Rural healthcare providers started out with a bang on electronic health record adoption, outpacing their urban counterparts, but once federal technical assistance through the regional extension centers (RECs) dried up, many rural healthcare providers fell out of the meaningful use program.

Some 82.3 percent of rural physicians have adopted EHRs, slightly ahead of the percentage posted by urban physicians, who had a 78 percent adoption rate, according to the analysis, conducted by researchers at the Office of the National Coordinator for Health Information Technology. In addition, rural providers were more likely than their urban counterparts to have achieved meaningful use.

Despite the fact that the vast majority of rural providers have adopted EHRs, the study also found that 38 percent of them skipped the meaningful use program for at least one year after initially attesting to it, compared with 34 percent of their urban counterparts.

The study, published in the January edition of Health Affairs, used meaningful use achievement data collected by the Centers for Medicare and Medicaid Services (CMS) between 2011 and 2014 on more than 548,961 providers and hospitals.

The results found a variety of mixed messages, says Dawn Heisey-Grove, author of the study and an analyst at the Office of the National Coordinator for Health Information Technology. Rural health providers tend to be doing really well with health IT adoption, in large part because of help from the RECs, which are geared toward helping them achieve meaningful use Stage 1, she says.

The drop-out rate is a concern because for each year providers are out of the program, they lose money, Heisey-Grove says.

Making matters worse, care in rural areas is mainly provided by advanced-practice nurses and physician assistants, and it was among this group of rural providers that the study found the most meaningful use dropouts.

This places rural providers at a disadvantage both financially—through loss of incentives—and in their ability to exchange data with other rural providers, decreasing the effectiveness of their care, Heisey-Grove says.

Other findings included:

  • Small rural hospitals with fewer than 100 beds achieved meaningful use at virtually the same rate as large rural hospitals with more than 400 beds (97.2 and 97.4 percent respectively).
  • Critical access hospitals had slightly lower meaningful use achievement rates (91.7 percent).
  • About 55 percent of providers in the largest rural practices had achieved meaningful use, compared with slightly more than one-third (36.3 percent) of rural solo practice providers.
  • Rural primary care physicians had the highest rate of meaningful-use achievement (53.2 percent).
  • Rural healthcare providers and hospitals were less likely to attest to all subsequent years of meaningful use, when compared with those in urban areas.
  • Some 38 percent of rural Medicare-registered providers who first achieved meaningful use between 2011 and 2013 skipped at least one subsequent year between 2012 and 2014, compared with 34.9 percent of urban Medicare-registered providers who similarly skipped at least one year.

Clearly, rural health providers—especially smaller physician practices and hospitals—heavily relied on help from the RECs to get through Stage 1, but then dropped out when that help ended. Multiple reasons can be identified, according to a study by, CMS that revealed some of the reasons behind the rural disparity in meaningful use achievement, including: retirement, confusion about program requirements or deadlines, and difficulty meeting program requirements.

“I completely expected this to happen when meaningful use was announced,” says David Roy Furnas, an information security consultant with TEKsystems and former chief information officer for Gila Regional Medical Center, a 68-bed acute care facility in Silver City, New Mexico.

“EHRs are easy to buy and implement for about a year. Then they have to be operated, maintained and supported for another 10 to 15 years. It’s not self-sustaining,” Furnas says.

Bigger still is the influence of the cloud, Furnas says. Health IT professionals are opting out of jobs in rural locations for higher-paying, more prestigious jobs at cloud companies in urban locations. Even if small rural medical groups and hospitals could afford health IT staff, they aren’t available. It makes complete sense that rural providers are beginning to lean toward using cloud-based EHRs, Furnas says.

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“Once the carrot is gone, the financial drive to keep up with progressing through meaningful use Stages 2 and 3 gets tougher.”

Stephen Stewart, a healthcare IT consultant for TruBridge, LLC, who in previous positions as a CIO helped guide rural hospitals through Stages 1 and 2, says the loss of REC assistance after Stage 1 is only the tip of the iceberg.

“The difference [in difficulty] between Stages 1 and 2 is significant,” he says. “Once the carrot is gone, the financial drive to keep up with progressing through meaningful use Stages 2 and 3 gets tougher.”

Now that many rural providers have achieved meaningful use on some level, the reality of the ongoing costs of maintaining an EHR is becoming a reality,” he says. “The fear is they are going to start doing the math, and they will think the meaningful use penalties will be better for their bottom line than participating in the meaningful use program.”

Despite that, Stewart says he is advising his clients to stay the course on meaningful use. “The government hasn’t spent billions on meaningful use incentives for nothing,” he says. “The stick will get bigger. We’re in a real difficult spot right now.”

Stewart says this is easier said than done for rural physicians, in particular. The remedy for many smaller physician practices with few IT resources is to merge with a health system that has an IT department, he contends.

“The days of small hospitals and small independent practices are over,” he says.

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