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Bridging the Urban-Rural EHR Gap

Vol. 16 •Issue 3 • Page 16
Bridging the Urban-Rural EHR Gap

America's 2,003 rural hospitals need a prescription for increasing adoption of electronic health record systems.

It wasn't long ago that electronic health records (EHRs) seemed as far away from Wray Community District Hospital (WCDH) as a Denver skyscraper.

Like many rural hospital executives, we regarded EHR systems as completely out of the financial reach for our 16-bed community hospital in Wray, CO. In short, EHR was for larger hospitals 175 miles away in Denver, not for rural hospitals like us. These perceptions closely matched the reality of the situation.

For decades, rural hospitals have lagged behind urban hospitals in their adoption of health information technology in general. And it was no wonder—EHR systems were too costly, too difficult and too risky to acquire, implement and maintain for smaller facilities like ours.

But we believe hopeful signs of progress are now emerging—not only at our own hospital, which is implementing an EHR system, but also at many of the estimated 2,003 rural hospitals across the country. According to Modern Healthcare's "By the Numbers Resource Guide" (Dec. 19, 2005), 2,003 hospitals (40.7 percent) are rural and 2,916 (59.3 percent) are urban.

National and state rural health associations are helping lead the way toward EHR adoption. They're educating health care executives at rural facilities about the importance and inevitability of digital records, and they're beginning to partner with vendors to offer their members affordable IT solutions.

Some technology vendors are also lowering the barriers to entry. They're introducing new pricing arrangements that enable cash-strapped smaller facilities to pay for the systems on a monthly subscription basis, tapping into their hospitals' ongoing operational budgets rather than precious capital reserves. Some vendors are also offering Web-based EHR systems that can scale to a rural hospital's needs and require little or no training to use effectively.

At the national level, we see signs of increasing recognition that rural hospitals lag behind in health information technology (IT), and there seems to be a push to bring them up to some-as-yet-unspecified national standard. For example, Minnesota Sen. Norm Coleman recently introduced legislation that would provide grants to rural hospitals for IT infrastructure modernization. It's programs like these that are vitally important to establishing the proper IT foundation for EHR implementations.

These factors and many others are coalescing and providing the impetus for more rural hospitals to join the ranks of EHR adopters. At WCDH, despite our small size and an annual operating budget of about $9 million, we have been able to move forward with the implementation of EHR and forms automation software from Optio Healthcare.

WCDH is one of two not-for-profit, tax-supported critical access facilities in Yuma County in northeastern Colorado. With 16 licensed beds, the hospital provides acute inpatient care, emergency care, obstetrics, general and orthopedic surgery, laboratory and imaging services. The Wray Clinic, attached to the hospital, delivers primary care services to 5,000 residents within a 30-mile radius. The hospital and clinic recorded approximately 35,000 total visits in 2005.

Partnership Is Key

In some ways, however, our situation is unique. We're very fortunate to have a strong strategic partnership with Banner Health's North Colorado Medical Center (NCMC) in Greeley, CO, a 350-bed hospital about 150 miles to our west. This strategic relationship has been in place for the past 15 years.

By regulation, critical access hospitals (CAH) like WCDH are required to have referral agreements in place with a larger partner—known in health care circles as a CAH-Daddy.

But our relationship goes well beyond typical emergency patient transfer agreements and reliance on Banner for hospital quality control and peer review. We're connected to their entire IT system, including the telemedicine/telehealth network for all of northeastern Colorado. They also support our clinic by flying specialists to WCDH 3 to 4 days a week.

Yet, we are not a Banner hospital, nor does Banner manage us. With 40 percent of NCMC's referrals coming from outside Greeley, the hospital has a vested interest in keeping NCMC's clinicians connected to WCDH clinicians, and they see their relationships with small feeder hospitals like WCDH as vital to their overall mission and objectives.

From an operational standpoint, WCDH's relationship with Banner is critically important. Our hospital utilizes Banner's IT infrastructure, as well as its patient accounting, medical records, e-mail, general ledger and other systems. Our allocated costs for these IT systems are very economical because of the scaled pricing available through a larger partner like NCMC.

Moreover, without a partnership like this, EHR would be far down our list of capital priorities. We believe win-win strategic partnerships like this and emerging regional health information organizations (RHIOs) will prove critically important to enabling EHR adoption at other rural hospitals as well. But it's not the only way to make EHR a reality at rural hospitals. Let's take a look at some other critical success factors.

Do Your Due Diligence

Due diligence and strategic planning are not routine efforts undertaken in many rural hospitals. Rural administrators often make project implementation decisions based solely on a "cash available" basis.

We believe this management behavior must change. Rural administrators must do their homework and begin planning for what we believe is the inevitable future for EHR creation and management.

In our experience, a thorough cost-benefit analysis should look not only at the software, but also take into account other across-the-board benefits. For example, rather than looking to achieve savings by reducing staff in the medical records department, we're looking to increase their overall efficiency and productivity. By reducing the volume of paper we're using by more than 50 percent, our three-member medical records team can spend more time on transcription and coding rather than filing. The faster they can transcribe and code, the faster we can bill and receive payment.

By the same token, we'll be able to reduce the paperwork burden on our nurses by automating forms-driven processes with Optio MedEx™. Nurses have immediate access to accurate patient information such as medication orders, lab reports and input-outflow sheets. They'll no longer be held hostage to after-hours record retrieval and assembly tasks, enabling them to spend more time on caregiving.

Finding a Good Fit

Rural hospitals should look for an EHR system scaled to their functional needs. A monolithic system designed for a larger hospital isn't likely to succeed in a rural facility. The system must be extremely easy to use, so that staff at every level of proficiency can use the EHR system productively.

Likewise, EHR implementation, training and support programs must also be geared to unique needs and limitations of a smaller hospital. For example, the Optio Quick-Record® Suite™ can be remotely installed, maintained and monitored, automatically applying updates and eliminating potential problems before they occur. This reduces the IT overhead requirements to run the system. Likewise, QuickRecord is so easy to use that it requires little—and in some cases no–training to use productively.

In short, rural hospitals need EHR solutions with minimal impact on capital budgets, low overhead requirements, IT support and a faster return on investment.

They need solutions that can be installed and running in months, not years.

Engage Clinical Staff Early and Often

Moving health care organizations to paperless processes, from admissions to the point of care to discharge and billing—requires significant changes in operating culture.

Users must participate in every step in the process—from providing input into the evaluation to gaining hands-on experience with the system before it's implemented. This creates a sense of ownership and makes the cultural and process changes possible for a successful EHR implementation.

Physician buy-in and acceptance of the EHR system are essential. It's not uncommon for EHR and computerized physician order entry (CPOE) implementations to fail because physicians weren't properly consulted on the front-end. At WCDH, the physicians had heard some of the horror stories of failed implementations and initially hesitated to support our plan to convert to EHR.

However, we were able to demonstrate and educate them about our vendor's proven success at Banner's Western Region hospitals in Colorado, Nebraska and Wyoming. We have physician residents who practice at both NCMC and WCDH, and their overwhelmingly positive experience with the system helped allay the other physicians' initial concerns.

Before our own implementation (scheduled for March 2006) we placed Optio QuickChart®–the clinician interface component of the QuickRecord Suite—in the hands of our physicians through 24/7 Internet access to NCMC's Quick-Record server. Our doctors can now access the records of their patients referred to NCMC specialists in Greeley.

A case in point: a patient with a pacemaker presented at the WCDH emergency department. The physician needed to know the type of pacemaker to accurately diagnose the problem. The normal approach may have been to do a full-body CT scan to help determine the manufacturer of the pacemaker.

This procedure would have cost $1,500, exposing the patient and the hospital to unnecessary financial risk. Because Dr. Nathan Vermedahl practices at both WCDH and NCMC, he was able to log into QuickChart to view the patient's record at NCMC and retrieve the information needed to determine the device's manufacturer.

Too often, referring family physicians at rural hospitals and clinics are practicing virtually blindfolded without critical information like this at their fingertips. The paper trail of medical records often lags far behind the patient when they return home. Consequently, the primary physician and staff face a struggle to gather the dozens of pieces of the patient record they need to continue treatment.

Not only does this lack of vital patient information increase the chance for a misdiagnosis, it also can result in duplicate and wasteful services that inconvenience the patient and erode the bottom line through payment denials.

One Step Closer

Now with instant access to comprehensive patient information—including history and physical, consult, op notes, admission/discharge summaries, labs, radiology, etc.—Dr. Vermedahl can practice what he calls "frontier medicine" using state-of-the-art IT. And at WCDH, we will be taking one more significant step toward bridging the EHR adoption gap between our small-town hospital and our big-city partners.

Rod Larsen serves as chief financial officer and Ann Brethauer is HIM director of Wray (CO) Community District Hospital.

EHR Gap Proposal Not as Helpful as Hoped

To assist in the effort to close the electronic health record (EHR) adoption gap, the Centers for Medicare and Medicaid Services' (CMS) Office of Inspector General (OIG) proposed regulations to the anti-kickback statute and Stark rules to help accelerate the adoption and use of e-prescribing and EHRs in October 2005.

David Brailer, MD, PhD, national health information technology coordinator, addressed the announcement during the American Health Information Management Association's National Conference in San Diego that same month, calling the proposal an important step.

According to the American Medical Association, the proposal included exceptions and safe harbors, allowing hospitals and other health care organizations to provide physicians and medical staff with the hardware.

This effort sounded like an ideal way to level the playing field between large, urban hospitals and small, rural hospitals. But the proposals fell a bit short.

About 2 months after OIG's announcement, it was reported that the gallant efforts to close the gap didn't provide as much hope as first thought. Unfortunately, the new regulations didn't remove the crippling adoption barriers. For example, according to, the proposal states that "hospitals may not give doctors equipment that is equivalent to what they already own, but determining equivalence is not clear cut."

Scott Wallace, head of the National Alliance for Information Technology, explained to, "The proposed exceptions create more uncertainty about what is permitted without eliminating barriers to investment in health care [information technology] (IT).

"In fact, the proposed exceptions work against the stated goals of fostering cooperation between potential donors and physicians to achieve interoperability," he explained.

Apparently, a lot was left unclear in regard to EHR adoption.

Law firm McDermott Will and Emory concluded in a white paper that "the proposed changes are probably too narrow to effectively encourage widespread adoption of EHR systems," according to

Equipment donation guidelines proved too foggy and the possibility of dependency on only one hospital network threatened interoperability, so more work on the "helpful" safe harbors is needed.

—By Tricia Cassidy


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