Advances in health information technology (health IT) hold great promise for helping small and rural communities overcome challenges in the provision of health care, such as distance and personnel shortages. Despite progress in the last few years, adoption rates remain low for clinical health information technologies, such as electronic health records (EHRs), computerized provider order entry (CPOE), and electronic medication administration record (eMAR) systems. A May 2006 report from the Flex Monitoring Team (PDF, 210 KB) , a consortium of rural health research centers from the University of Minnesota, North Carolina, and Southern Maine, showed that even though 95 percent of critical access hospitals (CAHs) have computerized their administrative functions (e.g., claims submission, billing, accounting, payroll, and patient registration), only 21 percent use some form of an EHR.
Many small and rural providers point to a lack of financial resources as an explanation for poor adoption rates. Implementation of health IT, such as EHRs, can be a very expensive undertaking. Apart from the software, numerous costs are associated with: (1) acquiring a health IT system, including hardware, peripherals, and networking expenditures; (2) implementation, such as staff time and initial lower productivity; and (3) maintenance. Furthermore, health IT investment must compete with other capital expenditures, such as the need for new operating room equipment. Small and rural health care providers also are hesitant to commit resources into a technological area that is not standardized and is constantly changing.
In small and rural communities, providers also face difficulty in obtaining and retaining the necessary staff and expertise to implement and maintain a health IT system. Staff turnover can be particularly challenging for small and rural providers. Each staff member often develops broad areas of expertise and assumes multiple roles within the organization and can be difficult to replace.
Although many CAHs and other small and rural providers have not adopted clinical health information technologies, many small and rural communities are using telehealth applications to provide services to both physicians and patients. The Flex Monitoring Team found that 80 percent of CAHs use teleradiology to support diagnostic imaging interpretation, and 24 percent of CAHs use telepharmacy to have remote pharmacists review medication orders prior to their administration to patients.
The reasons for low adoption of clinical health IT systems in small and rural communities revolve around the lack of resources, both in terms of funds and IT staff.
Financing. Health care providers in small and rural communities often need to seek grants and loans from Federal and State agencies to finance an information technology implementation. In 2004, the Agency for Healthcare Research and Quality (AHRQ) earmarked $139 million specifically for advancing rural health IT. The Office of Rural Health Policy within the Health Resources and Services Administration (HRSA) also has grant opportunities for small and rural providers, including in the area of telehealth. In addition, the Rural Health Care Program of the Universal Service Fund provides discounts to health care providers for telecommunication services and monthly Internet service charges. State rural health offices also can direct providers to State programs and other resources, such as foundation-based funding.
The recently passed American Recovery and Reinvestment Act of 2009 (ARRA) has a number of provisions that will impact the financing of health IT for small and rural health providers. Beginning in 2011, non-hospital-based providers enrolled in the Medicare program who implement and report meaningful use of EHRs can receive initial incentive payments up to $18,000 and total payments up to $44,000. Providers in rural health professional shortage areas will be eligible for a 10-percent increase on these payment amounts. Incentive payment programs also will be available under the Medicaid program to rural health clinics and other providers who are not hospital-based. Dually eligible providers will only be able to take advantage of programs under either Medicare or Medicaid. However, acute care hospitals, including CAHs, are eligible for incentive payment programs under both the Medicare and Medicaid programs.
Workforce. Overcoming limited numbers of available IT staff is challenging in small and rural communities. While no model fits all, each provider must determine ways to recruit and retain talented staff to implement and maintain IT systems. One approach for rural organizations is to augment the expertise of existing clinical staff by providing opportunities for additional training in health IT. Another option may be to seek new staff who will likely stay in the community and provide them with support for information technology education. Significant funding opportunities also are included in the ARRA for health IT training programs. These include grants to academic institutions to expand medical informatics training programs and to integrate information technology into the curriculum of their clinical programs. The goal is to increase the number of available workers with a background in health IT.
The Agency for Healthcare Research and Quality (AHRQ) has funded organizations across the country that are implementing and evaluating technologies in small and rural settings. Selected projects include:
Title: A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Principal Investigator: Gurdev Singh
Title: Closing the Feedback Loop to Improve Diagnostic Quality
Principal Investigator: Eta Berner
Title: Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality
Principal Investigator: James Veline
Title: Enabling Electronic Prescribing and Enhanced Management of Controlled Medications
Principal Investigator: Grant Carrow
Title: RxSafe: Shared Medication Management and Decision Support for Rural Clinicians
Principal Investigator: Paul Gorman