Critical Access: The Need to Connect

EXECUTIVE SUMMARY

Many small, rural critical access hospitals are reaching out to each other and to larger hospitals as a way of setting up affordable health information technology systems that will meet meaningful use requirements. CIOs who have followed this strategy weigh in on its benefits and potential pitfalls.

It's hard for hospitals to go it alone today. That is especially true for small, rural critical access hospitals, which are just as responsible as their larger siblings for meeting meaningful use requirements of the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act.

According to the Office of the National Coordinator for Health Information Technology (ONC) of the Department of Health and Human Services in Washington, D.C., there are about 2,073 hospitals with fewer than 50 beds, 1,305 of which are critical access hospitals. That is no small number. Recognizing the unique needs of these small hospitals and the potential difficulties they face in terms of support, the ONC allocated an additional $25 million in April for regional extension centers to help these small hospitals set up health information technology (HIT) systems. But as many critical access hospitals have already found out, working with nearby tertiary care hospitals-as well as each other-can be the best place to start.

“The key for everybody to understand is that we cannot survive being independent islands on our own,” says Jim Rieber, CIO at Perham Memorial Hospital and Home, a 25-bed critical care hospital with a six-bed long-term-care facility in Perham, Minn. “Technology is moving fast and patients' expectations are growing,” he says. Rieber believes that small hospitals can maintain their independence, but they are going to have to form partnerships or alliances-especially around IT needs.

Perham Memorial, for example, is part of a technology group of 15 hospitals whose IT directors get together via video conferencing to pursue group purchasing and share ideas, education, and training. “Independently it's hard to get those resources available to you,” Rieber says.

Bill Drozda, vice president of rural market strategy for Irving, Texas-based VHA Inc. agrees. VHA Inc. works with more than 1,400 hospitals across the nation, including more than 320 critical access hospitals. One of the association's primary business activities, Drozda says, is helping its members form regional collaborative networks for the purpose of sharing information. “Most of the small members are concerned about the mandate for EMRs [electronic medical records] because they don't know how they are going to be able to afford it,” he says. “Many are working through state organizations and networks.”

In addition to the state and regional initiatives, even an alliance of two critical access hospitals wields more power than a single entity. Memorial Medical Center, based in Ashland, Wis., is one example. It's comprised of two 25-bed critical access hospitals, one in Ashland and the other in Hayward, Wis. Todd Reynolds, IT director, says his office in Ashland acts as the data center for both hospitals. “Small hospitals cannot afford the technology that is available without some form of a relationship,” he says. “With two hospitals we have a little buying power.”

Though the two hospitals operate autonomously, they share software supplied by Reston, Va.-based QuadraMed Corp. for revenue-cycle management and clinical applications, and plan to upgrade the clinical package to QuadraMed's Computerized Patient Record, a component of the vendor's Care-Based Revenue Cycle solution. Fiber-optic cable connects the two hospitals, which are 60 miles apart. In addition, Reynolds recognizes the need to work with his fellow critical access hospitals. “The state of Wisconsin is in the process of creating a health information exchange, and we've been participating in that,” he says.

I've seen several of our larger hospitals try and put their EMRs into a small hospital, and it has not worked out well.-Bill Drozda

In addition to linking to each other, top-of-mind for many critical access hospitals is the information-sharing link with their local tertiary hospitals. That presents its own set of problems. Many CIOs agree that piggybacking onto a larger electronic health record (EHR) system is usually not a good solution. “Larger systems may not be able to adapt their big EHRs for a critical access hospital; and it may be inappropriate, overkill, and cumbersome,” says Drozda. “I've seen several of our larger hospitals try and put their EMRs into a small hospital and it has not worked out well.”

On the other hand, critical access hospitals have experienced success with smaller vendors. Perham Memorial Hospital, for example, uses Glenwood, Minn.-based Healthland EMR systems and exports laboratory or radiology data to its referral hospitals, regardless of which EHR systems those hospitals use. “They use Centricity [supplied by GE Healthcare, Barrington, Ill.] in the northern tier and Epic [Epic Systems Corp., Verona, Wis.] in the southern tier,” says Rieber. “I maintain all the outbound data, and they maintain all the incoming data.” He notes that the affiliated hospitals have developed common information standards and identity mapping standards.

Memorial Medical Center transfers patients to two Duluth, Minn.-area tertiary care hospitals, one of which uses Epic software and the other uses software supplied by Westwood, Mass. -based Meditech Medical Information Technology. “The physicians at both facilities have the ability to gain access to our records,” Reynolds says. “We don't transfer the record electronically but they do have access to it through a portal.” He says that though it's a view-only application, the physicians can get clinical results and picture archiving and communications system images through a virtual private networking tunnel setup.

But collaborating on IT with a large trauma center can have its downside for remote rural hospitals. A constant struggle is the need to be able to react quickly to their local environments, according to Rieber of Perham Memorial. “We can do that more aggressively than the large institutions because they are so encumbered by their processes,” he says. “A single change can have a dramatic effect across their platform, but it may not be what's best for us. The key is striking a balance.” That balance, he says, comes from using a small-scale EMR, such as Healthland's system. “We can pass all our information up to the Epics, the McKessons, and the Centricitys to allow them the access they need, yet not be burdened with so much additional functionality that will never be touched.”

A single change can have a dramatic effect across their platform, but it may not be what's best for us. The key is striking a balance.-Jim Rieber

Many CIOs of smaller hospitals agree that their counterparts at the larger hospitals can help maintain a balanced relationship with critical access hospitals by understanding their needs. Larger hospitals “have so many specialty silos in their organizations compared to ours,” says Rieber. He adds that critical access hospitals usually employ only one or two IT staff members who are responsible for everything. “There is a difficulty in understanding that the silos make it cumbersome to do business with them,” he says. “Their technical expertise is phenomenal and a great resource, but it's also intimidating for the small town person to wander through a system of bureaucracy that is very unfamiliar to them.”

One potential solution is to establish a liaison between the critical access hospital and the larger hospital-something both Rieber and Reynolds of Memorial Medical have done. “A liaison is a very good resource to have in order to get through all the red tape, rather than hitting obstacles all the time,” he says. “But the liaison needs to have a pretty good idea of how both organizations work.”

In addition to a liaison, many recommend sharing expertise through networking with organizations like VHA Inc. “We've got a lot more expertise and talent on board than any of these small places could ever hope to have,” says Drozda of VHA Inc. He also suggests that critical access hospitals and large hospitals should communicate not only on the IT level, but at the executive level as well-especially when it comes to planning.

“If you're a midsize hospital, include critical access hospitals in your planning,” Drozda says. “IT needs strategy and tactics around those small hospitals through a formal and ongoing effort to connect with them.” He suggests that the larger hospital set up a formal network, invite the critical access hospitals, and open a dialogue. “It may not happen quickly but it will gain momentum,” he says. “It's sustaining that effort that is important-and the big house should get out to them sometimes for the meeting.”

Going out to the rural communities can also help alleviate one of the biggest fears of the critical access hospitals-namely, that of a large hospital coming in, taking over and changing the status quo, Rieber says.

Drozda agrees, acknowledging that an open dialogue is important not only between the hospitals, but between any organization, such as VHA Inc., working with them. “We ask them, ‘what do you need, what do you want to learn?’ We find out what they want to talk about, not just what we want to talk about. It takes a while to build those relationships, and you've got to work together in order to survive,” he says.

Healthcare Informatics 2010 August;27(8):24-26