HIT Resource Scarcity Hobbles Rural Providers

Rural healthcare providers who delay meeting meaningful use implementation requirements put themselves and their patients at a disadvantage, research suggests.

Rural physicians and hospitals have long demonstrated that they're as enthusiastic as their urban counterparts when it comes to implementing health information technology.

While that's encouraging and not really surprising, a study in Health Affairs also notes that many rural providers are more likely to skip a year in declaring they've met meaningful use requirements, which puts them at a financial disadvantage, and creates a digital divide that potentially could harm patients.

Meaningful Use 'Bombshell' Leaves Nary a Mark

The study, compiled by Dawn M. Heisey-Grove, a public health analyst at the Department of Health and Human Services' Office of the National Coordinator for HIT, reviewed meaningful use achievement data from the Medicare and Medicaid Electronic Health Records Incentive Programs between 2011 and 2014.

That data includes information from nearly 550,000 providers and hospitals, and demonstrates dramatic variations among rural providers when it comes to implementation. For example, 91% of podiatrists used HIT, compared with only 9.5% of dentists.

Heisey-Grove spoke with HealthLeaders Media about the study and what the findings might suggest. The following is an edited transcript.

HLM: Why did you do this study?

Heisey-Grove: I started my career at ONC with the Regional Extension Center program, so I am always interested to see the impact they have and the provider populations we call up in this paper are highlighted by that program. It is always important to see the trends and what is happening with them.

HLM: The study seems to offer some mixed results for rural HIT implementation.

Heisey-Grove: The overall adoption numbers are not surprising; the fact that the overall numbers across rural and urban are similar and rural is slightly ahead. When you start digging into it is when you see these huge disparities.

We also see that rural is doing well in other areas that may not have been expected. In the electronic exchanges with other providers, they are doing as well, if not slightly better. But with the electronic exchanges with patients they are still struggling.

These are things that people know, but it is important to get it into public view in a documented way so that more technical and other assistance can be made available.

HLM: Is there a common thread in these variances between urban and rural? Is it simply a matter of scarce resources?

Heisey-Grove: It's nuanced. The thread throughout the original adoption and the subsequent attritions in the meaningful use program can be almost completely attributed to the Regional Extension Centers. The reason why rural adoption is as high as it is is because RECs worked with 50% of the providers and the data show they did much better as a result.

The attrition we see—and it may be a one-year drop off; it may not be permanent—but the REC programs only helped providers with one year. After that the funding was gone.

So what we are seeing is that meaningful use and the ongoing achievement of meaningful use is challenging. Without that assistance rural providers are struggling. That goes for hospitals as well. That is the common thread for the adoption and ongoing use.

HLM: Why is there such a huge disparity between podiatrists and dentists?

Heisey-Grove: I have a hypothesis. The first thing you have to remember is that [the data reflects only] those providers who are registered with the program. It doesn't account for any providers who are not participating in the EHR incentive programs. The numbers may be very different when you look at the non-participants.

The second thing is it may be that podiatrists are participating in a larger portion in the Medicare program, which does not allow skipping from year to year. Dentists are almost exclusively participating in the Medicaid program, which does allow skipping from year to year without losing an incentive payment.

What the subsequent data shows is that Medicaid providers are not making that transition from the initial 'adopt, implement, and upgrade' payment to the meaningful use payment as quickly as the Medicare providers who jumped in and did it. That is the way the programs are structured.

HLM: Is there any suggestion that rural providers are less receptive to HIT implementation?

Heisey-Grove: The data shows the exact opposite. Not a lot of the data in this study speaks to that exact question, but… rural providers are doing higher levels of electronic exchanges with other providers. If they were technophobes, I don't think you would see that.

That shows that if they can they are. There is other data that shows it's more of a resource issue rather than a technophobe issue.

HLM: Would these adoptions be higher if the Medicare HIT incentive program had been extended to include nurse practitioners and physician assistants?

Heisey-Grove: The NPs and PAs are eligible for the Medicaid incentive program, but not the Medicare incentive program. The NP and PA numbers in terms of progress would definitely be different if they were participating in the Medicare program in addition to the Medicaid program.

HLM: You talk about a growing digital divide for rural providers. How could that play out in rural communities?

Heisey-Grove: I will use my father as an example. The provider he sees does not have electronic health records. So, if my father needs to get his prescriptions filled, he has to go to the doctor's office, get a paper prescription, walk over to his pharmacy and get that filled.

If he has an emergency, his records are not going to be accessible to whichever emergency or urgent care center he goes to. In the five or six prescriptions he has, if he doesn't have somebody with him who knows what his prescriptions are, that is going to be a complete and utter failure of the system because they are not going to be able to pull that up readily.

So, the ability for information to follow the patient and be accessible when you need it, and in a format that is usable, is crucial.

If there are gaps because rural providers don't have the ability to capture that information electronically or send it electronically to other providers then those patients are going to suffer. That is what we are going to see. NPs and PAs provided a larger portion of the primary care in those rural environments and if they aren't on board at the same rates as the physicians and other providers in those areas there is going to be a gap as well.

HLM: Because the HIT implementation numbers have dropped off for some rural providers, does that mean that someone somewhere dropped the ball on this program?

Heisey-Grove: It goes back to a resource issue. It's hard to anticipate how hard it is to not only get people on to healthcare IT but to keep them there and maintain that effort. It's not a one off. It's not a 'here's the system and now you can go.' It's an ongoing continuous transition and new things are happening all the time. With the fewer resources available, rural providers are struggling a lot more than providers in large practices or in urban settings that have a larger technical workforce to tap into.