Rural healthcare organizations are accustomed to feeling a lot like David, worried that their relatively small size precludes them from taking on large challenges. Certainly, as the healthcare industry struggles with the challenges associated with achieving the meaningful use of electronic records required to receive financial incentives available through the American Recovery and Reinvestment Act (ARRA), rural and community healthcare organizations are once again feeling the pain of dealing with a Goliath-like challenge.
To receive their share of the $27 billion-plus available through the stimulus bill, healthcare organizations must comply with a detailed set of requirements. Those standards are designed to ensure that organizations not only install electronic health records (EHRs), but also use them in a manner that produces meaningful data and ultimately significant results.
The challenge has resulted in much trepidation throughout the industry. Many industry leaders are worried that organizations simply won't have what it takes to meet the requirements, which are considered to be somewhat demanding.
Rural hospitals, with their limited financial and operational resources, are experiencing even more panic, as these organizations typically are not as far along in their information technology implementation journeys. Consider the following: among hospitals with fewer than 100 beds, only 4.9 percent have implemented an EHR compared with nearly 16 percent of hospitals with at least 400 beds, according to a study published in the New England Journal of Medicine.
Louis Wenzlow, director of health information technology at the Rural Wisconsin Health Cooperative, based in Sauk City, points out that because small and rural providers are starting at the low stages of EHR adoption, these providers will be less likely to meet the meaningful use requirements and least likely to access incentives and avoid penalties.
According to the National Rural HIT Coalition, Duluth, Minn., small hospitals face an uphill battle because:
The 2011 meaningful use draft requirements roughly correspond to reaching Stage 4 of the seven-stage Healthcare Information and Management Systems Society (HIMSS) Electronic Medical Record [EMR] Adoption Model. Critical access and rural acute care hospitals average 1.2 on the HIMSS EMR Adoption scale, whereas general medical-surgical hospitals average 2.5.
A reasonable time required for any hospital to implement from Stage 1 to Stage 4 is three to five years.
Many critical access hospitals and rural acute care hospitals will be required to essentially start from scratch after determining that their existing vendors will not provide what's needed to reach meaningful use.
Critical network infrastructure issues need to be addressed just to get an EHR running.
Small in Staff, Nimble in Implementation: Parkview Hospital
Although many healthcare leaders fret over how they will meet all of the government's requirements for meaningful use, I simply believe that we will meet the requirements. Why? It's the right thing to do. And, throughout my career in healthcare, I've adhered to a pretty simple philosophy: If you do what's right, you will improve care.
With this philosophy in place, we started on the EHR path here at Parkview long before the government added the ARRA financial incentives to the mix.
As a matter of fact, when I took over as CEO here about eight years ago, I suspected that technology could help move the hospital forward. To start, when I initially came on board, patient medication errors averaged about 4 percent. Nurses at our critical access hospital dispensed medications to patients, and a traveling pharmacist was on-site only eight hours a week.
To me, it was obvious that we needed to change. So, we started using a remote pharmacy service and implemented an automated pharmacy management system, and subsequently drove our medication error rates down to less than 1 percent.
Such results whet our appetite for more. After speaking with my chief nursing officer and business office manager, we all agreed that we needed to pursue a comprehensive EHR. More specifically, we felt that an EHR could help us in our mission: providing high quality care to the members of our rural community. Although initially expensive, we thought that an EHR was a sound long-term financial investment, as the efficiency and quality results could eventually help us lower costs and realize a positive return on our investment.
To get the initiative started, I began to educate the board about the value of an EHR system in a rural facility. To do so, I met with the board several times over two years and presented several studies illustrating just how EHRs could have a positive impact on clinical care, operations, and ultimately the hospital's bottom line. I spent a year looking at systems and finally narrowed the field to what would work for our hospital.
After getting the board members to agree to an EHR initiative, I focused my attention on the medical staff. At the time, I had three physicians on staff; one who had been practicing here for 37 years, one who had been here for 35 years and one who had been here for only two years. Unfortunately, the two physicians who had been here for a long time didn't want to have anything to do with the initiative. After presenting all of the benefits and asking for their cooperation, I finally had to take a stand and I said to them, “We're going to do this with or without you. If you want to practice here, this is how it's going to be.” They reluctantly acquiesced.
I MET WITH THE BOARD SEVERAL TIMES OVER TWO YEARS AND PRESENTED SEVERAL STUDIES ILLUSTRATING JUST HOW EHRS COULD HAVE A POSITIVE IMPACT ON CLINICAL CARE, OPERATIONS, AND ULTIMATELY THE HOSPITAL'S BOTTOM LINE. -ANN FAGAN-COOK
I then created a steering committee of physicians and other staff members to weed through the sales pitches before selecting a specific electronic records system. By getting a cross section of staff members involved I was able to create organizational enthusiasm for the project. Most importantly, staff members started to see the project as their own, not something that was being forced on them by the CEO.
The committee chose to implement ChartAccess Comprehensive EHR (supplied by Houston-based Prognosis Health Information Systems). The system stood out as the preferred technology after a detailed analysis of many other vendors' offerings. The Web-native EHR provides the hospital and its clinicians with a complete view of their patients' data to support better patient information and outcomes. Users can access the system from any workstation in the hospital or by using a standard operating system and a secure browser when remote.
To make sure that staff members bought into the system, I worked with Prognosis to ensure that users were getting exactly what they needed out of the system. Together, we talked with all of the clinicians and asked exactly what they wanted to get from the system and how they wanted the screens to look-so that the EHR would be readily accepted upon its launch.
With our clinicians supporting the EHR initiative, I am confident that our facility will achieve meaningful use required to receive the government's incentive funds. To do so, I am keeping tabs on the evolving legislation to make sure that we comply with the specific requirements. Instead of wondering if it is possible to meet the requirements, I simply set the requirements out in front of the staff, and make sure that we are doing exactly what it takes to qualify for the financial incentives.
Although some leaders at small hospitals take a defeatist attitude, I believe that being a small hospital actually puts us in a good position to qualify for the funds. We have fewer people to train on electronic records and little turnover. So, we won't have to worry about constantly having to train staff.
The Difference of Having a Full-time Project Leader: Hemphill Community Hospital
Although it is important to believe in technology and to have a vision, community and rural hospitals also need to make sure that the day-to-day tactical leadership that truly enables facilities to implement EHRs is in place.
Frequently, community hospitals struggle to get an EHR up and running simply because the details fall through the cracks. Typically, these organizations do not dedicate a leader to the project-and the chief nursing officer or chief financial officer will add the project to their existing list of duties.
At Hemphill Community Hospital, our 13-bed facility, the EHR project is getting its due, however. To start, hospital executives chose to implement ChartAccess EHR because the Web-native system is easy to use and maintain, making it possible to drive toward meaningful use with relatively few resources.
Executives, however, also realized that the project would need to be nurtured. So, they specifically brought me in to implement the technology-and to make sure that the hospital would qualify for incentive funds.
As director of information technology, I am devoting significant time and energy to the EHR implementation. If the project had been assigned to a nursing supervisor or financial manager, it's likely that the initiative would get only a portion of that staff member's time.
I WORK CLOSELY WITH USERS TO FACILITATE ADOPTION. FOR EXAMPLE, I HOLD MEETINGS TWICE A WEEK TO GO OVER ADOPTION ISSUES WITH VARIOUS CLINICAL GROUPS. -PATRICK MURFEE
To start, I worked hard to understand existing hospital workflows-making sure that the electronic system supports or improves upon these processes. As such, I was able to structure the electronic systems to mimic paper workflows in some cases, and to change workflow for the better in other situations. When making these changes, I worked closely with staff members to explain why the change is a good one and why it will eventually help move the organization forward.
In addition, I devoted considerable time to integrating and interfacing the EHR with various other systems such as the pharmacy solution. With the best of breed approach, we are using multiple systems but still offering users an integrated computing experience.
Most importantly, I work closely with users to facilitate adoption. For example, I hold meetings twice a week to go over adoption issues with various clinical groups. We have many clinicians who have never worked with computers before so I have to work closely with them to make sure the whole process is not so intimidating. In addition, if a particular user is having trouble, I sit down with that person and provide one-to-one training.
By paying attention to all of the details, and leading the staff in the day-to-day implementation of the EHR, we were able to overcome all of the hurdles that typically keep smaller providers from fully leveraging technology in their facilities. As such, we were able to implement the EHR across the enterprise, and are well on our way toward reaching the meaningful use criteria espoused by the federal government. And, the once monumental, seemingly out-of-reach EHR challenge now seems well within our grasp.
In addition, smaller hospitals have an especially difficult time recruiting and retaining IT leaders and staff members. According to the Rural Assistance Center, Grand Forks, N.D., as the U.S. healthcare industry converts antiquated paper record systems to modern information technology systems, it lacks a comprehensive plan to educate an HIT workforce that will support the transformation. As a result, the ability to hire HIT professionals may become a serious limiting factor in the adoption and implementation of electronic health records and other HIT especially in rural America.
We believe that the challenge is, indeed, a daunting one for rural healthcare organizations. But it is one that can be met successfully with the right leadership. Our stories illustrate the importance of having a strong visionary leader as well the importance of having an adept tactical leader to tap into the benefits of EHRs-and get on the road toward achieving the meaningful use required by ARRA.
Ann Fagan-Cook is CEO of Parkview Hospital, Wheeler, Texas
Patrick Murfee is director of information technology at Hemphill County Hospital, Canadian, Texas. Healthcare Informatics 2011 May;28(5):34-38