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Averting a Digital Divide: Challenges and Successes in Rural Health IT

September 13, 2012
by Gabriel Perna
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In honor of National Health IT week, the National eHealth Collaborative (NeHC) recently hosted a webinar about the challenges and successes of implementing health IT in rural and underserved communities.  The webinar featured insights from Chantal Worzala, director of policy for the American Hospital Association (AHA), and Earle Rugg, CEO of the Rural Health IT Corporation. One of the main themes was the issue of averting a digital divide between rural and urban communities, something that has already begun.

Worzala started things off talking about the rural health landscape. She explained the differences between critical access hospitals (CAHs), sole community providers, and rural referral centers. Interestingly, nearly half of the hospitals in the U.S. are rural.

Worzala described the characteristics of a critical access hospital. As of March 30, 2010, there were 1,309 CAHs in the country. They are fairly spread out, touching all but five states. These CAHS are a 35-mile drive from the nearest hospital or CAH or more than a 15-mile drive in areas with mountainous terrain or only secondary roads. They have 25 acute-care beds. She noted while these hospitals do receive “special treatment,” when it comes to meaningful use, they still needs to meet a number of requirements to receive incentives from the Centers for Medicare and Medicaid Services (CMS).

The aforementioned digital divide was expressed in terms of numbers by Worzala. As of 2011, according to an AHA survey, while 29.1 percent of urban hospitals had adopted a basic EHR system, only 19.4 percent of hospitals had done so. Only 20.8 percent of small hospitals had adopted an EHR, while 43 percent of large hospitals had done so. Of the 1,133 hospitals that have met CMS’ meaningful use requirements, a mere 151 are CAHs. In a remarkable twist, CAHs have to meet these requirements by the end of fiscal year 2012, which actually comes in a few weeks, on Sept. 30.

As Worzala said, “I’m afraid the majority of critical access hospitals are not going to benefit from the Medicare EHR Incentives to the fullest extent.”

There are four major challenges for rural hospitals when adopting health IT systems, as outlined by Worzala. The most obvious three are a lack of access to capital funds, a lack of sufficient broadband, and market issues. They all play hand-in-hand. For instance, many rural hospitals can’t invest in a large EHR system, and even if the market presented them with a cloud-based EHR solution, there are still questions of having the bandwidth to support such a system. She mentioned how some hospitals are still on dial-up, which is a cold splash of reality. There are also challenges with regulatory actions, with the understaffed CAHs only having 2-3 people to understand compliance.

It’s not all a dark cloud, though. First, as Worzala mentioned, the FCC has created a pilot funding program to facilitate the development of a  nationwide broadband network dedicated to healthcare. After Worzala concluded her remarks, Rugg, of the Rural Health IT Corporation, which specializes in funding health information exchanges and EMR projects for the rural community through writing grants, talked about some successful implementations of health IT in a rural setting.

Rugg said in terms of implementing an EHR at a rural health facility, there have generally been three methods. 

  •        Purchasing a clinical module from the vendor of the financial management/billing software.
  •        Throwing out your legacy system, and going with single system.
  •        Integration or a best of breed approach, leveraging different applications. He focused on several examples that used this approach successfully.

Regardless of the approach, the successful implementations Rugg has seen were done when health IT leaders at rural hospitals brought in clinician champions to the process. Physician champions and nurse champions, he said, helped train the rest of the staff.

Rugg offered other important tips, such as determining the organization’s inefficiencies when implementing an EHR. He advocated for collaboration, using the example of multiple CAHs developing a successful HIE. In addition, both he and Worzla mentioned telemedicine, seeming to be positive and optimistic on its role.

Even with all of the challenges, both speakers had a strong sense of optimism. Rugg said he was bullish on the prospects of health advancing rural healthcare. Worzala said she has seen tremendous hard work and success in rural health, and people who are doing whatever it takes to do right by their community.