HIT and Rural: Why it isn't "Small Urban"

By Joe Wivoda, Chief Information Officer

The word "tractor" can be interpreted in a couple of ways, depending on where you are from. In a suburban neighborhood a "tractor" may be a John Deere, have four wheels, and have a seat and steering wheel. In a rural setting a "tractor" could still be a John Deere, have four wheels (or more) and a seat and steering wheel, but would look different and do very different work! The same goes for Health Information Technology (HIT) in urban and rural, the two can be different!

Rural Tractor

Urban Tractor

There has been a trend of larger integrated delivery networks offering their electronic health records (EHRs) to rural hospitals as a way for those rural hospitals to save some money and simplify the exchange of information for referrals. This may not be as simple and straightforward as it sounds, and the results may not make sense for the rural hospital.

For example, because staff at a critical access hospital (CAH) often have to wear many hats, there can be unique workflow requirements that an urban EHR may not be able to accommodate. I worked with one CAH that had a difficult time finding Pharmacy Technicians. They paid their Ward Clerks to get trained and certified as Pharmacy Technicians. This was a brilliant idea that made the Ward Clerks more valuable, solved a critical problem for the CAH and created a vexing problem for the EHR vendor! The urban EHR that the CAH was using did not have the ability to have staff in multiple roles (Ward Clerk and Pharmacy Technician are different roles in a role-based security model that most EHRs use), and why should it? This would likely never happen in an urban hospital, yet this is common at rural hospitals. They ended up having to use two logins, two passwords and some loss of efficiency because the EHR could not accommodate the two roles.

The benefits of exchange with an urban hospital or delivery network can be important, but often overstated. A higher proportion of rural patients are referred to home care, family practice providers, long-term care and other local providers than large urban centers. Implementing the same EHR at the urban and rural setting, with administration occurring centrally, will likely create barriers for the local providers to exchange with the local CAH. As an industry we have made health information exchange too difficult, particularly for those providers that are not eligible for meaningful use. It really is not that hard to exchange clinical information today using Direct, C-CDA and other technologies, yet hospitals and clinics seem to be struggling to make this happen. By moving the management and strategy for the EHR further from the CAH it makes it all the more unlikely that non-physician providers in particular will be approached to exchange information for patient care. We will continue to use FAX and envelopes laid on the chest of transferred patients. By using an EHR designed for rural, and managed by local staff, it is far more likely that real health information exchange will occur in rural settings.

Rural is not small urban! They do have different needs, processes and workforce challenges. The EHRs built for rural often take these issues into account. By "shoehorning" EHRs designed for urban hospitals into rural we can introduce less efficiency and create unsafe practices. Consider some of the challenges you face at your rural hospital and how a one-size-fits-all approach may not be best.

So, I am going to go plow my 10 acre field with the lawn mower and cut the grass with my Ford 2000 loader. Wait...

Cream of the Crop: A Personal Story of Life-Saving Rural Health Care and EMS

By Margo Kulseth, Information Specialist

Margo, Age 6

The importance of rural health care was proven to me in dramatic fashion at a tender age. It was September 1977 on my family farm in southern Minnesota, the epitome of rural America. I was six years old and had just started the first grade. My friend Jill and I were talking on the phone about which of Charlie’s Angels we liked best when suddenly I heard the running lawn mower outside my house make a strange sound and stop abruptly accompanied by a terrifying scream.

Now that almost 40 years have passed, the details of this traumatic day have blurred in my mind, but the emotion still comes back quickly as I recall the chain of events as best I can. I was a painfully shy, timid kid, so I think I talked to Jill about what I heard for a bit and wasted precious time before I hung up the phone, went to the door and opened it a little to peek outside. What I saw is something no child should ever experience.

My mother was lying on the ground with her leg bloody and mangled. Despite the pain and fear she must have been feeling, my mom told me later she was trying to be strong and stay calm so as not to scare me. I stood there in the doorway, too shocked and afraid to go to her, something I feel ashamed of now.

Kulseth Farm

I was fortunate that day and every day of my childhood to have my grandparents, my dad’s parents, living right next door on the same farm but in a different house. It was where my dad had grown up. After my parents were married, they had built our house on the same property as my dad and grandpa farmed the land together. So on this day, my mom hollered at me from her spot on the ground to get my grandma. For whatever reason, maybe because I was too scared to advance past the front door, I ran back inside the house to call my grandma on the phone rather than running over to her house, which is what my mom intended. This is yet another source of embarrassment for me as my mom must have thought I was not going to get help.

As luck would have it, I picked up the phone and heard a conversation in progress. Back in those days, we had party lines that were shared among neighbors. I recognized the voices as those of our pastor at the small country church about a mile away and another neighbor. Filled with uncertainty and indecision, I think I hung up and picked up the phone a few times before finally mustering the courage to interrupt them, something I had been taught not to do. I said this was an emergency and I needed to use the phone, at least one helpful skill I must have learned at some point. Our pastor, recognizing my voice, asked what was wrong, and I told him Mom was hurt. He hung up and headed over to our house.

Meanwhile, I called my grandma and told her Mom was lying outside and needed help. At this point, I didn’t understand what had happened, and in my six-year-old mind, my theory was that our neighbor’s big, loud, black dog named Chopper, of whom I was terrified, must have attacked my mom. So I think this is what I told my pastor and my grandma. They probably were skeptical and didn’t know whether to believe me, and I can’t blame them.

I must have gone back to the doorway to report back to Mom that I had called Grandma, but she had not come out of her house yet. My dad was picking corn that day, and Mom told me to go get him. At some point, my younger sister, age three, ended up with me. She had been playing or watching cartoons, I suppose, and heard the commotion, or maybe Mom told me to get her. Mom said to hold my sister’s hand and take her along to get Dad. She reminded me as I had heard many times before, growing up on the farm, not to go close to the dangerous spinning auger on Dad’s machinery.

I was wearing white socks, and I asked if she really wanted me to run across the farm in them with no shoes because I knew they would get dirty, which seems silly now but a valid question for a people-pleaser child, I suppose. Of course she reassured me it was okay this time. Again, my lack of urgency is embarrassing, but I have to remind myself of my youth, inexperience and timid demeanor at the time.

So my sister and I, hand-in-hand and shoeless, ran toward my dad, who was by the tractor with a wagon full of corn being dumped into the elevator and deposited into the corn shed. We got his attention while staying a safe distance away from the farm equipment as we had been taught, and he must have known something was wrong by the look of us. He turned off the machinery, and I’m not sure what I said, but somehow I conveyed that Mom was in trouble, and he needed to come quickly. By the time we got to Mom, my grandma had come out to investigate and must have called 911. Then she took my sister and I back into our house and wouldn’t allow us to go near the windows. Soon the ambulance arrived, stabilized and transported my mom to the critical access hospital closest to our home.

I learned later, of course, it was not Chopper who attacked my mom. She had been using a riding mower on the hill on which our house is built, and in an attempt to trim the grass close to the hedges, she had an accident that caused her leg to slip into the blade of the running mower. When she tried to stand up, she heard the bone break, so she dragged herself up the hill to where she could call for help. She ended up being transferred to a larger hospital in Mankato, Minnesota, where she had multiple surgeries over the next several months. My sister and I stayed with friends and neighbors sometimes while she was recovering, but we had fun playing with her wheelchair and crutches.

As an adult, I understand the severity of this medical emergency much better than I did at the time. What if my mom had been unconscious? What if she hadn’t been able to get my attention or that of anyone else? What if she bled to death? Farm accidents happen quite often, and sometimes they are fatal because no one else is around to witness the emergency or to get the victim to proper health care in a timely manner, or the transportation time to the nearest facility is too long. It may take longer to get to the victim also.

Mom's 70th Birthday
August, 2014

I am so grateful for the critical access hospital and ambulance service that was available for my mom that fateful day. Without them, I could have lost her. That is a thought so overwhelming, I can barely grasp it. How vastly different would life have been for my sister and me to grow up without our mother? Luckily, aside from a slight lingering limp, Mom is in reasonably good health today, and we had a party in August to celebrate her 70th birthday. My mom is one reason I am a proud advocate for rural health care.

Margo and Mom 2014

Should Rural Hospitals Use Social Media?

By Leslie Quinn, Program Coordinator

Who? What? Where? When? Why? How? I will answer all of these questions for rural hospitals wondering about social media. Let’s start with the why…

Why?

Social media is a FREE marketing tool! Yet only 26 percent of hospitals participate in social media. Why should you get on board?

• It provides a venue to communicate with patients, partners and your community
• Recruit and retain both providers and patients by showcasing your hospital
• Stop the outmigration of patients who are able to drive right past your rural hospital to the next urban center
• Attract the younger population (biggest users of social media) to come to your hospital and become lifetime patients
• Monitor what is being said about your hospital on social media and have the ability to respond

Who?

More people are using social media than you might think; yes, even in rural areas. Your patients and potential patients are on social media. Approximately 83 percent of adults age 33 and younger currently use social media. Internet users age 74 and older comprise the fastest growing segment, with 16 percent now using social media. Your competitors are on social media too!

What?

Show your social media network who you are, the organization, employees, services and more by posting pictures and stories of your facility, staff, community and events. Inform your social media network of available services at your hospital, wellness events at your facility or in your community and job openings. Social media users also find health information on the internet, so you can use social media channels to get patients more involved in their health and health care. You can ask questions to get feedback from you social media followers. Do not post any identifiable health information about patients, to be HIPAA compliant. If you want to post a story or picture of a patient, make sure they sign a consent form.

Where?

There are many social media websites, but the most popular for hospitals are Facebook, Twitter, YouTube and Blogs.

Source: http://thesparkreport.com/infographic-social-mobile-healthcare/?utm_source=pr&utm_medium=email&utm_campaign=infographic

Facebook has 1.15 billion users, making it the largest social media site. Facebook users can “like” your company page, which enables them to see when new content has been added. Facebook allows you to share messages, links, photos, videos, documents and more. Facebook users can interact with you by liking, commenting or sharing your posts.
Examples of rural hospitals utilizing Facebook:

• Transylvania Regional Hospital, Brevard, North Carolina
• Union General Hospital, Farmerville, Louisiana
• Tallahatchie General Hospital, Charleston, Mississippi
• Johnson Memorial Health Services, Dawson, Minnesota
• PeaceHealth Ketchikan Medical Center, Ketchikan, Alaska

You can also keep up with us on The Center's Facebook page.

Twitter has 500 million users that. You can “tweet” updates in 140 characters or less. Twitter users can “follow” your twitter profile to subscribe to your tweets. Tweets may include short messages, links, photos or videos. Twitter users can reply to your tweet or forward your tweet to their followers by “retweeting.” Hashtags (#) are used heavily in twitter to group similar tweets based on a keyword or topic area.

For example, the official hashtag for National Rural Health Day is #powerofrural.

We're also tweeting on The Center's Twitter feed.

YouTube has 1 billion users who post and watch videos. You can post videos to market your hospital and showcase your facility and staff or for patient education. YouTube users can watch, comment on and share your videos.
For example, Baptist Health Medical Center in Herber Springs, Arkansas produced a CAUTI Awards Winning Video.

Blogs have 329 million users. Blogs are growing in popularity with individuals and corporations. Nearly 40 percent of US companies use blogs for marketing purposes. Blog readers can follow your blog by signing up for email notifications when a new blog post is available.They can comment on your blog post or share the link to your blog post with others.

The Mayo Clinic is consistenly ranked #1 for hospitals using social media, one example is their Sharing Mayo Clinic blog.

LinkedIn has 277 million users and is a professional, business-oriented social media site. LinkedIn users can connect and network with colleagues, classmates and “follow” company pages. LinkedIn allows you to share messages, links, documents, photos and job postings with users.

For example, Jamestown Regional Medical Center in Jamestown, North Dakota uses their LinkedIn company page for recruitment, retention, services and hospital news.

You can connect our staff on The Center's LinkedIn profile.

Each social media site has a help center to answer any questions you may have with setup and use. You can also attend social media webinars and trainings to learn more. Self-help books are also available.

When?

There is no time like the present. Start making a plan now to incorporate social media into your marketing strategy. Make sure someone is responsible for actively posting to all social media accounts that your organization creates. A good goal would be to post at least once per week to LinkedIn, daily to Facebook and multiple times per day to Twitter. YouTube and Blogs are used to publish larger content, so it is not necessary to post as frequently. Someone should also be responsible for replying promptly to posts and questions, both positive and negative.

How to Start:

• Check out your local partners and competitors to see what they are doing on social media
• Decide which social media sites you want to start with. Choose one or two and expand later if they are successful. Start small – don’t get in over your head.
• Create an internal social media policy for employees that includes company policy and disclaimer as well as employee guidelines. Example: Mayo Clinic Social Media Guidelines for Employees
• Decide who is in charge of posting and managing social media sites
• Use your logo as the profile picture on all social media sites for brand recognition. You can also use a professional quality staff photo as the cover photo.
• Include hospital address, contact information, website, mission, vision and marketing slogans in the information sections 
• Promote links to your social media sites in the media and on hospital communications, including employee e-mail signatures. Encourage (but do not require) employees to interact with the company’s social media pages; it will encourage other followers to be more interactive.
• Set goals and monitor progress

Sources:
Healthcare Friending Social Media: What Is It? How Is It Used, and What Should I Do?
Social Media Toolkit from the Alabama Office of Primary Care and Rural Health

The Center's Wellness Program: Walking the Walk!

By Kim Nordin, Program Coordinator

We not only talk the talk, we walk the walk!

Happy National Rural Health Day week! At the National Rural Health Resource Center (The Center), we will be celebrating with a group walk and healthy food potluck on Thursday. Check out our Facebook page for photos! As a national leader in rural health, we at The Center recognize the importance and responsibility of being a best practice model for all things health.

This is the seventh month of our workplace wellness program, and today, I’m thinking about worksite wellness programs, which are a form of preventative health and can greatly impact a rural community’s health. I outlined The Center’s Wellness-a-thon in my last blog post, if you’re interested in learning more about it.

Joe and Margo, part of Team Centerites,

during a 5k benefiting the local YMCA

youth program. This was their 

first 5k and they rocked it! 

My favorite part of the Wellness-a-thon has been the weekly challenges. These weekly challenges target key wellness focus areas and challenge staff to try something new, learn something new, or focus on an aspect of health that we may not always think about.

“The weekly challenges put all aspects of wellness on your daily radar.” 

The main driver of our program and the reason I am so passionate about the importance of workplace wellness programs is that the future health care business model is based on patient value. The goal is to minimize the cost of care and enhance the overall health status of a given population by providing care (or supporting wellness) at the EARLIEST point in the care continuum. This approach redefines health care as an activity that includes far more than sick care and acute interventions. Worksite wellness programs are a good place to start.

“Healthy hospitals are a cornerstone of a healthy community.”

What better place for worksite wellness programs than hospitals, which are often the biggest employer in rural communities? They play an important role as respected leaders and role models in health and wellness in the communities they serve. If rural hospitals build a sustainable support system for employee health and wellness, the impact on the rural community’s population health is huge.

Angie, Alyssa, Kami, Joe and me, during one of our quarterly wellness activities: A surrey bike ride on the lake walk! Note: It’s more of a workout than it looks! 

Worksite wellness at The Center is having a positive impact as the program reaches its seventh month. We have engaged in several weekly challenges, and staff members track their progress in one master spreadsheet, which allows us to see our progress as a group.

Some weekly staff challenges:

• Workplace humor week - send a co-worker something funny
• Participate in a random act of kindness
• Positivity challenge week – read the tips provided and challenge yourself to take on a more positive attitude
• Schedule one health related appointment
• No cell phone use while in your vehicle
• Walk/bike to work
• Drink at least 8 glasses of water per day
• Participate in a fitness class
• Take the stairs (Our offices are on the 3rd and 4th floors)
• No sugary (soda) beverages during work

Recently, I sent a out survey to evaluate the program in a short five-question format. Staff members were asked to use a Likert scale of 1-4 where 4= Love it!, 3= It’s good to have, 2= It could be better, and 1= Total waste. 11 out of 17 (65%) of our staff responded. Overall, the wellness program was scored a 3.44 out of 4, which is pretty good for our first seven months!

Positive comments about the program: 

• It’s (The Wellness-a-thon is) very comprehensive. I enjoy the tips and wellness updates on Sharepoint.
• My own (health) patterns have improved, but in actuality less than my intention. I continue to appreciate the shared goals!
• Nice to have comradery. There could be more support between staff.
• I'm more mindful of specific wellness habits: e.g. not driving/texting
• It helps me be more conscious of things, though I haven't changed behaviors (at least permanently) because of it
• Down 15 lbs. and adding some muscle since December 2013 by committing to exercising
• I enjoy the weekly challenges and sharing info on Sharepoint
• We all work so hard on multiple projects which can be isolative (including extensive travel), however maintaining rapport and trust with coworkers is critical. The activities have promoted a positive morale and trust/communication.
• I really, really liked it. I liked the focus on all types of health and I must admit that if there was a day I was tempted not to exercise, I would because I wanted my points. The individual coupled with group goals was brilliant!
• I think every office needs some sort of wellness and "morale" committee that plans regular activities like this. Because our organization is rooted in health, it is especially imperative. The activities have been very creative and fun. The reminders on Sharepoint are also great, especially the list of reasons to be grateful and positive. Thank you for making this a priority.

Since the inception of the program, all but one staff member participated. With that participation rate, we will definitely continue the program. I’d like to kick off the next year with health risk assessments and health screening for all employees. Everyone will start the year with a personal health goal and a way to measure it. This will help us to track our accomplishments.

I’m proud of our program. We’re having fun and taking care of our minds and bodies! Can you say that about your workplace?

Rhonda, Kami, Leslie and me, enjoying a mid-day yoga class in the courtyard of our office building. Wellness Warriors!

Celebrating Rural, Celebrating Access to Care!

By Rhonda Barcus, Program Specialist

Imagine the stress…your greatest loved one has received a cancer diagnosis which requires frequent treatments…four rounds of chemo and then seven weeks, five days a week of radiation. The closest service is over 80 miles round trip. In addition to the emotional and physical uncertainty of a cancer diagnosis, you are now dealing with the challenge of getting your loved one to treatment! I am celebrating today because that did NOT happen to me.

The first part is all true. My greatest loved one was diagnosed with cancer this summer, did go through four rounds of chemo, and has begun seven weeks, five days a week of radiation. We however, are so fortunate to live in a rural community that has a satellite center for cancer treatment. When she finished chemo and we began planning for radiation, we weren’t sure there were services available where we live. My loved one told me if we had to travel that distance every day, she would refuse further treatment.  I’m not sure she would have gone through with that, but I am glad we never had to make that decision.

This summer was a more difficult journey than we ever expected. What looked like a cut-and-dry diagnosis and treatment ended up being worse than expected. In the midst of the worry, I often stopped to be grateful. We had insurance; we had a car to get to treatments; and we had caring friends and family. And above all, I thought over and over how much harder the summer would have been if every treatment and every doctor visit required that 80 mile trip.

So today, during the week-long celebration of National Rural Health Day, I’m celebrating The Power of Rural. The “power” is profound. It’s not just about convenience and easy access, but at a deeper level, it can be about who not only survives, but also thrives.