Rural is Not Small Urban: Issues in Rural HIT

By Joe Wivoda, Chief Information Officer

Recently, someone asked me what I thought the major issues were with Health Information Technology (HIT) in rural hospitals and clinics. I get this question quite often, and I realized I have never blogged on this before! Since it is National HIT Week, and I am blogging daily, what better time is there to blog about rural issues? Some of these barriers apply to urban facilities but are amplified in rural, kind of like in an urban yard, you might expect to see a push mower, while in my yard, there is a Ford tractor. Or something like that. My metaphors have been weak lately.

Workforce

Access to qualified HIT staff is still an issue in many rural areas. Networks and systems typically have HIT staff, but many CAHs and Rural Health Clinics (RHCs) make do with a local personal computer consultant or someone who has some basic troubleshooting skills. It is rare to have a skilled HIT person working at a standalone CAH or RHC, but when there is, the facility is typically far ahead of those without HIT talent.

It can be the same issue for clinical HIT staff. When the electronic health record (EHR) is put in, there usually will be some sort of “super user” that needs to be assigned. They are responsible for implementation and internal support moving forward. Most CAHs and particularly RHCs can’t afford to have someone partially dedicated to maintain and support the clinical side of the EHR, so a talented nurse who is the super user will often need to step back into nursing full time, and the EHR gets neglected.

Cost of Upgrades

Particularly this year, with the new Meaningful Use certified technology requirements, EHR upgrades have been very expensive. I am aware of several CAHs who have had to pay more than $200,000 to implement the 2014 versions of their EHRs. Additionally, many of these upgrades require re-implementation of several core features, like computerized physician order entry (CPOE). The new rule allowing delays in Stage 2 does not apply if you merely can’t afford it. This can be a difficult expense to justify, particularly when the financial incentives are coming to an end.

Transitions of Care

I have written about this in a couple of other blogs. Of all of the Meaningful Use Stage 2 measures, I feel this is the most important for making a difference in the communities we serve. Patients need this, and our referral partners are begging for this!

The Stage 2 requirements around transitions of care and summary of care records has been difficult for rural facilities. Many of them do not fully understand their referral patterns, which is a critical step. Also, many CAH referral partners are either not eligible for meaningful use and do not have the capability to receive continuity of care documents (CCDs) (long term care, home care/hospice) or they are not interested/motivated to work with the CAH/RHC to exchange the information (urban tertiary/quaternary hospitals and specialists). To achieve the stage 2 measures, it will be necessary to overcome these hurdles, but more importantly, it is the right time to solve the problem of poor information flow for referrals. We are harming patients every day by not solving this!

Clinical Quality Measures

Generating electronic Clinical Quality Measures is difficult even when you have qualified HIT staff, and with the workforce shortage in HIT/Clinical IT at most rural facilities, this can be nearly impossible. It isn’t that they just need someone who can extract the data either, because it is typical that either the data is not collected, or it is not collected in a uniform manner. The act of attempting to generate clinical quality measures electronically will always result in process improvement opportunities. Just take a look at how your facility is collecting smoking status. I bet it is being collected in multiple fields and may not even be discrete. Now try doing a report on falls…

ICD-10 Preparation

ICD-10 is coming. Most CAHs and RHCs have done little about this, and if they have, it is just the training of providers and coders. There is much more HIT work to do prior to converting to ICD-10, including testing with payers and interface testing. Now would be a good time for me to plug our ICD-10 Toolkit. Free to download!

Health Reform Preparation

Rural health has been slow to understand and implement technology to support health reform. In particular Health Information Exchange (HIE), data repositories and reporting technologies are not in place or being considered. This goes back to workforce and also awareness of the implications of moving from volume to value. Health reform is here; our payment models will be changing; and HIT is a core foundation piece for being able to operate under the new models.

These are a few of my thoughts. No, the sky is not falling. Yes, we can remove these barriers. It just takes some focus and new ways of working. That isn't easy, but we need to make the changes to survive and thrive in a world where the rules are changing rapidly.

Speaking of rapid change, tomorrow is my last blog entry for HIT Week, and it will be a doozy! I will be putting on my futurist cap and discussing what HIT will look like in the next several years. Tweet me @WivodaRural, and give me some of your thoughts. This will be fun!