Striving for 1,000: ONC Sets Rural Hospital Meaningful Use Goal

Date Posted: December 5, 2012

December 5, 2012 - Recognizing the value electronic health records (EHRs) could bring to America’s rural residents, the Office of the National Coordinator (ONC) for Health Information Technology has set a “stretch” goal that 1,000 of the nation’s critical access hospitals (CAH) and rural hospitals--equaling 60 percent--implement and meaningfully use EHRs by 2014.

“It’s an aspirational goal, but I’m not an optimist by nature,” said Dean F. Sittig, PhD, a professor at The University of Texas Health Science Center at Houston School of Biomedical Informatics. He doubts that goal is achievable, pointing out that in the first two years, only 205 of these facilities have achieved meaningful use of EHRs, also called electronic medical records (EMRs).

According to the General Accounting Office, 8.2 percent of CAHs and 12.2 percent of rural hospitals had achieved meaningful use in 2011.

“I think they are underestimating the task before them,” Sittig added. “It’s an admirable goal and an important step forward, but a huge change.”

Jason Fortin, senior advisor at Impact Advisors in Boston, called the goal optimistic, but added that’s what goals are for. Fortin said that now is the time to address the digital divide between rural and urban hospitals, because it will only get worse without interventions.

“It really is a stretch goal,” agreed Bill Rudman, PhD, RHIA, executive director of the American Health Information Management Association Foundation and the vice president of education visioning. “It’s possible, but it will be difficult.”

Others are more optimistic. Jim D’Itri, a partner at CSC Healthcare Group in Pittsburgh, Pa., said he considered it reasonable, with many such hospitals making progress toward that goal.

“It’s doable, if you put your mind to it,” D’Itri said.

California Health Information Partnership & Services Organization (CalHIPSO) in Oakland, one of the 62 federally designated Regional Extension Centers (RECs), is helping 40 rural hospitals in California achieve meaningful use. CEO Speranza Avram reported 33 percent of the hospitals it and its subcontractor, the Health Services Advisory Group, have helped have achieved Stage 1 meaningful use and 63 percent have begun using an EHR.

RECs are vendor neutral, assess facilities’ needs and help them evaluate different vendor offerings. CalHIPSO also assists with workflow redesign and helping the provider meet meaningful use.

“We’re well on the way to reaching our goals,” Avram said. “We’re feeling good but there are lessons learned. Technology is easy, but change is hard.”

Ramsey Evans, CEO of Prognosis Health Information Systems in Houston, called it a realistic goal, but cautioned that if hospitals are not moving forward in six months to a year, ONC will not get to 1,000.

“If all hands are on deck, everyone is sitting in the right seat and rowing in sync, it can be done. But not without major stress and challenges,” said Alan Kravitz, CEO and founder of MedSys Group Consulting in Frisco, Texas.

Barriers to implementation

The ONC recognizes barriers exist, hampering CAH and rural hospitals’ ability to achieve meaningful use. These barriers include remote geographic locations, small size and low patient volumes, limited workforces, clinician shortages, financial constraints and lack of adequate, affordable connectivity.

“There is a potentially significant capital investment that’s required, if their systems do not meet the current standards,” said Wes Sternenberg, a partner in the healthcare accounting firm Draffin & Tucker in Albany, Ga. “And as the program progresses, those standards increase.”

Sternenberg cautioned that federal incentives are for using an EHR but will not necessarily cover the IT system expenses at community hospitals, but CAHs are reimbursed based on cost. In addition, there will be reductions in reimbursements if hospitals do not implement the record systems.

“Hospitals cannot afford to pass up the incentives,” D’Itri said. “The incentives should more than take care of the cost of doing it, unless they are on a dead or dying hospital information system.”

D’Itri said hospitals could receive millions of federal dollars, based on Medicare volumes. Those that need only an update will spend much less than that. But the investment must be made up front.

“One of the major challenges is making sure these small rural hospitals can afford the price of implementation and meeting meaningful use, while awaiting the government’s reimbursement plan,” Kravitz said.

Lack of knowledge about cost and the right path also presents a major roadblock, Evans said.

“Paralysis by analysis, but there are not a lot of resources,” Evans said. However, some hospital associations have strong programs to help rural facilities.

“There are a couple major, major problems; the first is economic,” agreed Rudman, highlighting initial and ongoing costs to maintain a system and the challenge of selecting the right system for now and the future. “They don’t have huge margins for errors.”

Fortin agreed that with limited capital and staff, rural hospitals “have to get it right the first time.”

Hospitals must decide how to account for the funds based on their confidence of continuing to meet the meaningful-use requirements, Sternenberg said. He recommended creating the appropriate accounting from the beginning to make subsequent years easier and for budgeting.

Rural hospitals should consider products specifically designed for smaller facilities, because work flows are different, Evans said. And systems designed for smaller markets usually do not require as much IT support as those designed for larger hospitals.

The lack of an experienced, trained IT workforce presents another obstacle, Sittig said. One of the keys to success is to hire someone who has done an implementation before. But those experts tend to live in major metropolitan areas and are unlikely to move to rural America.

“[Rural hospitals] are not in areas where you get a lot of IT or health information management people moving to, and the hospitals don’t have the money [to hire experts],” Rudman said.

While Kravitz agreed that the shortage of qualified health IT staff is an issue, he said it is not limited to rural areas.

On top of the financial and personnel issues, existing clinicians are often resistant to change. Di’Itri described achieving meaningful use as a people motivation issue, not a technical issue. Computer provider order entry (CPOE) requires cooperation from the medical staff, but with fewer physicians, many employed, that may be an easier task in rural facilities, he said.

Rudman added that any program must begin with education to increase clinicians’ awareness about how EHRs can provide better care for patients.

“If you can get the physicians to buy in, it will make it a lot better,” Rudman added.

Meaningful use must begin with meaningful communications, Kravitz added. “Chief information officers must communicate with the organization and keep an open mind on resources and how these projects will be accomplished.”

Options for moving forward

Sittig indicated some loans are available to fund purchase of an EHR, but that rural hospitals also could look to hosted systems, since most places can connect to the Internet via satellite. He also suggested partnering with a larger hospital to use its system.

“The cloud model would fit in terms of scalability and be supported by a small IT staff, but there are some questions from a provider standpoint about security and privacy of data,” Fortin said. “[A cloud-based EHR] may be one thing that equals the playing field.”

Shane Pilcher, vice president of Stoltenberg Consulting of Pittsburgh, Pa., suggested partnering with a knowledgeable consultant firm and coming up with creative funding options, which can help hospitals reach the goal despite their limited resources.

“Rural and community hospitals need to understand that the path to meeting meaningful use is not a sprint, but a marathon,” Pilcher said. “Even though the future of rural and community hospitals may look bleak at first glance, there is a tremendous opportunity for the healthcare community to rally and help these hospitals in their journey towards meeting meaningful use.”

The ONC has agreed to provide up to $30 million in supplemental grants to RECs, which would allow them to assist as many as 1,501 CAH and small, rural hospitals. About 1,220 hospitals have asked for REC assistance.

“That’s not a lot of money [to implement an EHR],” Sittig said, explaining that Memorial Hermann Healthcare System in Houston has spent $250,000 on its EHR.

In addition, the ONC announced a couple of pilot programs. In North Carolina, Pitt Community College Consortium is developing custom online and in-person training for rural healthcare providers, funded by ONC.

The REC/Healthland Strikeforce! pairs RECs serving Texas, Minnesota, North Dakota, Iowa and Nebraska with the EHR vendor Healthland in Minneapolis. Robert Forrest, at Healthland, explained the program aims to identify barriers and how different entities can work together to achieve the 1,000 by 2014 goal.

“With a concerted effort at all levels of the organization, [meaningful use] can and will be done,” Kravitz said. “It just needs to be started now, not tomorrow.”


To help rural physicians, the American Health Information Management Association and Delta Regional Authority’s Health IT Workforce Revolving Loan Fund Program offers no-interest loans to rural physicians in eight states to help purchase an EHR system.


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