Senators: Rural Hospitals Hobbled by Digital Divide

Members of the U.S. Senate Finance Committee suggest that Farzad Mostashari, MD, the National Coordinator for Health Information Technology, has little or no idea of the challenges rural healthcare providers face as they grapple with Meaningful Use requirements.

With all of the fighting, delays, and splashy headlines surrounding the Patient Protection and Affordable Care Act, the evolving status of meaningful use and the adoption of electronic health records often take a back seat.

Yet, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the $33 billion that came with it are leading and funding the development of the complex HIT infrastructure that will make possible key components of PPACA.  

There are rumblings, however, that rural providers are falling behind with HITECH implementation. For example, only one-third of rural hospitals have electronic medical records systems, compared with half of all urban hospitals.  

Members of the U.S. Senate Finance Committee Wednesday sought answers on the status of meaningful use in rural America from Farzad Mostashari, MD, the National Coordinator for Health Information Technology. "I'm concerned about the digital divide may only get larger as rural hospitals are expected to take the leap into the more rigorous requirements of [Meaningful Use] Stage 2," Sen. John Thune, (R-SD), told Mostashari during the hearing.

"They have already expressed great concerns about Stage 2. I am of the view that [Office of the National Coordinator] and [Centers for Medicare & Medicaid Services] ought to develop a way for rural hospitals to achieve Stage 2 while allowing more advanced healthcare systems and providers to move on to Stage 3 if they are ready. The question would be will you commit to giving rural providers more time to achieve Stage 2?"  

Mostashari replied that federal officials "have been quite open to dialog with the rural community and how we can help them achieve success and not necessarily accept that they are necessarily going to be further behind."

While challenges remain, Mostashari says that rural providers have made tremendous progress in adopting electronic health records. In fact, Mostashari says he is so confident in the advances that smaller hospitals are making, that deadlines have been moved up, not back.

"We set a goal of getting 1,000 critical access hospitals to meaningful use by 2014. We are going to revise that goal to get 1,000 critical access hospitals to meaningful use by the end of this year," Mostashari says.  

"We think we are making good progress with those hospitals through the technical assistance and coordination that is possible. So, we are open to dialog. But I would much rather see the rural hospitals be able to keep up rather than me acknowledge that they are going to fall behind."  

An independent review appears to back up Mostashari's claims that rural America is making progress on the electronic medical records front. A report from the Robert Wood Johnson Foundation, co-authored by Mathematica Policy Research and the Harvard School of Public Health, finds that the proportion of rural hospitals with at least a basic EHR increased from 9.8% to 33.5% from 2010-12. During the same time urban hospitals saw EHR adoption rates rise from 17% to 47.7%.

"The inpatient divide between rural and smaller hospitals compared to better resourced urban hospitals, particularly teaching hospitals, remains, but it is closing," says study co-author Michael Painter, MD, senior program officer at Robert Wood Johnson Foundation.

"The other thing we are finding is that the rate of adoption seems to be accelerating among the small and rural hospitals compared with the larger better resourced urban hospitals. That makes sense because the better-resourced urbans accelerated early on and now that is leveling off. The more-challenged small and rural hospitals are accelerating. Where this all plays out is hard to see. We will keep monitoring it in the coming years."

Painter says the percentages of hospitals that have achieved meaningful use actually could be significantly higher than what his report found because it uses data from 2012.  

"Those numbers are a moving target. When we looked at 2011 data, only 4% were meeting Stage 1 Meaningful Use. From that dipstick to the next year it went to 44%. So we would expect that when we looked at who is close to pushing over on the Stage 1 criteria there is a huge number there."

"You can't get that mired down in what those snapshot-in-time numbers mean. What we are seeing is a trending all in the right direction, with some ongoing small and rural gaps, although that seems to be closing. But we are not out of the woods yet," Painter said.

Back in Washington, several members of the committee, including Sen. Pat Roberts, (R-KS), made jokes about Mostashari's trademark bow tie and suggested that he and other federal bureaucrats have little or no idea of the challenges that rural providers face as they grapple with meaningful use.  

"My concern is I don't think we are getting the word west of Highway 81 in Kansas…," Roberts said. "It's like Paul Harvey used to do with Page 1 and Page 2. Page one and I will be back in just a minute. Well you've got Phase 1 and Phase 2. If we could just pause and make sure that most of the rural providers know what is going on."

"I get two sides of the story. I talk with the people in Topeka and they say everything is going as best as it possibly can. But I get a lot of calls from providers saying this is the proverbial wet horse blanket. My suggestion would be [to] take this show on the road. I would recommend Hayes, KS or Dodge City, KS. That is my hometown. I'm not sure I would recommend wearing a bow tie in Dodge City. But if you could go out and sort of take this digital show on the road that would be helpful. Or maybe have these folks come in because I know you are extremely busy."

That sentiment was shared by Committee Chairman Max Baucus, (D-MT), who urged Mostashari to "get out… of your offices and out to rural America. See it. Smell it and taste it, and know what it is. It is one thing to conceptualize it. It is something else to experience it."

"I mention you, Dr. Mostashari. I don't know why. I sense you are a Philadelphia guy, an eastern guy, a big city guy. There is a huge difference. Eighty percent of life is just showing up, just getting out there, being there, seeing it. Get out from behind your desk. It is well worth it. You're going to make fewer mistakes with respect to rural providers if you get out and see it."