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Small, Rural and Critical Access Hospitals Lagging Behind On Electronic Data Exchange

July 28, 2016
by Heather Landi
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Small, rural and critical access hospitals are lagging behind larger urban and suburban hospitals with regard to interoperable data exchange and use of electronic health information, according to a data brief from the Office of the National Coordinator for Health IT (ONC).

The data brief takes a look at variation in interoperability among U.S. non-federal acute care hospitals, based on 2015 data. While ONC finds that hospitals, overall, are continuing to make progress with regard to electronic health data exchange and use of health information, there is notable variation in interoperability across hospitals, with small hospitals, rural hospitals and critical access hospitals (CAHs) advancing more slowly with significantly lower levels of health data exchange.

According to the ONC data brief, hospitals are shifting their means of exchanging data away from using paper-only methods of exchange. The percentage of hospitals that used only non-electronic means to send and receive information significantly declined between 2014 and 2015. For receiving summary of care records, 26 percent of hospital used non-electronic means in 2014 and that dropped to 17 percent, while with regard to sending summary of care records, 14 percent used non-electronic means in 2014 and that dropped to only 7 percent last year. There was a corresponding increase in the percentage of hospitals that used a mixture of paper and electronic methods to send and receive information. Three-fourths of hospitals now use a mixture of paper and electronic means to receive records, up from 67 percent in 2014, and 84 percent use both paper and electronic transmission to send summary of care records, up from 77 percent in 2014.

Hospitals indicated that they still use paper-based methods to exchange information due to their exchange partners’ limited capability to electronically receive information.

And, it seems progress has been made with regard to the capabilities of long-term care and behavioral health providers to electronically exchange data with external providers, according to the data brief. Rates of hospitals electronically receiving information from long-term care providers and behavioral health care providers increased significantly from 2014, by 35 percent and 44 percent, respectively.

However, the data brief findings also indicate that hospitals' rates of both electronically sending and receiving patient summary of care records to and from long-term care and behavioral health care providers remained lower than with outside hospitals and ambulatory care providers. With potential Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Medicaid funding to enable exchange among providers not previously eligible for Meaningful Use incentives, it is likely that hospitals will continue to increase their electronic exchange of information with a variety of providers across the care continuum.

The ONC data brief also examined the means hospitals were using to enable interoperable exchange. Secure messaging using an EHR served as the most common means of electronically sending and receiving summary of care records, followed by the use of a HIO or other third party. A majority of hospitals leveraged external entities to enable exchange. About 6 in 10 hospitals used both a HIO and a HIE vendor to enable their exchange capabilities, and another 3 in 10 hospitals used a HIE vendor alone.

The ONC data brief examined the rate of hospitals to engage in all four domains of interoperability, as defined by ONC—electronically sending summary of care records, receiving summary of care records, querying or finding records and integrating summary of care records—and that analyzed that by hospital type.

Compared to larger urban and suburban hospitals, small, rural, and critical access hospitals have lower rates of engaging in the four domains of interoperability, and also had lower rates of information electronically available from outside sources or providers, and lower rates of their providers' using information electronically received from outside their hospital system.

Specifically, rural hospitals had approximately half the rate of engaging in all four domains of interoperability –electronically finding, sending, receiving, and integrating – compared to suburban and urban hospitals (15 percent vs. 34 percent, respectively). CAHs had significantly lower rates of engaging in the four domains of interoperability compared to non-CAHs as well (17 percent vs. 30 percent). And, only 18 percent of small hospitals engaged in all four domains of interoperability compared to 34 percent of medium and large hospitals.

While at least three-quarters of small hospitals, rural hospitals, and CAHs were electronically sending summary of care records, their rates were still lower than medium and large hospitals (90 percent), non-critical access hospitals (88 percent) and suburban and urban hospitals (90 percent).

A little less than 6 in 10 of small hospitals, rural hospitals, and CAHs were electronically receiving summary of care records. About 4 in 10 of small hospitals, rural hospitals, and CAHs queried patient health information from outside sources. About 3 in 10 small hospitals, rural hospitals, and CAHs had the ability to integrate summary of care records into their EHRs.

In an ONC HealthIT Buzz blog post, Vindell Washington, principal deputy national coordinator at ONC, wrote that further analysis is needed to better understand the causes of these specific disparities, and he noted that a key tool for reducing health and digital disparities overall in these communities is improving the rural health information technology (IT) infrastructure.

“Growing up in a small town in Virginia, I understand the vital role that health care providers in rural settings play in delivering essential health services, and the unique challenges that providers and individuals living in rural areas face. For example, more than half of the population in rural areas, and nearly two-thirds of the population in tribal areas, lack access to advanced broadband services,” Washington wrote.

In the blog post, Washington outlined the steps that ONC has taken to address rural health IT infrastructure and the challenges faced in rural healthcare.

“In particular, we are focusing on increasing access to financing for everything from brick-and-mortar infrastructure to software and broadband connectivity. For example, on behalf of the White House Rural Council, the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Agriculture (USDA) have been leading a Collaborative Rural Health Financing initiative to link health care providers serving rural, poor and tribal communities, as well as communities with large populations of rural veterans, with financing necessary for facility upgrades, telehealth and health information exchange. Between 2012 and 2014, this HHS and USDA led initiative generated approximately $1 billion in rural health care financing across 13 states.  As of May 2016, we have expanded this initiative to 18 states,” Washington wrote.

“In addition, on behalf of the Broadband Opportunity Council, we have partnered with the FCC, USDA, the Department of Commerce, the Appalachian Regional Commission, HRSA’s Federal Office of Rural Health Policy, and others, to convene Federal and non-Federal partners to address challenges associated with the broadband connectivity necessary for telehealth and health information exchange. Additionally, ONC has partnered with the VA’s Office of Rural Health on various initiatives under the White House Rural Council umbrella to support interoperable exchange of health information between small, rural hospitals, Critical Access Hospitals, and VA hospitals, since many rural veterans seek care both within the VA system and at their local health care provider or hospital,” Washington wrote.




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