Rural Healthcare

The viability of rural healthcare relies on evolution

Choice can be a double-edged sword—we all want more of it, but with too many choices paralysis can set in. Choosing a physician or hospital, for example, in an urban or suburban area without some kind of recommendation can truly be a daunting task.

But it beats having few or no choices. Increasingly, that’s the situation rural Americans find themselves in as the number of hospitals decreases and specialists stay in the cities.

While this may have been the trend in rural healthcare over the past 10 or 15 years, the current advance of technology in healthcare and the introduction of new care models offers rural hospitals much-needed opportunity. Heartland hospitals have the ability now to revamp and re-envision care in the essential areas where America produces energy and food.

What strategies and adaptions available now can ensure affordable and efficient rural care for the foreseeable future?

Strategy 1 - Forge relationships. As with all hospitals, Winona Health (99 beds, Minnesota) had more than a few patients using the ER for chronic but manageable health conditions. To get ahead of and maybe prevent ER visits, Winona Health established relationships with organizations that included a nearby senior center, the state health department and Winona State University to provide support for the chronically ill. This led to the formation of the Community Care Network in 2012, through which Winona Health trained Winona State University students as health coaches.

By providing basic emotional support and performing a few tasks like grocery shopping, the Community Care Network reduced ER visits by 91 percent and hospital readmissions by 94 percent in the first 90 days of the program.

Are there organizations in your community that can contribute to managing the health of those who need support and preventing health emergencies in the ER?

Strategy 2 – Innovate around care. Even where there are sufficient providers in a rural area, there are seldom enough specialists, which means patients sometimes have to travel long distances for specialized care. The University of New Mexico’s Project ECHO works to address this need through educational innovation by connecting specialists with physicians in rural areas, giving them the understanding they require to meet particular patient needs.

For more than 20 years, Stanford University has organized the Chronic Disease Self-Management Program (CDSMP). The program trains patients with chronic illnesses to manage their own emotions and behaviors—eating well, taking medications appropriately, communicating with friends and family, getting enough rest. Results demonstrate that the CDSMP improves the lives and satisfaction of chronically ill patients, and it saves money on reduced hospitalizations and readmissions.

Are there cost-saving care innovations your organization is not yet utilizing? How can you implement proven programs to keep costs down and bring patients deeper into the provision of care?

Strategy 3 – Focus on what you do well. Most doctors willing to live in rural areas are not specialists.

“Specialty has a powerful effect on physician location choice …” according to a study on physicians and rural America published in the Western Journal of Medicine.  “Family physicians distribute themselves in proportion to the population in both rural and urban locations and are the largest single source of physicians in rural areas. All other specialties are much more likely to settle in urban areas.”

Specialized care is not and probably never will be the strong suit of rural physicians. But this perceived weakness gives rural hospitals the opportunity to focus on natural strengths.

“A rural environment lends itself to population health and wellness,” says Jennifer Lundblad, CEO of Stratis Health, a Bloomington, Minnesota, nonprofit that promotes innovation and collaboration. “Providers probably know the patient and their family, they may go to church with them, they see them at the grocery store. If rural communities can figure out how to harness those assets, they will be well-positioned for the future.”

Of course, rural health providers remain the most important interface with patients, making them primarily responsible for creating access to specialists by forging relationships and innovating around care (above), and by maximizing the use of technology (below).

Are the wellness and population health efforts in your organization robust enough to create lead time when your patients have to utilize your relationships with specialists?

Strategy 4 - Use technology. Much has been written about the potential of telehealth to alter the rural healthcare landscape.

In South Carolina, the state Department of Mental Health worked with the University of South Carolina School of Medicine and 18 hospitals, mostly rural, to provide telepsychiatry services. Most of the hospitals had no psychiatrist in the ER when mentally ill patients arrived, and the program provided that resource 16 hours a day, 7 days a week.

The telepsychiatry services have reduced both wait times in the ER and inpatient admissions, and it has lowered costs. Patients are going to their scheduled outpatient appointments more often, and levels of satisfaction are up for both patients and physicians.

Telehealth services, while not the only approach to technological innovation, are now seen as the most promising technical cure for what ails rural hospitals.

“There are two kinds of healthcare innovation: more-for-more and more-for-less,” write Nathan Washburn and Karen Brown in the Harvard Business Review. “The American healthcare system exemplifies the first kind, offering more and more value at higher and higher costs … Virtual consultations … are at the heart of a reconceptualization of rural hospitals (and eventually urban clinics and hospitals as well) because they provide access to higher-quality care at much lower costs.”

Of course, rural hospitals cannot provide effective population health and wellness services without effective, affordable, interoperable healthcare IT systems; the technology is a prerequisite. While rural health organizations currently lag behind their urban and suburban cousins in terms of adoption, government initiatives are helping to close the gap.  

Is your organization maximizing affordable technologies, including telehealth and electronic health records, that improve the bottom line without busting the budget?

Strategy 5 - Merge. Wafer-thin profit margins (if they exist at all) and threats of insolvency would cause any rural hospital executive to consider merging or being acquired. Predictably, activity in the hospital M and A sector has been brisk over the last several years as rural facilities sign on with larger, more financially stable urban and suburban health networks. 

So, is independence even realistic, let alone desirable, for rural facilities? The answer is yes, though with caveats.

“The trick to staying local and ‘going it alone’ is often through configuring creative but limited partnerships with larger systems,” writes Beth Nelson in Hospitals and Health Networks. Complete independence may be completely historical, but that doesn’t mean rural hospitals can’t maintain a semblance of self-determination.

Have you explored the alliances available to you that may enable your hospital to survive and provide for the needs of the surrounding community?

A piece of good news: At least one study shows that rural hospital closures have not had a measurable impact on local mortality. The not-so-good news: rural residents are generally less healthy than urbanites, so having no local hospital and healthcare organization eliminates the opportunity to improve care through various wellness and population health programs.

Just as they always have, rural hospital executives and clinical leaders are doing all they can with the resources available. The difference in our current technological age is that so many more cost-saving tools exist than just ten years ago. By employing strategy and technology, rural healthcare organizations finally have the tools to move beyond survival and become catalysts for healthier communities. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

America has a rural healthcare crisis. Technology can help.

As 2017 begins, around 81 percent of Americans live in urban areas, up from 79 percent in 2000. At the same time, urban and suburban areas where vacant land exists (so, not you, San Francisco) have been expanding, redefining what used to be rural. With this demographic shift comes a transition of resources and tax bases that leave rural areas and rural services, including healthcare, struggling to survive.

Indeed, we can learn a lot about the state of rural healthcare from several access-related statistics:

  • As of last year, more than 70 rural hospitals had closed since 2010 and 673 were vulnerable to closure, of which 68 percent were critical access.
  • The distance to hospitals in rural America is often much further than in urban areas, sometimes meaning the difference between life and death.
  • The number of doctors per 10,000 residents is 13.1 in rural areas and 31.2 in urban environments, simply making care harder to get. With regard to specialists per 100,000 residents, the average is 30 in rural areas and 263 in urban.
  • More than half the counties in the country have no practicing psychiatrist, psychologist or social worker to deal with mental health and addiction issues.

More generally, America’s rural population is older, makes less money, smokes more, is less healthy and uses Medicaid more frequently. All these factors dramatically complicate access issues and yield predictable results.

Opioid-related addiction and overdoses, for example, are disproportionately higher in rural areas than in urban. Improvements in the death rate for rural residents have evaporated. For rural white women, death rates have increased as much as 30 percent in recent years, a stunning reversal of previous trends.

Why this is happening is complex and not easily fixed—certainly lack of economic opportunity is a factor, as demonstrated in the recent election—but in many ways technology can make a discernable difference.

Opiate Addiction and Treatment

“While my city patients are well aware of the fact that most physicians consider opiates high risk for addiction, this fact may totally elude my rural patients,” writes Dr. Leonard Sowah in a recent KevinMD post. “I had a few experiences with individuals who were clearly addicted to opiates but would constantly state they were not addicts since they received opiates only from licensed prescribers.”

Certainly, increased awareness and better educational materials will help this situation, but the responsibility will ultimately fall to physicians. Without the Prescription Drug Monitoring Program (PDMP), this would be a near impossible task. The PDMP—a database of electronically prescribed medications and patients that functions in 49 states—makes it possible for doctors to see a patient’s prescription history and identify potential “doctor shopping” and addictive behaviors.

Behavioral Health Treatment

If the National Health Service Corps, which uses loan repayment as incentive for doctors to work in high-demand areas, isn’t doing the trick, what’s next on the list of ideas?

Right now, almost all bets are on telehealth, which has proven effective thus far in treating depression and PTSD. Congress made funding for telehealth a significant part of the recently passed 21st Century Cures Act and is requiring CMS to periodically report back on how telehealth is being used in Medicare and whether or not it is working.

Telehealth may also provide relief on the cost side of the equation for rural hospitals. According to a 2012 Institute of Medicine report, telehealth increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. To make it really effective, all insurers need to embrace telehealth and all providers need to implement the technology.

Hospital Closures and Access to Care

Telehealth is also one solution to hospital closures, even if it’s not ideal or even effective for every scenario where a hospital would improve or save lives.

Electronic health records (EHRs) and participation in health information exchanges (HIEs) and accountable care organizations (ACOs) offer benefits in terms of streamlining patient care and improving efficiencies, as well as having ready access to best practices and specialists when referrals are necessary.

“The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare,” said CMS Acting Administrator Andy Slavitt. “In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.”

No, the ACO Investment program is not a technology, but it is almost completely hamstrung if rural providers don’t adopt technology to make improvements.

Non-technological Factors

Of course, technology alone won’t fix the issues that plague rural healthcare. It’s not magic, after all. Economics and public policy will also come into play.

For example, the slim profit margins, if they exist at all, that rural hospitals create necessitate an affordable EHR system that doesn’t require a huge pile of cash up front to implement. Most hospitals have used Meaningful Use to help pay for those systems, but the unique financial challenges of rural healthcare might necessitate a Stage 3, even though CMS has signaled that the program is about done.

Using policy to assist rural providers is the focus of the recently formed CMS Rural Health Council, which operates with an all-encompassing agenda:

  • Improve access to care for all Americans in rural settings
  • Support the unique economics of providing healthcare in rural America
  • Make sure the health care innovation agenda appropriately fits rural health care markets

A solution that meets all three of those objectives will have to be creative, flexible and effective.

The ongoing changes to American healthcare occur in a time of social and political upheaval, and it will take some time to know whether or not past legislation and upcoming changes to those laws have had a positive impact. If not, the nation may have a difficult decision to make about rural care. If the economics don’t improve and technology can’t make a significant financial difference, what are the alternatives? Can acquisitions by larger hospitals keep facilities alive AND keep costs down?

It’s an important conversation, and solutions will be difficult to hammer out, but what hangs in the balance for the people that grow our food and harvest our energy is essential to the entire nation. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Will CMS efforts be enough to buoy rural healthcare?

Imagine you’re living in Brooklyn and you have a medical emergency. If the hospital nearest you, say Lutheran Medical Center, were to close, you could go to Maimonides or New York Methodist a short taxi or ambulance ride away.

Now, let’s say you’re badly injured and you live outside rural Tulare, California, in one of the most productive agricultural counties in the U.S. If Tulare Regional Medical Center went away, you might have to life flight to Bakersfield, Los Angeles or the Bay Area. (Really, Tulare may not even be representative given that there are more than 1,300 critical access hospitals in the U.S., some far more remote than Tulare.)  

The scenario is far from unrealistic. For the most part, non-urban healthcare organizations are not doing well. In fact, almost every rural hospital in the country is operating near the margin or in the red. According to iVantage Health Analytics Senior Vice President Michal Topchik, speaking to Health Data Management, 67 rural hospitals have closed since 2010, and 283 were vulnerable to closure last year. Already in 2016 iVantage has identified 673 vulnerable rural hospitals, with 210 at very high risk.

While only about 15 percent of the American population, roughly 46 million people, live in rural areas, they do some of the nation’s most essential work. Mostly, they grow food, produce energy or provide services to the people that grow food and produce energy.

Obviously, the rural healthcare situation matters in terms of food and energy security at home, but also in terms of economics—the United States is by far the largest global exporter of food, with roughly $40 billion separating America from number two, and is on the cusp of ending energy imports for the first time since 1950.

In reality, rural healthcare is transitioning, not disappearing, mostly because doing nothing is just bad economics. People in rural areas need care. If they can’t get it locally, they have to be flown to the nearest facility, which ends up being more expensive over the long term than funding a local hospital.

To their credit, the Centers for Medicare and Medicaid Services (CMS) are already aware of the situation in rural America and have been taking steps toward fixing it.

Speaking recently to the National Rural Health Association, CMS Acting Administrator Andy Slavitt explained that the agency is “establishing a CMS Rural Health Council to work across the entire agency to oversee our work in three strategic priority areas– first, improving access to care to all Americans in rural settings; second, supporting the unique economics of providing health care in rural America; and third making sure the health care innovation agenda appropriately fits rural health care markets.”

As Slavitt points out, rural Americans tend to be older, earn less money and they generally lack health insurance—more than 60 percent of citizens without health insurance live in rural areas in states that have not expanded Medicaid through the Affordable Care Act. Nearly 75 percent of government health insurance exchange users make less than 250 percent of the federal poverty level—currently a bit less than $12,000 a year for an individual and slightly more than $24,000 for a family of four.

So, if the argument could be made that rural America is home to the greatest number of healthcare challenges, then it also represents the greatest opportunity. If we can make affordable healthcare work outside urban areas, we may have a template applicable to other scenarios.

On Slavitt’s first two points—access and economics—CMS is working to sign rural Americans up for health insurance and adjusting requirements and payment models for rural care.

Which brings us to the “innovation agenda,” Slavitt’s term for the digitization of healthcare and the all-in bet the federal government has made on the benefits of health IT. The goal here is to transform rural hospitals and clinics into efficient, wired, lean operations that can absorb the realities of rural care and still operate in the black.

With 35 percent of rural hospitals losing money and almost two-thirds running a negative operating margin, there’s simply no way rural facilities can invest in health IT without help. From CMS, that help takes the form of several planned or in-process programs:

  • Medicaid State Innovation Model grants for technical support in smaller rural hospitals
  • Aggregation of services in rural communities creating benefits from population health
  • The Frontier Community Health Integration Project (summer 2016), developing and testing new models in isolated areas using telemedicine and integration approaches
  • The ACO investment model for hospitals that can’t invest in ACO infrastructure; the model now serves 350,000 rural beneficiaries through 1,100 rural providers
  • Incorporating telemedicine where appropriate; CMS is publishing a Medicaid final rule that for the first time allows for face-to-face encounters using telehealth

It’s clear that CMS understands we can’t leave rural hospitals to fend for themselves.

But it also seems clear that a lot of hospitals invested in electronic health records (EHRs) they could ill afford to qualify for Meaningful Use funds—dollars that seldom covered implementation costs for solutions that didn’t yield significant cost savings and required additional technical personnel. By and large, that MU money has been dispensed. The carrot has been eaten. What Medicare- and Medicaid-heavy hospitals can expect next is two sticks: more stringent reporting requirements necessitating EHR use and direct penalties (for now) related to Meaningful Use non-compliance.

“The high capital and operating costs associated with health IT, specifically EHRs, have put some hospitals in a difficult position,” wrote Becker’s Hospital CFO in a prescient January 2014 article. “Do they absorb the financial hit now, even if they know they can't afford it? Most organizations are doing so …”

Yes, CMS is trying to help lessen the impact of that metaphorical beating, but these rural hospitals also have to make decisions to help themselves. Too many are paying for systems they can’t afford to maintain. Moreover, they are unable to invest in necessary security, leaving them increasingly open to data breaches. Many are also still handicapped by the costs of ICD-10 transition, for which there was no federal reimbursement.

Rural hospitals need a comprehensive EHR platform that integrates with a revenue cycle system so they can properly capture charges and manage the billing process, and effectively collect on previously lost billing. These systems need to be available as a subscription service so that rural hospitals don’t have to come up with huge money down. And they can’t require the hiring of an additional 50 application specialists to make the new systems work.

“The benefits of IT are still to come,” Standard and Poor’s Marin Arrick told Becker’s Hospital CFO more than two years ago. Still the economic crisis in rural care rages on, certainly lessening access to care for millions of Americans and arguably impacting the labor force that produces food, energy, etc.

Despite all the fixes CMS is working diligently to implement, something more dramatic may be in order. Market-oriented reforms can be argued in urban areas where there is competition, but it’s difficult to advocate for similar approaches where there is no market. Also, Meaningful Use is coming to an end and the new regime is not yet clear, so it’s difficult to say what more might be necessary when we’re not able to predict how rural healthcare will be impacted.

Personally, I see the programs and plans CMS is putting together to assist rural healthcare as valuable and impactful, but they are not sufficient in and of themselves. What will transform rural care is the same thing that will revolutionize American healthcare in general—affordable, interoperable, comprehensive platforms that, when combined with application programming interfaces and robust security, enhance the care provided by knowledgeable, dedicated professionals.

Does that sound like a solution you’ve heard of before?

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Rural Healthcare

Are physicians really dissatisfied with EHRs? Should we be concerned?

Microsoft Office was first introduced by Bill Gates at COMDEX, Las Vegas, in August, 1988. 

Here we are almost exactly 27 years later, and if you plug the words ‘hate,’ ‘Microsoft’ and ‘Office’ into Google, you’ll get more than 4 million results. Remove ‘Office’ and Google returns more than 33 million results.

Clearly, some people don’t feel like Microsoft has perfected products to their satisfaction.

The perpetual unhappiness with a monolith like Office comes to mind as I read reports on the most recent surveys of physician satisfaction with electronic health records (EHRs). Let’s sum up, for those unfamiliar with the reports

First, reporting on survey data from last year, the American Medical Association (AMA) and American EHR, a division of the American College of Physicians (ACP), recently published “Physician Use of EHR Systems 2014.” Among other findings, the reports includes these nuggets:

  • 42 percent thought their EHR’s ability to improve efficiency was difficult or very difficult.
  • 72 percent thought their EHR’s ability to decrease workload was difficult or very difficult.
  • 54 percent found their EHR increased their total operating costs.
  • 43 percent said they had yet to overcome the productivity challenges related to their EHR.

Contrast those figures and levels of satisfaction with a survey of large physician practices released last week by market research firm Black Book that shows significant increases in physician EHR satisfaction. In particular, physician experience satisfaction has risen from 8 percent to 67 percent in the last three years. Physician documentation satisfaction went from 10 percent to 63 percent over the same time period, while practice productivity enhancement satisfaction has gone from 7 percent to 68 percent.

Worth nothing is that, with the AMA/ACP surveys, “Each society was allowed to select the population of their members to receive the survey. Information about EHR use by individual society members was not available. Therefore, the survey went to both users and non-users of EHRs.”

Also important: A similar ACP survey from five years ago showed significantly higher levels of satisfaction among the physicians surveyed.

The cognitive dissonance over EHRs continues, giving rise to theories on the Interwebs about the actual source of this disconnect.

At Healthcare IT News, contributing writer Jack McCarthy wonders if the constraints of Meaningful Use are antagonizing doctors, or if increased expectations and more sophisticated technology that fails to improve the daily challenge of patient care (in effect, a mashup of the two ideas) is creating dissatisfaction.

“Now, however, we have a lot more users who were forced to adopt EHRs meaning their tolerance for poor performance or usability will be lower,” notes health IT expert Shahid Shah in the article’s very interesting comments section. “I think it's pretty easy to see why clinicians are less satisfied -- if it was their choice they would be more tolerant. Since it's not their choice in many cases, they're less tolerant.”

Adds O’Reilly Media editor Andy Oram: “They [doctors] could be more familiar with the advantages computers offer in other areas of life … In short, having seen what a good interface can do, doctors become more demanding of the sub-par interfaces on EHRs.”

Expanding on the ‘why’ question, Michelle Ronan Noteboom (formerly ‘Inga’ of HIStalk fame) offers similar theories—MU forces doctors to use EHRs a certain way, compared to Facebook and Amazon most EHRs are clunkers, EHRs don’t deliver the ROI they promised—for the ACP survey results and asks if we should care whether or not physicians are happy.

“I'm of the opinion that physician satisfaction matters, but not nearly as much as improving the quality of patient care,” she writes at Healthcare IT News. “Patient care will be enhanced when all providers have access to thorough and accurate documentation. Ideally the patient records from one provider will integrate with records from other providers to create a single longitudinal record that is easy to decipher and provides a full picture of the patient's health history.”

That sounds like a worthwhile goal. And Noteboom also has an explanation for the ACP survey results, pointing out “a direct correlation between physician satisfaction and the number of years a physician used his/her EHR. For example, among physicians on their system for three years or less, only 25 percent reported any level of satisfaction; satisfaction jumped to 50 percent among physicians that had used their EHR for five or more years.”

Sure, the differences between the two cited surveys could be attributed to methodology. But we know too much about how EHRs are influencing clinical culture to leave it at that. Physicians are human and subject to the same impulses—resentment when forced to do something; envy and confusion when seeing technology function well in other contexts; fear and consternation when learning something new—we probably faced when Microsoft started to become a rather sizeable part of our lives.

And, let’s recall, we’re really not that far into the ongoing transformation of American health care. Only now are we on the leading edge of value-based care as a replacement for fee for service. As EHRs evolve to improve quality, increase revenue, ensure patient safety, etc., instead of just meeting the contrived requirements of Meaningful Use, they will become the essential tools we envisioned at the beginning of this long and complex dance.

So it’s encouraging when both surveys show that physicians who’ve had their system for a while are happier with it. Indeed, while we continue to ask the specific question, “Are you happy with your EHR?”, maybe we don’t consider often enough the general frustration of digitizing processes that were once manual.

Also, it appears that plenty of hospital and health system administrators didn’t get the memo about creating buy-in before selecting and implementing an EHR. As David Whiles, former CIO at Midland Memorial Hospital said of their EHR journey, “Implementing an EHR is definitely an organizational project, not an IT project.”

And even though we are dealing with computers, this isn’t a binary choice of EHRs OR physician satisfaction. No one thinks computers are going anywhere, even if the Meaningful Use program ends. And physician satisfaction, to a reasonable extent, must be a high-level consideration for all clinical organizations. Over time, EHRs will improve and doctors will become more satisfied with them, perhaps will even depend on them, as essential clinical tools.

In the meantime, plug ‘hate’ and ‘EHRs’ into Google from time to time and see what you get. When we get over 30 million results, we’ll know we finally achieved Microsoft-ian levels of influence. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Rural Healthcare
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