RHPI: End of the Journey

by Terry Hill, Senior Advisor for Rural Health Leadership and Policy

Listening to Jerry Garcia this morning singing about a "long, strange trip," brought to mind the impending conclusion of our Rural Hospital Performance Improvement (RHPI) project journey in support of rural hospitals in the Mississippi Delta Region. Beginning with an initial hospital consultation in Tallahatchie County, Mississippi in 2000, the National Rural Health Resource Center (The Center) and its many partners supported 323 onsite hospital projects in eight states between 2001 and 2014, and put on hundreds of educational events.

Funding was provided by the Health Resources and Services Administration's (HRSA) Federal Office of Rural Health Policy (FORHP). We are grateful for their stellar leadership as well as the many contributions of our state partners, including state offices of rural health and state hospital associations. Our original corporate partner was the Mountain States Group, and our deep appreciation goes to their staff and to our stellar cadre of consultants too numerous to mention.

We have also had an amazingly dedicated staff here at The Center. They have worked hard to bring excellence to every aspect of the RHPI program, including measurable outcomes, education and customer service. And finally, we are grateful to the many hospital leaders in the Mississippi Delta Region that we have come to know and have proudly served over these many years. They are the real heroes of our journey, and their accomplishments have been documented by Dr. Eric Scorsone on three separate occasions, as returning $3, $11, and most recently $7 in hospital improvement, for every $1 invested in RHPI by the federal government.

In an era of value-based healthcare, we at The Center, are most proud of the documented value our RHPI program brought to more than 200 rural hospitals and the communities they serve. As we wrap up the RHPI project, we thought you might enjoy a few "fun facts" about the work done to support the Delta states:

• From 2001 to 2014, RHPI supported 323 onsite hospital projects
• Financial Operational Assessments were the most requested project with 110 completed
• Strategic Planning was second most requested and 37 projects were supported
• 170 different hospitals were eligible for onsite projects and 127 facilities took advantage of the opportunity
• A Return on Community Investment (ROCI) analysis completed in 2014 indicated that for every $1 invested in RHPI, a return of $6.8 was generated 

Health IT In 2024: Time to put on your futurist hat!

By Joe Wivoda, Chief Information Officer

National Health IT Week 2014 has been a blast for me! I have blogged every day and tweeted about it as well @WivodaRural. I spoke with people in my community about the importance of patient portals and convinced quite a few people to sign up and access their health information. We even made signing up for a patient portal (or a family member’s) one of our wellness challenges at The Center! Life will be so much less exciting when HIT Week is over. Insert sad face here.

Regardless, this is the final HIT Week blog, and what is a blog series without a wild prediction for the future? I have been blathering on about how we are in the “bag phone” stage of HIT, and now it is time to imagine what life will be like when we are in the “iPhone” or “Android” stage of HIT. Well beyond Meaningful Use, when patient access to data is universal and expected. Data is easily shared among providers. Welcome to 2024!

Ten years from now, patient engagement will not be a buzz word, it will be just another way we access health care. Primary care visits will begin with accessing our mobile device. Thanks to interfaces with wearable devices such as watches and glasses, the provider can see our heart rate, temperature, Sp02, respiration, and other vital signs over the last several weeks. If we have a chronic condition, such as diabetes, there will be a near-constant monitoring of our blood glucose levels. Since this information can be stored indefinitely (storage is essentially limitless) and computing power is significantly greater than today (Moore’s law will have broken down, but still…) most providers will be notifying their patients when the data indicates that there may be a problem. No longer will we need to call the clinic, they will call us when our data indicates there may be something wrong.

Telemedicine will be commonplace. What we may call an “e-visit” today will just be a “visit” to the provider. Primary and specialty visits will utilize technology that is at our fingertips to provide the right care at the right time, and most often at the patient’s home or office. Simple, inexpensive peripherals will be able to monitor our vitals and likely be able to perform common lab tests. Imagine doing your own urinalysis in the “comfort” of your home.

Apps on your smartphone will be able to utilize powerful centralized systems like IBM's “Watson” to diagnose complex diseases. Already apps like iTriage can be very useful for simple diagnoses, so imagine where we will be in 10 years!

A few years ago, a futurist told me that we might be 10 years away from having a “tricorder” from Star Trek: A device that can be held up to a person that can “sense” what physical disorders may exist. There is now an X Prize for just such a device, so I expect in 10 years that invasive testing will be rare. Instead we will walk in a “phone booth” (Remember those? They are collectible now.) that will analyze our vitals and other things to determine what ails us.

This is a long way from where we are in 2014. Consider that the cores of most of our EHRs were written 20 years ago or more, so we do have a long way to go. Increased data analytics, more complete data capture, and huge data repositories that include DNA data will be required in the future. This isn't science fiction; we are well on the way to be able to do these things. In fact, I am probably being much less imaginative than I could be. What do you think National HIT Week 2024 will be like?

Rural is Not Small Urban: Issues in Rural HIT

By Joe Wivoda, Chief Information Officer

Recently, someone asked me what I thought the major issues were with Health Information Technology (HIT) in rural hospitals and clinics. I get this question quite often, and I realized I have never blogged on this before! Since it is National HIT Week, and I am blogging daily, what better time is there to blog about rural issues? Some of these barriers apply to urban facilities but are amplified in rural, kind of like in an urban yard, you might expect to see a push mower, while in my yard, there is a Ford tractor. Or something like that. My metaphors have been weak lately.

Workforce

Access to qualified HIT staff is still an issue in many rural areas. Networks and systems typically have HIT staff, but many CAHs and Rural Health Clinics (RHCs) make do with a local personal computer consultant or someone who has some basic troubleshooting skills. It is rare to have a skilled HIT person working at a standalone CAH or RHC, but when there is, the facility is typically far ahead of those without HIT talent.

It can be the same issue for clinical HIT staff. When the electronic health record (EHR) is put in, there usually will be some sort of “super user” that needs to be assigned. They are responsible for implementation and internal support moving forward. Most CAHs and particularly RHCs can’t afford to have someone partially dedicated to maintain and support the clinical side of the EHR, so a talented nurse who is the super user will often need to step back into nursing full time, and the EHR gets neglected.

Cost of Upgrades

Particularly this year, with the new Meaningful Use certified technology requirements, EHR upgrades have been very expensive. I am aware of several CAHs who have had to pay more than $200,000 to implement the 2014 versions of their EHRs. Additionally, many of these upgrades require re-implementation of several core features, like computerized physician order entry (CPOE). The new rule allowing delays in Stage 2 does not apply if you merely can’t afford it. This can be a difficult expense to justify, particularly when the financial incentives are coming to an end.

Transitions of Care

I have written about this in a couple of other blogs. Of all of the Meaningful Use Stage 2 measures, I feel this is the most important for making a difference in the communities we serve. Patients need this, and our referral partners are begging for this!

The Stage 2 requirements around transitions of care and summary of care records has been difficult for rural facilities. Many of them do not fully understand their referral patterns, which is a critical step. Also, many CAH referral partners are either not eligible for meaningful use and do not have the capability to receive continuity of care documents (CCDs) (long term care, home care/hospice) or they are not interested/motivated to work with the CAH/RHC to exchange the information (urban tertiary/quaternary hospitals and specialists). To achieve the stage 2 measures, it will be necessary to overcome these hurdles, but more importantly, it is the right time to solve the problem of poor information flow for referrals. We are harming patients every day by not solving this!

Clinical Quality Measures

Generating electronic Clinical Quality Measures is difficult even when you have qualified HIT staff, and with the workforce shortage in HIT/Clinical IT at most rural facilities, this can be nearly impossible. It isn’t that they just need someone who can extract the data either, because it is typical that either the data is not collected, or it is not collected in a uniform manner. The act of attempting to generate clinical quality measures electronically will always result in process improvement opportunities. Just take a look at how your facility is collecting smoking status. I bet it is being collected in multiple fields and may not even be discrete. Now try doing a report on falls…

ICD-10 Preparation

ICD-10 is coming. Most CAHs and RHCs have done little about this, and if they have, it is just the training of providers and coders. There is much more HIT work to do prior to converting to ICD-10, including testing with payers and interface testing. Now would be a good time for me to plug our ICD-10 Toolkit. Free to download!

Health Reform Preparation

Rural health has been slow to understand and implement technology to support health reform. In particular Health Information Exchange (HIE), data repositories and reporting technologies are not in place or being considered. This goes back to workforce and also awareness of the implications of moving from volume to value. Health reform is here; our payment models will be changing; and HIT is a core foundation piece for being able to operate under the new models.

These are a few of my thoughts. No, the sky is not falling. Yes, we can remove these barriers. It just takes some focus and new ways of working. That isn't easy, but we need to make the changes to survive and thrive in a world where the rules are changing rapidly.

Speaking of rapid change, tomorrow is my last blog entry for HIT Week, and it will be a doozy! I will be putting on my futurist cap and discussing what HIT will look like in the next several years. Tweet me @WivodaRural, and give me some of your thoughts. This will be fun!

Usability and HIT: Evolution and a Brief History of Cell Phones

By Joe Wivoda, Chief Information Officer

All week I have been using a cellular phone analogy for Health IT. I stated a couple of times that we are in the “bag phone” stage of HIT: bulky, unreliable, difficult to use and not very appealing. Our electronic health records (EHRs) and patient portals, it could be argued, are in the same state. At least I hope so. It can be somewhat comforting to think about what happened with cellular phone technology. From bag phone to iPhone, the evolution has been astounding. But also remember that cellular technology is a consumer product with an enormous market, and this evolution still took thirty years or more.

Consider how far we have come with EHRs in the last 10 years, however. It was common to have terminal-based (“green screen”) EHRs not that many years ago, and these were primarily billing and lab systems. Thanks partially to Meaningful Use, EHRs are commonly implemented with computerized physician order entry (CPOE), patient portals, radiology, clinical decision support, and all sorts of other safety or productivity features. Unfortunately, we hear more and more that the EHR is not user-friendly or that productivity has decreased for some users.

I did say “some users.” Other users of EHRs report significant improvement and would never go back to paper. Consider billing and lab for a moment. EHRs started out as billing systems for the most part, and although they are still not perfect, we hear much less from billing departments about usability. Similarly with lab, since lab was the next area to be automated, the EHRs have gone through an evolution of usability and functionality. The same will happen in nursing and provider documentation, but when?

It is really up to the users of EHRs to work with the vendors to improve their systems. We are the “environmental stimulus” in the evolution of EHRs. How do you communicate ideas and suggestions to your vendor? What process does your vendor have for listening and using your input? Do you have a cohort of similar facilities that has a stronger voice? Particularly in rural and with EHR vendors focused on rural, working with a cohort of similar facilities carries much more weight. Talk with your friends and see what their issues are, I bet you have some of the same ideas!

It is easy for me to say, “be patient, this is a normal part of the evolution of technology.” I don’t have to use EHRs every day! There are ways to speed up the evolution, with government regulation (Meaningful Use), customer pressure (suggestions and feedback), and market forces (have you seen how many mergers are occurring?). Remember when Nokia was hailed for its innovation when they came out with cell phones that had a choice of colors? Then the iPhone happened. If you have an EHR, do this today:

• Use the test system to understand how documentation workflows can be modified
• Think about all the steps in those workflows, not just the number of clicks or screen changes. Is there a better workflow? Flow chart it!
• Consider what information would be useful to have at each step in the process. Don’t think in terms of the paper-based ways that have existed for 100 years; think about the basic information you need.
• Keep looking for improvements and innovative ideas, the communicate those to the vendor 

We will get there. Evolution takes time, but we can help speed it along.

The Public Face of HIT: Patient Portals and PHRs

By Joe Wivoda, Chief Information Officer

This is my second blog for National HIT Week, or as we are spelling it on Twitter, #NHITWeek (shameless plug: follow me @WivodaRural and The Center too @RHRC). Yesterday’s blog was really an introduction and short discussion of the concept of a national week dedicated to Health Information Technology (HIT). So exciting! So many opportunities for me to opine! So many late nights behind the keyboard! This time I want to discuss an HIT topic that we can all participate in as consumers.

There is no more important HIT topic to me right now than patient engagement. We have such a great opportunity now to start engaging patients in their own care by providing them with the data and information that we have locked up in our newly-installed electronic health records. Just about every industry you can think of does a better job of providing information to their customers. My car company provides a portal for the health of my car. My Honeywell thermostat even notifies me if my house gets too cold. One of the most data-rich industries in the history of human kind is just now providing patients with access to their health information.

I often hear that rural has unique challenges with providing patient portals or personal health records (I think these are separate, and I will explain why later) for a variety of reasons:

• “Our patients are older”
• “We have poor broadband out here”
• “Our patients just don’t want that information”

These things may indeed be true, but that doesn't mean that we shouldn't work hard to provide access to those patients and their caregivers. Older patients likely have family that are involved in their care, and that family may not be close by. Cellular technology is putting the internet into the hands of more people in more places than ever before. Even if your patients say they don’t want it today, they will very soon.

I said yesterday that we are in the “bag phone” era for HIT. When cell phones were new, there were large areas of countryside where trying to use your new phone made about as much sense trying to plug your laptop into a currant bush. It just wasn't going to work! Our model for providing patients with their health information is not much different: locked up in proprietary silos that make scheduling appointments easy, communicating with providers difficult, and functions for exporting your data into a universally accepted form (C-CDA) obscure. Personal Health Records (PHRs) like Microsoft HealthVault allow you to take the information from the various patient portals that you may have and import the data to one location. The beauty of these PHRs is that many national providers, like pharmacy chains, can automatically send information to these portals. Sadly, so can just about any local hospital, clinic, or healthcare system. The hookup is free, but few take advantage of it today. My healthcare provider knows I prefer my health information to be in a PHR of my choice and I will keep asking them to support that (someday, hopefully, please?).

What is your assignment for today? Go get access to your health information from your clinic, hospital, pharmacy, or other provider. Already have access and enjoy “checking your own oil”? Then talk to someone in your family and have them sign up. If you are responsible for the patient portal at a health care provider, is it user friendly? Does it allow patients to download their information easily? Is it easy to contact providers directly?

Soon patients will be demanding better access to their information. This patient does. So should you. Let’s move from the bag-phone era to the coveted flip-phone soon. Now that reminds me, I need to order an iPhone 6…

P.S. Cue the foreboding music! Tomorrow's topic is usability in HIT. Everyone has an opinion on that, send me yours @WivodaRural!

Welcome to National HIT Week!

By Joe Wivoda, Chief Information Officer

As a species we enjoy celebrating things. Birthdays (mine is November 28), anniversaries, National Joe Day (March 27th – you can call yourself Joe that day if you like), even National Sneak Some Zucchini onto Your Neighbors Porch Day (August 8). Today happens to be National Felt Hat Day, but more importantly for me, since felt hats make my head itch, it is the beginning of National Health IT Week! I haven’t been this excited since I found out there was a National Joe Day.

HIT is important to rural health care. HIT offers an opportunity to improve the health of the communities we serve, to improve the efficiency of the services we provide, and to improve the quality of the care that we provide. HIT has become an important fundamental technology, almost as fundamental as telephones or the lights. The infrastructure nature of HIT will become more obvious as health reform efforts move care from pay-for-volume to pay-for-quality in the next few years. It’s important to stop and consider how far we have come, and how far we have yet to go, in HIT.

What are you going to do for HIT week? Well, you don’t need to buy a present for your local HIT professional. Please don’t look for ways to make more work for your HIT person by deleting random files from your computer or violating HIPAA in such a way that an extensive privacy audit will need to be completed. I recommend the following:

• If you are not signed up for your patient portal, do so!

• If you have more than one patient portal because you see several providers and they do not share data, consider setting up a personal health record of your own (I use Microsoft HealthVault) and copy all of your data there.

• Read this blog every day this week. There will be a new post each day about HIT. Sorry, shameless self-promotion is one of my weaknesses.

• Look around at all the ways HIT is present in our community: hospitals, clinics, home care, long-term care, medical supply, pharmacy, school nurse, behavioral health provider, state corrections facility. These are all businesses that likely use significant HIT. Heck, in my small town of Hibbing, MN we have an HIT vendor (IRCS – they make behavioral health EHRs)!

Spend some time thinking about the future of HIT as well. We are in the “bag phone” stage of HIT. When cellular phone technology was first made available the phones were large, expensive, unreliable, and were presented in a less-than-stylish black canvas bag. Our current EHRs will seem silly and incomplete in five years, so consider what HIT will look like. I will be blogging on that later in the week, so feel free to comment with thoughts below or send me a tweet @WivodaRural.

Also, to celebrate HIT week, I just might have a whiskey over ice!