Meaningful Use Outside of the Metropolis: The Challenges of Rural Health IT Adoption

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Rural hospitals face numerous challenges in the realm of health IT adoption. However, thanks to a helping hand from the federal government and other organizations, they're making progress.

Michael Archlueta is more than just the director of IT of Mt. San Rafael Hospital, a 25 bed critical-access hospital in Trinidad, Colo. Essentially, he serves as the individual responsible for a never-ending list of responsibilities, which would normally be dispersed unto many individuals within the IT department.

"At times, I've faced difficulty in regards to having limited resources made available to me," he says. "The challenge has been the tremendous work-load that I’m juggling and expectations that I’m continuously striving but successfully overcoming all obstacles."

Michael Archuleta Pro PicIn a community of about 9,000 people in rural Colorado, he says it's "extremely difficult" to recruit individuals that have the required health IT background. And that's not the only challenge rural hospitals face. Implementing an electronic health record system isn't very affordable, and the pressure is on for rural hospitals to turn the increasingly large sums they have spent into a worthwhile investment that will eventually improve quality, safety and efficiencies; reduce health disparities; engage patients and their families; and improve care coordination and population and public health, all while maintaining the privacy and security of patient health information, Mr. Archuleta says.

"In order to become fully successful in implementing an EHR, while also meeting meaningful use, we all need to work together toward the common goal at hand, as a team," he says. "We need to make sure that we complete these tasks in a timely manner, while remaining as efficient as possible and most importantly we must provide the best patient care for our community."

Mt. San Rafael is not alone in facing these obstacles to implement a successful health IT adoption. According to the Office of the National Coordinator for Health IT, CAHs and other small, rural hospitals — which serve the approximately 60 million Americans residing in rural communities — can face hurdles when it comes to funding, personnel and other resources needed to implement EHRs and other forms of health IT.

However, the situation isn't as grim as it might seem for rural providers. The ONC and other organizations such as the Health Resources and Services Administration's Office of Rural Health Policy have provided resources and launched efforts to keep smaller, rural hospitals from falling behind in health IT.

"My mandate is to make sure that rural communities and rural healthcare providers aren't left behind in the push to leverage technology in healthcare," says Leila Samy, the ONC's rural health IT coordinator. "These rural safety net hospitals are anchor institutions. They are often the largest or second largest employers in their communities. Health IT in these rural communities is really a tremendous opportunity to fuel economic development."

The challenges: Lack of resources, funding stand in the way of IT adoption
All hospitals and health systems — not just rural ones — face significant incentives to adopt health IT, especially EHRs. The American Recovery and Reinvestment Act of 2009 authorized CMS to award incentive payments to eligible healthcare professionals and hospitals that demonstrate meaningful use of EHRs.

Through the Medicare and Medicaid EHR Incentive Programs, eligible hospitals, including CAHs, can earn $2 million or more, according to the ONC. At the same time, Medicare and Medicaid providers that don't adopt EHRs will face financial penalties starting in 2015.

Demonstrating meaningful use involves using certified EHR technology to improve quality, safety and efficiencies and reduce health disparities; engage patients and their families; and improve care coordination and population and public health, all while maintaining the privacy and security of patient health information. The scheduled meaningful use objectives will be implemented in three stages involving first capturing and sharing data, then advancing clinical processes and, finally, showing improved outcomes. Attestation for both incentive programs began in 2011.

Rural communities have the potential to benefit enormously from adopting EHRs, according to the ONC. In rural areas, health IT can help increase access to care, improve disease monitoring, target health education and compile regional data. It can also help reduce travel time for patients and their families and provide instant access to key information such as lab results, medication interaction and allergy safeguard details, among other benefits.

"I really think that a different set of guidelines and expectations should be implemented to better suit our smaller, rural critical-access hospitals," Mr. Archuleta says. "What needs to be understood is that not all hospitals operate similarly and that funding can often times be limited. If the government guidelines could be specifically written in a manner which would allow different timeline expectations in regards to the hospital size and demographic location, it would allow smaller, critical-access hospitals to prepare for the required funding ahead of time by being able to include it within their budget. This alone would lift the financial strain that these implementations often times generate."

On average, Ms. Samy says CAHs lose money on patient care, making IT investments even more challenging. In 2010, she says the median operating margin was 0.75. They also face obstacles to health IT adoption related to isolation, the surrounding geography and their size, in addition to workforce shortages and a lack of local access to resources such as consulting services.

"Rural patients are more likely to be uninsured or insured through a public program," she says. "[Rural hospitals] have low patient volume coupled with extremely small operating margins. They really do need help and assistance in this area."

Helping hands: Federal and state officials reach out to rural providers
Since 2010, the ONC and the Health Resources and Services Administration's Office of Rural Health Policy have spearheaded various efforts to provide that help and assistance, fostering the adoption and use of health IT in rural communities.

For instance, the ONC and ORHP have partnered with the Department of Veterans Affairs to award funding to several states so they can use health information exchanges to improve care coordination and quality for rural veterans. Through this initiative, the ONC and ORHP were able to award a total of $900,000 to Maine, Montana and Alaska to use health information exchange to improve the quality of mental health care and other services for veterans in rural regions.

Additionally, in 2011, the ONC and ORHP entered into an agreement with the U.S. Department of Agriculture to give rural health clinics and hospitals access to USDA grants and loans for the acquisition of health IT infrastructure including hardware and software. Initially, the agreement applied to the USDA's Community Facilities grant and loan programs. In 2013, the effort was expanded to all Rural Development funding and assistance programs through pilot initiatives in Kansas, Iowa, Mississippi, Texas and Illinois. By September 2013, the initiatives had generated more than $38 million for participating CAHs and rural hospitals.

The ONC and ORHP have also partnered with the Federal Communications Commissions to expand rural broadband access and connectivity, and they have joined forces with the Department of Labor to help build a better health IT workforce available to serve rural providers.

Furthermore, the ONC has dedicated $30 million to the Regional Extension Center program, which has established 62 centers nationwide to assist primary care providers with EHR implementation and other health IT needs.

Rebecca Madison, executive director of the Alaska eHealth Network, says her organization — which manages the state's REC — aids rural providers with few resources and little funding by supporting them in implementing EHRs and connecting their EHR systems with others through a health information exchange.

"One of the things that we try to help providers understand is what their best options are using the resources available in their area," Ms. Madison says. "That often…is a solution that's cloud-based so the need for software or hardware maintenance is lowered. Overall, we try to help them find solutions that fit their needs."

AeHN uses health information exchange technology from the software company Orion Health to help providers achieve interoperability. Suzanne Cogan, Orion's vice president of sales and client relationships, agrees that "zero footprint," cloud-based solutions work best for rural hospitals and health systems.

"Due to the lack of financial and human resources to implement and maintain EHR technology, rural health facilities tend to be better served by web-based or cloud solutions," she says.

In Colorado, the state's office of rural health has created the nonprofit organization Data Services for Healthcare to provide health IT assistance to providers in frontier, rural and urban underserved regions of the state. DaSH Executive Director Bill Bolt, PhD, says his organization has pinpointed a data management solution for rural healthcare providers.

"Certified electronic health records are in and of themselves designed for the input of data," Dr. Bolt says. "But they're not designed to effectively and efficiently extract data and then transform that data into what we call actionable information. That is a real dilemma not only for rural healthcare but especially for rural healthcare because of the cost involved in being able to put a software system of place that will allow for the extraction, transformation and loading of the data in the EMR and then turning it into actionable information for improving clinical outcomes."

The solution DaSH has identified involves a business intelligence tool called Enterprise Cyberquery, which Dr. Bolt says can be used as an EHR system enhancement. This database query and reporting tool can extract data from various systems within a facility and is easy to use, which means providers can implement it without having to hire new IT personnel to operate it.

"The ECQ product actually saves having to hire someone," he says. "It's something that can be replicated throughout any rural or frontier area."

Making progress: Rural hospitals exceed expectations
It seems like all of the effort the ONC and others have put into helping rural hospitals is paying off. Last year, the ONC issued a nationwide challenge, with the goal of helping 1,000 CAHs and small, rural hospitals attest to meaningful use stage 1 by 2014. By July 2013, 1,115 had achieved meaningful use.

"We were really impressed to see the incredible amount of progress that happened just in the course of one year," Ms. Samy says.

As of October 2013, about 70 percent of CAHs and about 85 percent of other small rural hospitals had attested to meaningful use stage 1, roughly on par with medium and large hospitals, 85 percent of which had attested to stage 1, Ms. Samy says.

She also says there have been "bright spots" in terms of REC successes. The Regional Extension Center of New Hampshire, for instance, has been ranked as one of the best-performing RECs. As of August, more than 85 percent of CAHs in New Hampshire (10 out of 13) had attested to meaningful use stage 1.

Gary Tomlinson, RECNH's CAH consultant, attributes his success to his background as the IT director for Cottage Hospital in Woodsville, N.H., the first CAH in the state to reach meaningful use in July 2011.

"I got really excited when the regional extension center had an opening so I could go out there and help these other hospitals," he says. "That's really our main mission, to get out there and help those small hospitals. We were there to help them get through the meaningful use process."

Mr. Tomilson says he assisted the hospitals in reaching meaningful use measures by, in most cases, overhauling their workflow to make sure the right people were addressing the right measures.

"You don't want the clinician to be responsible for entering demographic information," he says. "That's solely the job of the registrar."

Additionally, he says it's important that the hospital management and administrators are on board with health IT adoption.

Looking forward to the future: Meaningful use stage 2
Mr. Tomilson predicts the biggest concern for rural hospitals in the next few years will be getting the financing necessary for the tools required to attest to meaningful use stage 2 (which CMS recently extended through 2016). He says RECNH is staying in constant contact with CMS to ensure it can clearly interpret regulations for the state's hospitals.

"It's going to be a challenge, but with the foundation they have now, I think the hospitals are going to be successful," he says. "I believe all 10 of the hospitals we've helped will reach stage 2 in 2014."

Ms. Samy of the ONC also seems optimistic about rural hospitals' ability to continue forging ahead with successful health IT adoption.

"I see this as a really exciting time for rural health IT," she says. "The distinct impression I'm getting from the feedback speaking with physicians in rural communities and with CEOs and CIOs of critical access and small rural hospitals is that stage 1 of meaningful use essentially served as a jumping off point, a diving board to help them go where they want to go."

More Articles on Health IT:
OIG: CMS Should Develop Best Practices to Detect EHR Fraud  
The Evolution of Telehealth: Predictions for 2014 and Beyond  
ONC Leads Initiative to Improve Rural Health IT Adoption 

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