Aalpen Patel, chairman of the radiology department at Geisinger, explains how point-of-care ultrasonography (POCUS) technology is revolutionizing imaging operations and improving both business and clinical outcomes.

Healthcare organizations are moving away from the bulky ultrasound machines of years past and embracing digital health platforms that make imaging more mobile and integrate directly with the EHR to improve care management and workflows.

One of those health systems is Geisinger, which today announced a partnership with medical imaging and software company Exo to streamline the mobile ultrasound process. The Pennsylvania health system is using point-of-care ultrasonography (POCUS) in its women's health, emergency, and sports medicine departments and plans to expand to more than a dozen other locations in the future.

The streamlining of inpatient services is on every executive's to-do list as healthcare organizations seek to reduce workflow stress on staff and clinicians, reduce hefty medical costs, and boost clinical outcomes through better data access and analysis. Medical imaging costs are a significant burden on a hospital's bottom line and an area ripe for innovation.

"POCUS is perhaps the single most revolutionary technological advancement in medicine in the last 30 years," says Aalpen Patel, MD, MBA, FSIR, chairman of the Geisinger's radiology department, in an e-mail conversation with HealthLeaders. "Its scope spans almost every specialty and exponentially extends the clinician's ability to make rapid diagnoses and guide many procedures safely."

"Historically, ultrasound was performed in radiology or cardiology, where in-depth, time-consuming studies performed by techs were then interpreted by a physician (not at the bedside). This often required the patient to be transported to another area of the hospital, which is problematic, especially if the patient is unstable. POCUS has significantly extended the bedside clinician's ability to rapidly answer important clinical questions about the patient and narrow their differential."

Aside from improving workflows and care coordination, the technology also impacts clinical outcomes.

"POCUS allows clinicians to rapidly diagnose or exclude life-threatening conditions at the bedside," Patel says. "It is also used for procedural guidance, making procedures significantly safer for patients. Having the ability to archive images and generate reports in a streamlined workflow allows other members of the healthcare team to view this data and make clinical decisions."

According to Patel, hospitals are turning to this technology for several reasons.

"First and foremost, using an enterprise POCUS workflow can improve the quality of care for patients," he says "It allows the ability to perform quality assurance on images. This data can be used for assessing clinician competency, helping with credentialing and privileging, and providing quality feedback for continuous POCUS skill improvement and education."

"It also allows health systems to collect previously uncaptured revenue for POCUS studies," Patel adds. "Creating a POCUS workflow and archive also provides a database for quality review and helps mitigate medicolegal risk. And it can improve ED and hospital throughput, decreasing procedural complications and high-end radiology utilization such as CT, MRI or Interventional Radiology."

On the other side of the ledger, there are challenges to adopting this technology. And in this turbulent economy the biggest barrier may be the cost. Imaging systems aren't cheap, and it's up to the CIO or radiology department head to connect the dots for the CEO and CFO between expenses and ROI.

"Sometimes it can be difficult to convince leadership that a standardized POCUS workflow is needed to ensure that POCUS is performed properly and safely," Patel says. "However, demonstrating the quality and safety benefits along with the positive ROI from both soft and hard revenues gained by investing in an enterprise POCUS workflow solution can help overcome this barrier."

Ther's also the challenge of integrating new technology into the workflow.

"Clinicians are extremely busy, and every extra click they are asked to make takes them away from direct, patient-facing care.," Patel says. "Ensuring that the POCUS workflow is streamlined and seamlessly integrated in the EMR can help overcome this barrier. These exams allow the clinician more time at the patient's bedside, and [the technology] has been shown to improve patient satisfaction and experience scores."

"Another challenge is the ability to standardize a POCUS workflow across multiple departments," he adds. "Different specialties have different needs and expectations from a POCUS workflow. Providing a flexible workflow with customizable reports can help overcome this challenge."  

And finally, Patel says, it's important to have resources on hand to educate staff about how to use the technology.

"Some specialties have POCUS education embedded in their residency and fellowship training curriculum, but others do not," he says. "Providing attending clinicians with educational and training resources including internal courses, didactics, image review sessions, and hands-on training sessions and simulation can help overcome this challenge. Fortunately, POCUS is being incorporated into not only residency and fellowship training but in many medical school curriculums." 

A lot of the potential around this technology lies in its mobility. As health systems look to move more services outside the hospital and closer to the patient—be it in the home, a community health center, a remote clinic or doctor's office or even an accident scene—mobile ultrasound platforms are showing their value for providing on-demand care.

"POCUS technology and workflow is evolving at light speed," Patel says. "In the last 10 years these machines have transformed from large, clunky, cart-based machines with suboptimal image quality to compact and handheld units that can be taken to almost any environment inside or outside the hospital. Many newer machines are equipped with Wi-Fi capabilities, wireless technology, significantly improved imaging quality, and various Doppler technologies. Many of the newer devices have built in AI/machine learning [capabilities] that allow for auto-labeling and auto-calculations, and they can direct novice learners to the correct scanning plane and beam angle. And POCUS workflow reporting from various vendors allows mobile reports to be generated on iPhones, iPads, and android devices with a few swipes of the finger." 

The recent flurry of collaborations between healthcare organizations and Big Tech is a good sign that health systems are finding their footing in AI development.

Healthcare organizations are joining forces with some of technology's heaviest hitters to push AI projects out of the planning stages and into the hospital.

The announcements are, in part, an effort to get in front of the AI hype machine and demonstrate that health systems are putting this technology to work to improve critical issues like workforce stress and administrative overload. The industry doesn't want to repeat the missteps of the EMR rollout, when news stories about bad experiences overwhelmed talk of the positives and hindered EMR adoption and development.

In just the last month:

• Mass General Brigham announced the rollout of an AI algorithm for radiology "that will help increase operations' effectiveness and productivity." The technology was developed in a partnership with GE HealthCare, which agreed to a 10-year collaboration in 2017 "to explore the use of AI across a broad range of diagnostic and treatment paradigms."
• HCA Healthcare announced that its partnership with Google, forged in 2021, had led to the pilot of an AI platform to document emergency department conversations between doctors and patients, and that the two were now testing an AI tool to facilitate nurse handoff reports.
• Duke Health and Microsoft announced the launch of an AI Innovation Lab and Center of Excellence as part of a five-year partnership "aimed at responsibly and ethically harnessing the potential of generative artificial intelligence (AI) and cloud technology to redefine the healthcare landscape."

"Everyone's trying to get ahead of it," says Avishkar Sharma, MD, CIIP, director of AI at Jefferson Einstein, part of the Philadelphia-based Jefferson Health network, which has been working with Aidoc in the radiology space for several years and is considered a leader in that space. "It's an ever-present conversation [in every health system boardroom]."

At the AIMed Global Summit this past June in San Diego—as well as other healthcare conferences like ViVE and HIMSS—the focus on AI was around what many call "low-hanging fruit." To wit, healthcare organizations are looking to use the technology to handle administrative tasks that consume time and energy for staff, including doctors and nurses.

"That's the immediate benefit," says Stephen Motew, MD, MHA, FACS, executive vice president and chief of clinical enterprise at the Virginia-based Inova Health System. "Where are the small, value-added opportunities in our day-to-day operations … that can be made more efficient?"

Indeed, while questions remain around AI governance and policy, health system executives who want to get their foot in the door are launching small programs that use tightly controlled, non-PHI data, finding the benchmarks and the benefits, then moving on to more ambitious projects.

Sharma fits AI adoption into the Gartner Hype Cycle, which charts the maturity, adoption, and social application of technologies. The five stages of that cycle are Innovation Trigger, Peak of Inflated Expectations, Trough of Disillusionment, Slope of Enlightenment, and Plateau of Productivity. He says AI has moved beyond that first stage and sits between the second and third, with health systems looking to find meaningful value beyond the hype and potential.

"We're very much in that turbulent phase," he says.

And that's why these recent announcements are important. They show that health systems are putting skin in the game and moving forward with pilot projects.

Motew says these partnerships are also important at a time when operating margins are thin and health system leaders are hesitant to take on new ideas. Few health systems have the IT talent on hand to make these moves on their own or scale them out to the enterprise.

Furthermore, these partnerships support health systems who are moving their data into the cloud and need help with cloud management.

"This is what everyone is trying to figure out now," he says. "And we want a seat at that table."

Sharma says partnerships are essential to developing and scaling AI programs across the enterprise, but they also have to be nimble. Owing to the evolving nature of the technology, an AI program created now that will use a specific subset of data to address a specific pain point won't be the same program in, say, a year's time. The technology, the data, and the governance around it will mature dramatically.

"You have to build relationships that are ongoing," he says.

Lastly, AI programs coming down the pipeline need to be guided by clinicians. Both Motew and Sharma also say that while the C-suite needs to set safeguards and parameters for AI use, the true value of the technology will be found by those using it.

"We encourage our teams to play around with it," Motew says. "The best ideas are going to come from the people using it every day."

"Clinicians very much need to be in the conversation and in the driver's seat," adds Sharma.

The health system is reporting positive results from a chronic care management program launched in 2021, and now wants the Geek Squad to manage more patients at home.

Geisinger is expanding its partnership with Best Buy Health to bulk up a remote patient monitoring platform that’s showing positive clinical outcomes.

The Pennsylvania-based health system launched ConnectedCare365 in 2021 and joined forces with the retail giant's Current Health subsidiary to give patients better access to chronic care management tools at home. According to health system officials, the program has enrolled more than 1,100 patients and is seeing an almost 20% improvement in care plan adherence, while speeding up the time patients begin the program after leaving the hospital and cutting technical issues by almost 20%.

The collaboration is being closely watched by the healthcare industry as more health systems move care pathways into the home and RPM programs show results, particularly in managing care for patients living with diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and other issues.

[See also: Assessing the Evolution of Remote Patient Monitoring Programs.]

The partnership enables Geisinger to refer patients identified in the hospital for RPM to Current Health, which visits the patient's home, sets up each patient with the right equipment for the program and ensures the devices are transmitting data to the care team at the hospital. Through the 'Geek Squad' format made popular by Best Buy's retail electronic and computer departments, Current Health keeps in touch with patients and helps with any technical issues.

"We know the myriad benefits of care at home for patients, families, and the health system, and the Current Health platform allows us to care for patients with chronic diseases in the home," Karen Murphy, Geisinger's executive vice president and chief innovation officer and founder of the health system's Steele Institute for Health Innovation, said in an e-mail to HealthLeaders. "In addition, working with the Geek Squad is a fundamentally different approach to a remote patient monitoring program. Instead of a patient receiving devices in the mail, the Geek Squad provides personal instruction on how to operate the device and how to communicate with the care team."

"Best Buy Health and their large supply chain and logistics capabilities offered a very promising solution for us," she added. "We’ve seen great results so far and are excited to expand the program to more use cases."

[See also: At Geisinger, Karen Murphy Maps Out Innovation Strategy With a Wide Lens.]

This isn't Best Buy's only partnership. Earlier this year the retailer joined forces with Atrium Health to support the North Carolina health system's Hospital at Home program. At the HIMSS conference in Chicago shortly thereafter, Chris McGhee, Current Health's co-founder and CEO, said the deal is indicative of a healthcare industry looking to be more consumer-friendly and apply some retail strategies to its platforms.

"We're fundamentally changing healthcare," he said, noting the Best Buy can pick and choose the technology needed to make the best and most reliable connections between a patient in the homes and his or her care team at a hospital. "Hospitals value that curation."

That's especially true as health systems like Geisinger expand their RPM programs to manage more patients with more health concerns. The ability to scale programs up and out and have Current Health manage the technology deployment and monitoring takes pressure off of health system executives and clinicians, giving them more time to focus on the clinical side of the program.

"Technology-enabled care-at-home programs allow us to extend their reach beyond the confines of traditional settings and bring high-quality care directly to the comfort of patients' homes," Murphy said. "These models have been shown to improve outcomes—especially readmissions—and provide more comfortable experiences and lower costs."

"Our work with Best Buy Health allows us to better cross the threshold into patients' homes and, through the Geek Squad, enable them to use RPM technology," she added. "The data shows the impact on the patient – they are getting the technology faster, adhering to their care plan better and having fewer technical issues.  And they’re giving their experience high marks afterwards."

A new partnership will open primary care clinics in select YMCAs around Memphis, offering more convenient access to care for local neighborhoods as well as businesses.

A new partnership in Memphis aims to address local businesses' needs for primary care access for their employees as well as access to care in underserved neighborhoods.

Chamber Benefits, a health plan subsidiary of the Greater Memphis Chamber of Commerce, is joining forces with the YMCA of Memphis & the Mid-South and WeCare, a Florida-based provider of onsite and near-site primary care centers for businesses, to open primary care health centers in YMCAs across the greater Memphis area.

The project addresses an acute care gap in many cities: A lack of accessible primary care services for both businesses looking to get a handle on employee healthcare costs and underserved neighborhoods. Some cities have partnered with community health organizations and others to put health clinics in such sites as libraries, retail locations, and pharmacies or grocery stores.

These clinics are also good opportunities to address health equity issues in urban locations.

The goal here is to improve community health as well as support local businesses. It also aims to reduce the strain on local health systems by improving access to immediate and preventive care and cutting down on unnecessary emergency room and clinic traffic.

Each 2,500-square-foot clinic will have full-time staffs that include primary care physicians and health coaches.

“This is a partnership united by its love of Memphis and desire to see greater access to primary care throughout our community,” Ted Townsend, president and CEO of the Greater Memphis Chamber, said in a press release. “ChamberCare Health Centers are designed to improve not only the health of our community but of our economy. Enrolling in this program will help small businesses, which create two out of every three jobs, provide their employees with exceptional benefits at low costs in a highly competitive jobs market.”

“This partnership perfectly aligns with our mission to support programs that build a healthy spirit, mind, and body for all," added Jerry Martin, YMCA of Memphis & the Mid-South's president and CEO. Providing access to quality healthcare, especially in areas with fewer options, enables us to broaden our services to continue to help families and individuals thrive on their journey to wellness.”

Organizers are currently deciding on three sites to open health centers, beginning in 2024. Businesses can enroll employees in the program for $40 per month per employee, while community residents can also enroll for $40 per month. Dependents are added on at no charge.

Following the opening of the first health centers, the partnership will open a new clinic in another YMCA location for every 2,000 people enrolled in the program, including dependents.

The key to getting doctors on board is to present them with the evidence, and then put it to a vote.

One of the biggest hurdles in supply chain is gaining physician support for clinical product procurement.

In this interview, Dan Hurry, president of Advantus Health Partners, the Cincinnati based supply chain mangement and group purchasing organization, says the key to getting doctors on board is to present them with the evidence, and then put it to a vote. Hurry spells out the process that he recommends in this, the first of a two-part interview with HealthLeaders. This transcript has been edited for clarity and brevity.

HL: How big of a factor is physician preference in supply chain?

Dan Hurry: From a quality of care, from an economic, and from an efficiency standpoint, it's probably 60% of what you should be talking about and working on at any given time. The activity is revolving around the ORs, the cath labs, because that’s the implant space, whether it's cardiac, whether orthopedic, those are the predominant spaces where the engagement between a physician and a manufacturing rep and your operational leaders interconnect.

Would hospitals always be looking for the lowest cost? No. They’re looking for what’s the best outcome for the patient at hand. Now with that, it's always debatable about what is the better product. So, we lean into clinical evidence in all those scenarios. The cost of goods, how much we're buying it for is only one part of the equation.

HL: Where is the potential for conflict?

DH: In many cases it may be relationships that a manufacturer's rep has with a physician. What is their role in the OR or the cath lab, and how does that impact choice? That space is always under scrutiny with the potential for conflict, but there's usually a superficial point that's brought forward, so we lean into most of the evidence and that all comes from the physicians’ side of the house.

We collect and organize data on the front end, and we put together a “fact pack.” Using cardiac rhythm devices as an example, we ask what the patient looks like, how the physicians use the devices, where do they use these devices, what does that look like from either a regional or a national market share utilization perspective, what do the outcomes look like with any particular devices, etc.

The fact pack yields data that allows some comparables between different scenarios, different companies, different products, whatever that looks like. Once you get that homework done, it's time to engage the physicians and see what the state of the union looks like.

Typically, there will be a very brief engagement with the physicians on the front end, before gathering the data, telling them we're going to review this. When we've got bigger, better and deeper data, we'll engage you on a deeper level.

Then when we engage them on all the facts, they're scientists, they want to see the data they want to see what this looks like, and we have some dialogue from there. Ultimately, we ask where do we want to go with the product based on its lead with that clinical evidence? Then we'll ask how do we negotiate for the best quality products.

HL: How important is volume in price negotiations?

DH: We’ll use the Costco model as an example. They usually don't put sub-quality products on their shelves. They negotiate for the best quality within a category or product mix and match what deserves shelf space. We do that at the front end. What are the products that deserve some shelf space, where we agree that this is a quality product made by a quality company with outstanding outcomes? How do we negotiate to come up with the economic package to support continuous use?

Once that's done, there is a perpetual review, with continuous improvement exercises constantly engaged with category management teams of cross-functional players in quality, clinical, economic and operations.

HL: To what degree is cost part of the equation?

DH: We do not chase low-cost goods. We chase the best quality goods and then drive the best economic outcome for those quality goods. Cost is always a factor, but it is a tertiary concern, behind outcomes and quality.

We contract with a few outside companies that are run by physicians who do independent assessments of outcomes, quality, the attributes associated with any given product. We’ll ask if these assessments align with our physicians’ experience. They may or may not agree with an analysis and that's where we want to gain their input.

HL: Who has the ultimate say in what product is purchased?

DH: We have a cross-function of folks, physicians, C-suite executives, quality, economics, finance. Supply chain is run by a certain group of folks that go through this process. There’s a vote and a proxy and what we land on and what's approved. It's no independent group in and of itself.

Once we've landed on the right product or product mix, like any other consumer, we negotiate based on attributes, our commitment to the products, the optimal logistics solution, what do our payment terms look like, everything that kind of supports the economic equation for the products that we've selected. There’s no rocket science out there.

What will it take? Rural health executives share their solutions to healthcare desert challenges.

Editor’s note: This article appears in the July-September 2023 edition of HealthLeaders magazine.

Virtually every problem that exists in healthcare today is exacerbated for rural providers due to lack of resources and funding, a smaller talent pool, and fewer points of access. What can be done? Can the problems facing rural healthcare be solved? Rural healthcare executives share ways that can help alleviate specialty care access, staffing issues, and financial challenges.

Telehealth can conquer rural access challenges for both patients and specialists

Access to primary care in rural and remote parts of the country is tough enough, but what about when someone needs to see a specialist?

According to the National Rural Health Association (NRHA), there are roughly 30 specialists available per 100,000 people in rural parts of the country, compared to 263 per 100,000 people in urban regions. Simply put, specialists tend to live and work in well-populated areas, where they can work near large health systems and have access to a large patient base. The only time you'll likely find a gastroenterologist or neurologist in rural America is if they've retired there.

Rural communities and health systems are addressing this challenge through telehealth and digital health tools and platforms. They're using platforms that enable rural residents to meet with specialists online, either from their homes or from telemedicine stations set up at local hospitals, health clinics, or doctor's offices. In addition, these platforms enable specialists to live in rural regions and build their own patient base.

Organizations like the MAVEN Project are contributing as well by forming virtual networks of specialists to help remote health clinics access specialists for mentoring and support. The MAVEN Project is a nonprofit organization that has built a network of retired and active providers and specialists to virtually mentor and support providers in rural areas and those who work with underserved populations.

"We want to be in an environment where everybody can have access to health services when they need them, and that includes specialists," says Suzan Bast, service excellence manager at Fairbanks Memorial Hospital in Fairbanks, Alaska, a city of roughly 100,000 that's closer to the Arctic Circle than the nearest major metropolitan center.

To facilitate access to specialty care, Fairbanks Memorial has a partnership with Troy Medical, a Texas-based telehealth company that provides virtual specialist services. Local residents who are referred to a hepatologist, rheumatologist, or gastroenterologist, or who need to see a neurologist or dermatologist and can't wait for the region's one specialist to clear time on the calendar, can visit the hospital's Tanana Valley Clinic to see a doctor located thousands of miles away.

"It's six hours to Anchorage," says Bast. "So if you need to see [a specialist], you're traveling a lot." That's time-consuming, costly, and exhausting to patients and their families, she says.

Standing up telehealth

Troy Medical was, in fact, launched by an Alaskan to meet that need for specialist services. Kara Hartl, MD, an ophthalmologist who'd spent roughly 15 years in Fairbanks, launched the company after struggling to find care for a patient who was living with a debilitating medical condition and needed to be seen by three specialists.

"I couldn't get them the access to care they needed," says Hartl, who named the company after that patient. "COVID made it a lot worse, but it also helped to validate telehealth as a way to provide that access."

Hartl says Troy Medical saw great success in its first year of operation in Alaska, at which point she decided to extend the company's reach to another state with similar rural health issues: Texas. She set up shop in Austin, began working with the Texas Organization of Rural and Community Hospitals, and launched a second site in Sulphur Springs, a city of 15,000 in the northeast corner of the state, about 80 miles east of Dallas.

Rural Texas faces many of the same healthcare access issues as Alaska. With smaller populations and a troubled economy, it's difficult to sustain a health system at all, never mind one with its own specialty services. Twenty-one hospitals in Texas have shut down over the last decade, more than any other state, and roughly a quarter of those still open are at risk of closure, notes the Texas Hospital Association on its website.

Hartl's business model is to establish relationships with local hospitals and communities, rather than just setting up a telemedicine platform and letting the chips fall where they may. As with Fairbanks, Troy Medical built a clinic in Sulphur Springs where residents can go for appointments. The hospitals have a role in selecting which specialists are needed, and the clinic is staffed with support personnel to handle administrative tasks and help patients with virtual visits.

"You need to have the presence on the ground," Hartl says. "Keeping it local is so important to those community hospitals."

That's because many specialist consults lead to more consults and care management, as well as treatments and other services that can be coordinated with local providers. The idea is to make sure care remains in the community.

"We're creating relationships and helping these patients navigate the healthcare system," she says. "The only thing we request of community hospitals is promotion."

State licensure rules often hinder telehealth expansion

Texas is proving an easier place to establish this platform, Hartl says, because the state has a lot of doctors. That means it's easy to find specialists in state and set up the virtual care network. Alaska doesn't have many doctors, so Hartl must expand her network into other states to fill the ranks.

That's one of the biggest challenges to this type of program. Each state licenses and regulates its own providers through state medical boards, and not everyone is comfortable treating a patient in another state through telehealth. The pandemic did make the healthcare industry aware that telehealth could be used to practice across state lines, and many states relaxed their rules during the public health emergency to allow certain telehealth services. But licensure is still a complex process, and doctors must apply for a license in every state in which they want to practice. This means telehealth platforms like Troy Medical must ensure the specialists they're providing can treat a patient in a certain state.

Hartl says she prefers to work with states that are part of the Interstate Medical Licensure Compact (IMLC), a network of states that have adopted a streamlined licensure process to allow providers to practice in other states (ironically, Alaska isn't in the IMLC).

That said, with successes in Alaska and Texas, Troy Medical is poised to expand to other states.

"The technology for this is straightforward," she says, referencing technology partners that include athenahealth and Logitech, among others. Troy Medical will spend roughly $100,000–$150,000 to stand up a clinic, then work with local hospitals and providers to bring in specialists virtually.

"Sometimes you feel like a rock star," she says, talking of providing access to a specialist in a rural area—which can save a patient and family thousands of dollars in travel costs, reduce stress, and uncover pathways to stronger care management, better clinical outcomes, and improved health and wellness. "It's what we want medicine to be like."

Back in Fairbanks, Suzan Bast says the platform can work both ways. While it gives residents access to the experts, it also gives her hope that the region can attract more providers.

"The benefits of Alaska don't necessarily appeal to everyone," the native Alaskan admits. But not everyone wants to live in a big city or densely populated state. Thanks to the technology now available, a doctor can think of moving to a rural area and develop a patient base that spans the country.

"The work-life balance isn't bad," she adds.

Why nurse practitioners are a solution to rural healthcare

With more than 100 million Americans lacking access to primary care, employing more nurse practitioners (NP) and allowing them to practice at the top of their license is critical to making healthcare more accessible in rural areas, NP leaders say.

NPs could ease "care deserts" created by physician shortages and rural hospital closings. Nearly 80% of rural U.S. counties are medical deserts, according to the NRHA. About 35% of all U.S. counties are "total maternity deserts"—no access to prenatal or delivery services—and another 54% are considered partial deserts, which equates to 7 million women without access to maternity care, according to the March of Dimes.

"There are many people who don't see a doctor or get healthcare on a regular basis, and when they are really sick, they go to the emergency room for their care," says April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, immediate past president of the American Association of Nurse Practitioners (AANP).

"It is definitely a need in rural health that we get providers out in every community," Kapu says.

Growing in number

The demand for NPs is growing and their role is expanding, thanks in part to an aging U.S. population, increasing infectious diseases, rising chronic diseases, and fewer physicians, the AANP says.

The percentage of rural physicians has declined—12.8% from 2008 to 2016. But the percentage of NPs increased 17.6% during that same time period, according to a 2020 study.

"We're growing at a rate of about 9% a year," Kapu says. "We are up to more than 355,000 nurse practitioners across the U.S. today, and we are estimated to grow by 46% by the year 2031."

Nearly 90% of NPs are certified in an area of primary care and 70.3% of all NPs deliver primary care, according to the AANP, with 83.2% of full-time NPs seeing Medicare patients and 82% seeing Medicaid patients. Additionally, nearly half of all rural primary care practices have at least one NP, according to the NRHA.

A well-rounded approach to healthcare

NPs' holistic, wellness-centered approach to primary healthcare—health promotion, prevention, and chronic disease management—is particularly beneficial to rural patients who must travel long distances when illness requires acute care.

"One really valuable thing they bring to rural health is the approach to healthcare, which differs a bit from the medical model," says Michele Reisinger, DNP, APRN, FNPC, a working NP and assistant professor of doctoral nursing at Washburn University in Topeka, Kansas. "Nurse practitioners are trained to look comprehensively at the individual."

NPs are well positioned for primary care roles because of their education and training, says Reisinger, who has helped obtain an advanced educational nursing workforce grant centered on educating nurse practitioners for rural practice.

"When we train them as nurse practitioners, we train them to manage chronic disease states; we train them to be experts in promoting health and wellness [as opposed] to an urban setting where they may work only in urgent care … or have a very targeted education in cardiology or neurology," Reisinger says.

Instead, rural nurses treat the spectrum of pregnant women, infants, children, adults, and geriatric patients, along with entire families, she says.

"Nurse practitioners in rural areas wear many hats," she says. "They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So we try to prepare them in a way that it's global in that manner."

Working closely with patients allows NPs to create collaborative prevention plans to help patients make lifestyle changes and health choices that can stave off chronic disease and keep them out of the emergency department, Kapu says.

"We know that timely access to care, particularly preventative care, is crucial to the early detection of health issues," Kapu says. "It has a huge impact on the mitigation of healthcare cost, and so important to health and well-being overall, and whenever that care is delayed, we know that individuals face a greater risk for complications for not following up on chronic diseases."

Such preventive care makes a difference to rural patients, Kapu says. "Many large-scale reliable studies have shown that we have a tremendous impact on the reduction of unnecessary emergency department visits," she says.

Breaking down barriers

Despite the advantages that NPs can bring to rural, underserved areas, barriers continue to limit them from working at the top of their license, Kapu says.

For example, even though more than half of U.S. states have granted NPs full practice authority (FPA)—which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—nearly as many states make it illegal for NPs to practice their profession without a collaborative agreement with a physician.

The American Medical Association (AMA) and other physician groups accuse FPA of "scope creep"and charge that nonphysicians practicing medicine is a threat to patient safety. At its annual meeting in June, the AMA passed a policy amendment calling for advanced practice RNs (APRN) to be licensed and regulated jointly by the state medical and nursing boards. Nursing groups denounced the policy amendment.

States that have embraced FPA have increased their nursing workforce and helped ease care deserts, Kapu says. When Arizona enacted FPA in 2001, the NP workforce doubled across that state within five years and grew by 70% in rural areas, and North Dakota's adoption in 2011 saw its nursing workforce grow by 83% within six years, she says.

Some barriers are being reconsidered. The Improving Care and Access to Nurses Act (ICAN) was reintroduced in the U.S. Senate in April and would allow NPs, physician assistants, and other APRNs to provide particular services under Medicare and Medicaid. ICAN would, among other things, authorize NPs to order and supervise cardiac and pulmonary rehabilitation, certify when patients with diabetes need therapeutic shoes, and certify and recertify a patient's terminal illness for hospice eligibility.

"These are substantial barriers that, if they were removed," Kapu says, "we will be able to provide much-needed, timely care, and [for] our elderly and Medicare beneficiaries who live in these rural communities."

Financial stability in rural health

According to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, 136 rural hospitals closed between 2010 and 2021. The Sheps Center says 19 rural hospitals closed in 2020, the most closures in a single year in the past decade.

A pair of top healthcare executives told HealthLeaders that four factors pose significant financial difficulties for rural hospitals:

1. Declining and stagnant populations in rural areas
2. An unattractive payer mix dominated by Medicare and Medicaid patients
3. Sicker patients in rural areas compared to urban areas
4. Financial challenges related to workforce shortages
    

"Declining and stagnant populations in rural areas are a challenge. About 80% of rural counties nationally have declining populations. Traditionally, rural hospitals had sufficient patient volumes, and they were able to provide care to most patients. That is just not the case anymore," says Brian Shockney, MHA, president of Indiana University (IU) Health South Central Region.

To address the impact that declining and stagnant populations are having on its rural hospitals, IU Health is careful about the kinds of services its facilities provide and it reviews the services relative to the population’s needs, he says. "Every three years, we do a community health needs assessment, and every year we reassess our services based upon that community health needs assessment."

Grants play a crucial role in providing services at rural hospitals with low patient volumes, Shockney says. For example, IU Health received a U.S. Health Resources and Services Administration grant to provide dementia and Alzheimer's disease care in Lawrence County, Indiana. "We are able to provide that care for patients through those grant dollars," he says.

The high percentage of Medicare and Medicaid patients at Lebanon, New Hampshire–based Dartmouth Health is a payer mix challenge, says Wendy Fielding, MBA, chief financial officer of Dartmouth Hitchcock and system vice president of finance of Dartmouth Health.

"For us, governmental payers are about 60% of our revenue mix. Medicare is about 46% and Medicaid is about 14%. Northern New England has an aging demographic, so we expect that percentage of Medicare to increase year over year. In our 2024 budget, we have a $15 million to $20 million expected erosion in our net patient revenue as a result of the ongoing growth of Medicare in our payer mix," she says.

New Hampshire has among the lowest-reimbursed Medicaid programs in the country. Dartmouth Health is dependent upon commercial payers to overcome the low reimbursement rates of Medicare and Medicaid, Fielding says. "We struggle to overcome the low payment rates. Ultimately, we are shifting the burden of these low governmental payment rates onto our commercial payers."

Other efforts to address the unattractive payer mix have generated limited results, she says. "We are always advocating for ourselves with our representatives in Washington, and though we work internally to become more efficient, we are still taking it on the chin."

IU Health sees sicker patients at its rural hospitals compared to the health system's urban hospitals, Shockney says. "Our rural citizens are not as healthy, and many are living in poverty. When we look at our rural populations and the death rates in rural areas, it outpaces urban areas in the top 10 causes of death, including heart disease, cancer, stroke, and Alzheimer's disease. They are expensive patients to care for. So, that raises the cost of care."

Medical home models of care have been effective in treating patients with high medical needs, he says. "At all of our practice sites, we have telemedicine for behavioral health, and we embed pharmacists, social workers, and dietitians where there is a need to address high diabetes rates and care for those patients. We provide a team of caregivers who surround the patient. In a rural clinic, we may not be able to provide a full-time pharmacist or a full-time dietitian, but we have the telemedicine capability to connect patients with behavioral health services, or a consultation with a dietitian, or something of that nature. That reduces the cost of having to have a physician, and it manages the care of the patient holistically."

Fielding says Dartmouth Health's biggest financial challenge is related to the health system's workforce. "Even though we are located in a rural environment, we are close enough to Boston that we do need to compete with that marketplace, so our workforce is more expensive than what you might think of for a rural setting. Like other healthcare organizations across the country, we have been dealing with an increased reliance on contract labor such as agency nurses. That is having a significant financial impact on us."

To make Dartmouth Health more competitive with the Boston labor market, the health system has been working with local real estate developers to boost affordable housing, she says. The health system has also been looking for ways to increase childcare options for its workforce, Fielding says. "We have explored investing in childcare centers and building up the workforce in those facilities."

She says keeping contract labor costs under control has been difficult. "In the short term, we have gone back to our payers to reopen contracts to negotiate higher payment rates for our health system members to reflect the labor cost inflation that we are experiencing. In the long term, the situation requires us to do things like work redesign to make sure if we are going to be using very expensive labor, we better be using those folks at the top of their license."

The purchasing power and economies of scale at health systems are pivotal in stabilizing the finances of their rural hospitals, Shockney says. "There is no doubt about it. That is why the hospitals in Bedford and Paoli came to IU Health. From a financial perspective, we knew we could improve those hospitals overnight. We could improve their purchasing power, reduce their costs, and spread those factors across the health system."

Healthcare remains a challenging commodity for both residents and care providers living in rural and remote parts of the country. Sparse populations, geographical challenges, and a dearth of financial resources all play a part in hindering access to care. But new ideas and technologies can change that paradigm, and in some places those innovative strategies are taking root and showing results. Telehealth and digital health tools and platforms, new collaborations, workforce initiatives, and innovative funding programs are all helping rural healthcare organizations provide access and improved health outcomes for their residents and communities.

Eric Wicklund is an associate managing editor and the innovation and technology editor at HealthLeaders. He can be contacted at ewicklund@healthleadersmedia.com. Carol Davis is the nursing and post-acute editor at HealthLeaders. She can be contacted at cdavis@healthleadersmedia.com. Christopher Cheney is the clinical care editor at HealthLeaders. He can be contacted at ccheney@healthleadersmedia.com.