This report originally appeared in the July 2009 issue of DOTmed Business News

As politicians in Washington duke it out over health care, rural and community hospitals are certain to be a focus. The mission of primary care, the need for chronic disease management and caring for the uninsured are priorities for small hospitals and for national health policy. Whatever form reform takes, the nation's rural hospitals are likely to benefit, or at least not be overlooked (Policy Update: Government Agencies Showing New Focus on Rural Health).

This sector is no stranger to bureaucracy. No matter what regulations Uncle Sam throws at them, small and rural hospitals, particularly the nation's designated Critical Access Hospitals (CAHs) are experts at meeting regulatory requirements. Unlike large hospitals that are paid according to diagnoses, CAHs are reimbursed more fully, providing a cushion in hard times that helps to serve a disadvantaged patient base.

"The PPS or prospective payment hospitals are paid on a DRG or diagnosis related group. CAHs are paid on a cost basis," said Lora Key, CEO of Sabetha Community Hospital, a CAH in Kansas. "Through the year, Medicare will set an interim rate for us. Depending on our patient loads, they may be underpaying us or overpaying us. That Medicare cost report is like a tax return-at the end of the year either we owe them or they owe us."

Sabetha is also doing a balancing act to determine the right blend of technology investments to stretch their dollars.

"We have a mobile MRI that comes once a week," Key said. "It's a great solution for us. I don't think we have enough scans to afford a unit in-house, but to have that capability of the mobile scan is great."

Creative solutions like mobiles are helping, but one pressing need that must be handled in-house is the transition to electronic medical records (EMR), which is already underway at Sabetha. As part of the Great Plains Health Alliance, Sabetha is dovetailing with the network to install the Siemens MedSeries4, a comprehensive hospital information system positioned for community and rural hospitals.

"We are going in stages of implementation, getting staff used to order communications. Right now, the nursing staff is doing their clinical documentation piece. Then, bit by bit, we will build on that," Key said, anticipating fuller EMR implementation in August.

The challenges for rural providers and all hospitals as they dive into EMR, relate to money, systems, and most importantly, people.

"Smaller budgets have typically made it difficult for them to afford certain technologies and some rural areas have limited technology resources. But we are talking not just about technology, we are talking about leveraging technology for clinical practice redesign," said Ruth Bowen, MBA, CPHQ, CPHIMS, Business Management, MedSeries4, Siemens Healthcare. "It is really about evidence-based medicine, best practices, and how to use technology to get improved outcomes in patient safety. In order to do that, you have to bring a team together to think about how to use technology to better deliver care."

Funding and IT are essential issues, but training and changing long-held work processes can also stand in the way of progress.

"Implementing an electronic medical record is really not an IT project. It really is a clinical project ... that uses technology. So you have to bring those IT resources into the clinical area and build that team's core strength. That is one of Siemens' biggest Health IT goals with [government HIT stimulus for] training: making certain we have resources to be able to do that," Bowen said.

One positive for rural hospitals may be that their late adoption of health IT will ensure they get the best and latest solutions at the lowest cost since OEMs have worked out the kinks on earlier versions of EMR systems.

Technology to the Rescue in Remote Areas

Another example of a rural hospital tapping some high-tech solutions comes out of Alberta, Canada. Wainwright Healthcare Center, a 26-bed hospital, more than an hour's trip from the nearest stroke center, installed a portable CT scanner to triage stroke patients.




"Given their remoteness, most small outlying hospitals do not have fixed CT capability. It is just an expense they have been unable to justify given the relatively low volume," said Colin Timothy McDonald, M.D., who serves on the medical advisory board of NeuroLogica, Inc. The company's portable CereTom CT scanner is providing an affordable solution for initial evaluations and to connect Wainwright with the University of Edmonton.

Prior to the installation, whenever a patient was suffering from a traumatic brain injury or possible stroke, they were flown to Edmonton for initial imaging, costing precious time that could negatively affect outcome.

"Since they installed that particular scanner, they have seen a dramatic impact on the neurologic emergencies. They have been able to avoid transport in some cases; they have been able to treat certain patients with time-sensitive clot-busting medicines. They have been able to identify bleeding problems in some of the patients that could be managed locally as opposed to incurring the expense of flying back and forth to [Alberta] Edmonton Hospital," Dr. McDonald said.

The installation includes a telemedicine hookup for specialist consults. Compared to a fixed CT, the portable saves not just on the scanner, but power supply needs and shielding as well. In addition, local X-ray technicians can operate the unit so that a CT tech is not required, although it is important to note that in the U.S., some states vary in these staffing requirements.

Similarly, in the U.S., CAHs all have alliances with larger centers to provide acute care when needed. This creates an important role for medical transport to serve outlying areas.

"One of the problems is that many small hospitals don't have depth as far as specialties go. They don't have staffing if someone is critically ill or injured. So the helicopter is a way to bring tertiary care to a primary care area," said Daniel G. Hankins, M.D., Co-Medical Director, Mayo Clinic Medical Transport and board member of the Association of Air Medical Services. He noted that strokes, heart attacks, major trauma from motor vehicle accidents or farm injuries, sepsis, and kidney failure are among the conditions that frequently require medical evacuation.

"Increasingly, air medicine will become the safety net as hospitals close and specialists concentrate in urban settings," he said. He added that many areas of the U.S. are too remote to be within an hour of a large hospital even by air. Initial stabilization of the ER patient becomes a vital service for rural hospitals. Also, emergency medicine staffing problems persist since younger residents required for that care often choose to work in cities.

A Measured Approach to Equipment Investment

There are many clouds and some silver linings for rural providers. The economic downturn hit hard in blue collar towns and areas that were already struggling before the recession.




"The biggest challenge right now for hospitals in rural areas is that the economic situation has affected them greatly due to the high Medicare, Medicaid and uninsured mix. It's pretty stable, but doesn't afford the operational margins they need to continue to invest in technology," observed Mark Samii, Vice President of Sales, DMS Health Technologies, Maple Grove, MN. "The net effect is that capital budgets are on hold, they are not able to invest in technology and are in a maintenance and survival mode right now."

As a vendor-neutral company, DMS provides economical packages, including mobile medical imaging services to many rural providers to help deliver better community access to health care.

Despite the bad news, rural hospitals do represent a business opportunity for those health technology firms that have affordable solutions. In fact, the nation's approximately 1,200 Critical Access Hospitals plan to continue capital investments in medical imaging to serve rural populations, according to a survey by Regents Health Resources, Inc. (See DM 7719 and DM 7296). Over 63% of CAHs have plans to implement new or additional technology support systems this year, including PACS, RIS, HIS, and EMR.

Several companies package these technology solutions in a way that is affordable and adaptable to small hospitals or rural settings.

"A major issue that small, rural and isolated clinics and hospitals continue to face is access to fast, quality interpretation of the imaging studies performed at their sites. Many facilities feel that the solutions available on the market today are even further out of reach financially due to the recent economic downturn," noted Jeffrey S. Kennelly, RT(R), CIIP, Senior Sales Engineer, NovaRad Corporation. "With all the government intervention in the private sector as well as the open discussion of meaningful health care reform in our country, many of these providers are hopeful for funds to assist them in obtaining these systems. Many who are putting projects off in the hope of this coming to fruition soon are finding themselves continuing to lose market share due to the inability to compete. They are losing money due to the costly, manual processes they continue performing without these systems."

NovaRad's NovaPACS is available at near or even less expense than analog, film-based operations, presenting an attractive option to small hospitals.

"This affords these sites the ability to select the highest quality interpretation service from many available providers. They aren't limited to just the regional radiologists' service offerings. This translates to fast and accurate interpretations for their ordering clinicians thus equating to greater patient referrals. These rural facilities can essentially operate with the same abilities as their competition in the metropolitan environment with the same budget or less."

Clinical technologies are just one dimension, others being billing and administrative.

"At rural hospitals, resources and workforces are limited without a fully staffed business office. With the complexity of healthcare billing, it's not easy to stay on top of government requirements, rules, regulations, and even private insurance requirements for billing and follow-up to recoup the money that the hospital has earned but not received," said Merle Glasgow, Vice President Sales & Marketing, ARx, LLC, Franklin, TN. The company provides business office operations and revenue cycle services. One of their offerings is a centralized business office model to bring economies of scale to rural hospitals.

"We want to put in a centralized business office to serve the needs of local hospitals and provide resources, tools and technology-based solutions that individually, they would not be able to afford but could collectively," Glasgow said.

For all the focus on IT, EMR, PACS and other technologies in health care today, the ultimate problem for rural hospitals remains very human - recruiting and retaining clinicians.

"As younger physicians graduate from medical school, they have been trained using technology. All of the medical schools and hospitals associated with those schools have clinical information technology," Siemens' Bowen said. "The younger physicians go out to rural areas and IT capabilities like access to medical images via PACS or remote access to patient information or access to comprehensive patient records aren't available; very often they are not interested in going to areas where advanced technology isn't available. So technology is also becoming a prerequisite to effectively recruit physicians to rural areas."