Azure’s secure cloud, with annual upgrades, disaster recovery and high availability for planned and predictable maintenance during non-peak times, making it a more secure shield against the cyberthreats targeting community hospitals that Mr. Black discussed.
Allscripts and Microsoft are established partners that consistently seek new ways to strengthen their collaboration. In fact, Allscripts is Microsoft’s 2019 U.S health partner of the year. In January 2019, Microsoft and Allscripts subsidiary Veradigm inked a memorandum of understanding to develop a product to help researchers conduct clinical studies through the Allscripts cloud-based EHR. The collaboration will first focus on extending Allscripts cloud-based EHR platforms with innovative technologies that enable integrative research, such as automated match-making to pair patients and providers with the right study protocols.
Casey McGee, vice president of partner development for Microsoft US, said the relationship with Allscripts is symbolic of Microsoft’s philosophy for innovation. Since it was founded in 1975, Microsoft has viewed itself as a company built upon partnerships and relationships within the ecosystem. This outlook is principal to Microsoft Co-Founder Bill Gate’s philanthropic efforts with the Bill and Melinda Gates Foundation, which through its Global Health Division, aims to reduce health inequities and eradicate disease.
“The work we do with Allscripts is built on trust. We need partners like Allscripts to come to us with innovation,” said Mr. McGee. “What we create comes alive when our partners come to us with new ideas and projects. The only way that Bill and Melinda Gates solve diseases or improve care is through partnerships.”
A system approach to address clinician burden in community hospitals, one interaction at a time
One difficulty Allscripts aims to alleviate through innovation is clinician burnout, a pernicious problem affecting hospitals of all sizes in all locations. No one organization has cracked the code on how best to counter it. “Leaders are spending a significant amount of money on burnout; it’s an ongoing problem that isn’t going away,” said Ross Teague, PhD, director of user experience for Allscripts.
But Dr. Teague also pointed out that burnout is not necessarily a new problem. The uncomfortable reality is that healthcare has burned out clinicians for a long time, but patient outcomes have remained steady since clinicians are quite proficient in adapting to their environment.
This reality doesn’t mean clinician fatigue is something hospitals can afford to ignore — for a host of reasons. There are varying degrees of burnout, but even the most moderate are detrimental to organizations. On a daily basis, burned out clinicians are less likely to mentor peers or participate in initiatives, such as task forces and governance groups. Patients are also less engaged when members of their care team are not engaged.
Allscripts believes burden is a system problem. There are many causes, but not one is singularly responsible. “You can’t view it as, ‘If we didn’t have as many regulatory problems, burnout would go away.’ Some health IT vendors also say they are the secondary problem, thinking it’s other things that cause burnout,” said Dr. Teague.
It’s critical to consider all of burnout’s contributing factors when designing solutions to conquer this longstanding, growing problem. If burnout is viewed in a single modality, any attempted solutions will only exacerbate other demands on clinicians’ time and energy.
How is Allscripts addressing clinician burnout? The company begins by targeting one the biggest culprits: cognitive fatigue.
Cognitive fatigue can be defined as a subjective lack of mental energy that interferes with our activities. Experts say it most commonly results from the accumulation of excess: too many decisions, too many interruptions, too much work in too little time, and too many demands or shifts in attention without proper time to pause and restore cognitive reserves.
The thing about cognitive fatigue is that it’s often experienced in the background compared to the primary pain points clinicians encounter in the foreground of their daily EHR use. Take clicks, for example. If asked whether Allscripts should create an EHR that required substantially fewer clicks, most clinicians would cheer in agreement.
But if an EHR contained all of the same data fields for patient demographics, progress notes, vital signs, medical histories, diagnoses, medications and immunization dates in a single frame — yes, clicks would be eliminated. But the cognitive effort required to navigate such a dense interface would undoubtedly result in fatigue and in little time. “It would be an unusable EHR. It doesn’t matter if you get rid of clicks or scrolling if it can’t be used,” said Dr. Teague.
Instead, Allscripts is focusing on incremental but meaningful adaptations within its EHRs, including Sunrise Community Care, to cumulatively reduce clinicians’ cognitive exertion when using the EHR and related software.
When IT interfaces put clinicians’ cognitive resources in competition, straightforward work takes more effort than it otherwise could. Dr. Teague compares it to a jog around a park, but while wearing 45-pound firefighter gear — for no reason.
Consider the presentation of dates. It is much easier to comprehend a date when it is spelled out with the month — Dec. 12, 2020 — versus numerated as 12/12/2020. Simple issues with alignment, like a desktop with off-center tabs, can slow users’ reading and comprehension rates. Even use of color matters. When we visually read signs with colors, we need positive contrast between the foreground and background. Poorly contrasted colors result in unnecessary cognitive burden.
Allscripts spends a great deal of time assessing how products are used, and its technicians aim for products to be actively helpful instead of passively useful. This distinction inspires other relatively straightforward yet meaningful adjustments for the user. Dr. Teague highlighted several, including strategic icon placement that reduces the amount of time it takes users to research treatment options.
The Allscripts team makes these changes knowing that the communication of dates, placement of icons or use of color individually do not significantly move the needle on burden but the collection of these design alterations can positively change the user experience. The team also knows these modifications alone will not solve clinician burnout. Rather, it’s users’ collective experience that makes these adjustments worthwhile.
“Users don’t review us on our features; they don’t care about the features,” said Dr. Teague. “They instead evaluate us on how these features help them achieve their goals. Are they spending more face-to-face time with patients? Can they go home to enjoy dinner with their family?”
Population health and creating a smart healthcare community
The goal of population health is to create a smart healthcare community, in which care is safe, timely, efficient, effective, equitable and patient-centered. A single hospital will likely define several populations for which it aims to improve health outcomes and behaviors, and the work of maintaining a healthy population is not limited to any one care setting.
“Historically, we waited for patients to come to the hospital — it was sick care,” said Michael Blackman, MD, medical director of population health for Allscripts. “But if you are responsible for an entire population, you have to care for the people who don’t come into the hospital.”
Rural residents’ physical proximity to care is a primary challenge community hospitals face in their pursuit of population health. This obstacle is added to an existing series of economic and demographic shifts that all healthcare providers must account for when executing their population health strategy:
- Patients are living longer, and they will continue to live longer, which poses challenges to healthcare access and clinicians’ time. Clinicians are ill-positioned to care for patients beyond their presenting problem when they only have several minutes for each visit, for instance.
- Costs are on the rise. The U.S. spends about twice what other high-income nations do on healthcare, largely due to steeper prices for drugs, medical devices, physician and nurse salaries and administrative costs. At the same time, the country has the lowest life expectancy and the highest infant mortality rates, studies have found.
- CMS is moving to a value-based model, which overhauls how care is reimbursed and how hospitals are funded. Hospitals must know their data to properly assess performance-based contracts and protect their revenue from risk.
- Healthcare accounts for only 20 percent of a patient’s outcomes, while health behaviors, social and economic factors and the physical environment comprise the remaining 80 percent.
No one believes population health is achievable through the EHR alone, noted Dr. Blackman. Healthcare providers must account for major socioeconomic, demographic shifts that span well beyond software and health IT. But even still, technology can do more now than it has in the past to bridge the gap in care for these populations.
EHRs and other technology solutions have delivered an ample amount of data; now the question is whether organizations are using this data effectively and in alignment with their population health goals. Hospital needs tools that turn available data into information clinicians can use to direct care for patients while also refining the data over time.
“You have to take every opportunity you have with the patient,” said Dr. Blackman. He noted that every office visit is an opportunity to deliver more complete care, such as ensuring patients are up to date with their preventive care services, such as vaccines, mammographies or colonoscopies.
From its position in the health IT environment, Allscripts believes four major components of population health combine to ultimately result in the care outcomes patients experience. These are:
- Aggregation and interoperability. Is the data combined and normalized? How is the data pulled and analyzed? Is the care team able to discern, from the data, whether the patient has already received the same care at another facility, for instance?
- Analytics. Is the data leveraged to inform decisions at the point of care? Does the data create actionable information for clinicians? With the right data, hospitals can design interventions based on risk factors and identify patients who need to be monitored.
- Care coordination. Are high-risk, high-cost patients effectively managed? Optimal care coordination ensures patients do not undergo unnecessary, duplicative administrative work and medical care. “The chances that a patient is only receiving care from a single provider are very slim,” said Dr. Blackman. “That’s why you hear patients ask, ‘Don’t you people talk to each other?'”
- Patient engagement. Are patients involved in their care? When they are, clinicians and care teams are much better positioned to take a holistic view of care and better account for the 80 percent of health determinants outside of the clinical setting.
With the right data turned into actionable information, small and midsized hospitals can take better advantage of every interaction with patients to address gaps in their care and address patients who are not being seen. Advanced analytics make it possible to slice and dice data, arming care teams with a variety of perspectives on their patient populations. But these tools must be available within the clinician’s workflow and from the EHR, aggregated and normalized into information that clinicians are motivated to act upon.
“How do we take data, turn it into information, and then get insights from it to create actions?” Dr. Blackman voiced this question, one he targets daily with his team at Allscripts as the company builds EHRs and software that ensure hospitals’ population health strategies become population health accomplishments.
Driving out variability in care to drive organizational change and patient outcomes
Statistical methods are central to healthcare, allowing the study of diseases, patients and epidemiological events. But when it comes to their experience and outcomes, medians and means are less palpable to patients.
“People don’t perceive averages — they perceive variability or extremes,” said Christopher Caggiano, MD, solutions director for Allscripts. “If you give a patient an average experience, they won’t remember it. And if you give them a bad experience, they are often more vocal than someone with a positive experience.”
Consider the familiar process of transitioning a patient out of the hospital. If a patient note is written at 6 a.m., it can take 7 hours to get him or her out the door. “Why does it take so long?” asked Dr. Caggiano.
Patient transitions need not be such a time-consuming task. To move patients out of the hospital and back into their homes more quickly, care teams need data to identify existing inefficiencies and eliminate them. “All that matters to the patient is that they leave the hospital,” said Dr. Caggiano. “If you have quicker discharge times, patients will be more satisfied.”
Patient transitions are but one place where unwarranted variabilities occur and persist over time until the resulting inefficiencies are accepted as normal. Same goes for variations among physician practices. Perhaps Physician Practice A schedules appointments differently from Physician Practice B. Perhaps Clinic C moves from another product than Clinic D. Perhaps when two patients visit Physician E at different times of the week, they receive prescriptions for different medications for the same condition.
Unwanted variation in care is a substantial, multifarious category of waste in the American healthcare system. In a study published in JAMA in October 2019, researchers estimate that failure of care delivery, failure of care coordination and overtreatment or low-value care — all of which involve variation in clinical operations or practice — cost the system $205 billion to $346 billion annually.
Health systems, and community hospitals in particular, won’t drive out wasteful variation overnight. But health IT can serve as a targeted intervention to help time-strapped, well-meaning care teams make more clinically sound and cost-effective decisions. Consider the ordinary order set, which has long been a workhorse within the EHR yet was often underutilized as a tool to better control for variation.
Now, machine learning combined with human oversight has the potential to transform order sets to reduce variation and clinician burden while improving care processes and outcomes. Sepsis order sets, for instance, use evidence-based content to standardize care and reduce variation for a condition that can have subtle, non-specific signs and can mimic other conditions.
Dr. Caggiano says the EHR, when equipped with the right tools and streamlined workflows, is an effective way to nudge physicians toward clinically effective decisions that reduce unwarranted variation among providers and sites of care.
“You can’t dictate a physician to do it one way, but you can constantly show them,” he said. “If you input in the EHR why they should use a specific antibiotic, they will then use that. It makes it difficult for them to order something outside the norm.”
Conclusion
Despite their thin margins and distinctive economic, social and geographic disparities, there is no way around it. Hospitals in small-town America have the same mission as hospitals in New York, Chicago, Los Angeles and any other town. They care for the sick and prevent disease in their communities. The size of their footprint may be small, but their missions and reasons for being remain enormous.
Tight resources and thin margins mean rural and community hospitals cannot make investments lightly, even as they strive to solve for the same challenges that affect larger academic medical centers — population health, clinician wellbeing and reducing unwanted variation in care.
“There is a reality to what you do, and I want you to understand that’s something I get,” said Mr. Black. “That’s why we are building the solutions we’ve built and the infrastructure we have, in order to make that affordable for you. Our view is to give you all the functionality of Allscripts products and give you a single place to go for all of them.”
