In the study entitled “Variation In Rural Health Information Technology Adoption And Use,” recently published in Health Affairs, Dawn M. Heisey-Grove noted that while initial health IT adoption and meaningful use achievement were higher among rural providers and hospitals than those in urban areas, these populations were less likely to return in subsequent years of the incentive program.

On the other hand, the author found that technical assistance from a Regional Extension Center (REC) was strongly associated with meaningful use achievement among rural providers. A variety of factors are leading to these results, which underscore the challenges that rural healthcare providers face today with IT.

It’s clear that rural providers have relied heavily on REC resources and skills to implement the Certified EHR technology (CEHRT) and produce the data for initial MU submission. Then, when the REC resources move on to their next implementation, it leaves the providers without sufficient qualified FTEs to operate and maintain the CEHRT in a manner that enables timely production of MU data in subsequent rounds, so they drop out of the program.

Paradoxically, the MU incentive funds are only intended to support the capital-intensive activities of CEHRT implementation. That’s not sufficient to help rural providers recruit, compensate, train and retain the qualified staff needed to sustain the operation and maintenance phase of the CEHRT, which can be more than 90% of the lifetime cost for a large, long-lived information system.

I believe trends in urbanization, education and technology are the main drivers of this issue.

Population trends have shown that more people are moving to urban areas; 70 percent of our country’s population will be living in urban areas by 2050, and the highest rate of urbanization is in the 15-to-34 age group, who believe that metropolitan areas offer more choices for education, healthcare, dining, sports, community services, entertainment, employment and more.

In terms of education, trends are actually moving in the wrong direction for IT. By 2005, nearly all U.S. colleges and universities were experiencing decreases in enrollment in their information technology and computer information sciences programs, and these declines are continuing. At the same time, jobs continue to move offshore, and many IT/CIS functions have been outsourced to foreign entities. Domestically, it takes money and time to obtain specialized certifications required by most employers, as well as two years of experience, which makes it difficult for new IT/CIS grads to enter the U.S. workforce.

Technology is also in transition. Providers used to “own” their entire business framework, ranging from the people to the process to the technology. They hired and paid their own IT staff; their business processes defined the services they delivered to their patients; and they purchased their technology assets with capital dollars. But with increased adoption of cloud delivery models and services, that’s cutting previous levels of investment, both in capital dollars and operating dollars. It’s no surprise that the shrinking number of new IT grads are drawn to work at large cloud services providers (often located in urban areas), rather than going to work in the increasingly marginalized IT department at a hospital or multi-physician practice in a small rural community.

In terms of education, trends are actually moving in the wrong direction for IT.

As the use of cloud services becomes ubiquitous and providers no longer employ their own IT staff beyond what is needed for tier-1, onsite support for their local networks and endpoint devices, and they no longer purchase their own technology because it’s included in their cloud service, the only part of the business framework remaining in the ownership of the providers will be the business processes.

When cloud service providers have achieved majority control of the people, the technology and the recurring charges for making those assets proportionally available to their customers, it will be interesting to see if costs trend higher or lower on a per-unit-of-service basis.

Using cloud-based services, to some degree, will make sense for rural providers. When you consider the high cost to build, operate, secure and maintain a modern data center and the assets within the data center, those funds might be better invested by moving a percentage of the capital dollars to the operating budget to pay for cloud services, leaving the remaining capital dollars for investment in new medical technologies, new service lines and new patient-care facilities that may enhance the potential to improve both quality and outcomes at the point-of-care, in recovery, and in rehabilitation.

Rural providers will need to move beyond looking for additional assistance to support their ongoing use of health IT, because that additional assistance is not going to somehow magically appear in rural communities, given the trends in urbanization, education and technology, Providers may be better served by reassessing their delivery and operating models for CEHRT and related health IT services.

At this time, I have only drawn my own conclusions about the apparent root causes of the continuing decreases in the availability of assistance to support the lifecycle of CEHRT and related health IT in rural communities, based on publicly available statistics. However, it would not surprise me similar trends exist in all operational disciplines in rural provider settings. Over some timescale, this could potentially threaten the very survival of rural healthcare in the U.S.

At the same time that providers are becoming increasingly dependent on CEHRT and related health IT services to deliver care to their patients, it is also important to remember that they still need more of their core assets to be successful—doctors, nurses, and beds, not more servers and server administrators.

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