No small achievement

Some small, rural healthcare organizations have become health information technology front-runners and their leaders techno mavens, despite the digital divide that separates the larger, urban health IT have-nows from the smaller, rural IT have-not-yets.

Four rural providers show how it can be done. Two each from West Virginia and Louisiana were identified by health IT officials in their states for their pluck in crossing the divide, demonstrating that size and geography need not create insurmountable barriers. All have qualified for federal EHR incentive payments, either as an eligible organization or by their member physicians, under the American Recovery and Reinvestment Act. They've joined health information exchanges and used data from their systems to advance public health and direct patient care. Common traits these organizations and their leaders exhibit are collaboration, determination, faith and savvy grant-writing.

Few states are more country than West Virginia, where 51% of its people live in rural areas. (Only Maine and Vermont have higher percentages.)

In 2000, 20 of the state's community health centers banded together as the Community Health Network of West Virginia, in part to create economies of scale for healthcare IT projects. The network first offered a remote-hosted practice management system, then, in 2008, through a pilot program funded by the Health Resources and Services Administration, it added an electronic health record, the Resource and Patient Management System developed by the Indian Health Service from the Veterans Affairs Department's VistA EHR.

“We really wanted to do population health,” says David Campbell, the network's CEO. “We knew that's where healthcare was going, and in our rural communities we had to look at a very diverse population. We wanted a public utility that you could plug into with a subscription model. For what we were trying to accomplish at the time, RPMS was the best system available.”

One network EHR user is Pendleton Community Care in Franklin, population 720. Pendleton County, on the eastern edge of the Alleghenies, is hemmed in by four major mountains and “lots of hollers, as we call them,” says native West Virginian Michael Judy, the clinic's CEO. The only other healthcare provider in the county of about 7,700 residents is an office staffed by a part-time physician assistant.

The clinic is staffed by three family practitioners, a pediatrician, three physician assistants and a nurse practitioner. It has a satellite office elsewhere in the county. Coming soon is a preventive, primary-care program in four public schools. Its clinicians handle 18,000 patient encounters a year, including those from about 300 veterans, whom the clinic treats under a contract with the Veterans Affairs Department.

RPMS is piped to the clinic from the Community Health Network's data center in Barboursville, 240 miles away. VistA is fed to the clinic, too, from a VA hospital in Martinsburg, 133 miles north.

Dr. Laura Nulph, a family physician at the clinic since 2008, leads its quality-improvement committee, using RPMS to gather and perform data analysis on a host of measures, a task that would have been so labor-intensive as to have been almost impossible with paper records.

Over the past year, clinicians have increased the percentage of patients getting Pap tests from 42% to 47%; colorectal cancer tests from 42% to 48%; diabetic eye exams from 39% to 49%; and diabetic foot exams from 52% to 57%.

“We're seeing small gains, but it's better than standing still or going backwards,” Nulph says.

In the central West Virginia village of Clay, with a population of about 490, Dr. Sarah Chouinard heads Community Care of West Virginia, also a Community Health Network member. With nine clinics, six pharmacies, a dental clinic and multiple school-based clinics, it serves patients in nine counties, handling about 100,000 encounters a year.

Community Care, an early RPMS user, switched to a Web-based EHR and practice-management system from Athenahealth in October, although starting with the Indian Health Service's EHR was “one of the best learning experiences we could have had,” Chouinard says.

“We learned how to practice medicine in a medical home,” she says. “What you really have to do is data analytics—of all my patients, X are women, and what percentage is due for mammograms?” RPMS excels at that sort of population management reporting.

Chouinard says the new system is taking the clinic network to the next technological level. More than half of the clinic's patients have signed up to use its patient portal, for example.

The technology is also helping the network target specific patient populations. Bonnie's Bus is a mobile, digital breast cancer screening service run by West Virginia University, but utilization of the service by Community Care patients had been low. The clinic would distribute fliers before its visits, Chouinard says, but with its EHR and practice-management systems now fully integrated, the clinics can identify patients both in need of a mammogram and without health insurance coverage who'd benefit most from the free service. “Now, we can call up and say, 'Sandy, don't miss this opportunity.' So, it's just better care coordination.”

Statistically speaking, Louisiana is considerably less rural than West Virginia. About 27% of its people live in rural areas, but it has other challenges.

“The IT push for us all got started after hurricanes Katrina and Rita,” says Linda Deville, CEO of Bunkie (La.) General Hospital, an 18-bed critical-access hospital with an eight-bed psychiatric unit. Refugees from New Orleans and Baton Rouge fled north and west from Katrina in August 2005, and north and east from Lake Charles from Rita a month later. The human waves of patients without medical records crashed on Bunkie, a town of about 4,100 people.

“We're in central Louisiana, so we were the first stop,” Deville says.

The one-two punch of Katrina and Rita raised health IT consciousness all along the Gulf Coast. The Louisiana Legislature allocated $15 million to start a health information exchange and offered $1 million grants to the first seven healthcare organizations to purchase health information technology, Deville recalls.

Bunkie won a grant, and then rushed to get its new EHR up and running by the state deadline. The installation started in January 2008 and “had to be substantially complete by June 30, when state funding ended,” Deville says. The thinking was, “We may never have another $1 million to do this. It was rip the Band-Aid off. We were the first critical-access hospital (in Louisiana) to go fully electronic.”

Bunkie also was the first of the state's 29 CAHs to join the information exchange, run by the Louisiana Health Care Quality Forum, based in Baton Rogue. The link went live in September 2012. So far, 130 Louisiana hospitals, 35 in rural areas, including 20 CAHs, are connected to the information exchange, says spokeswoman Linda Morgan.

“It's just the very beginning of this, so there's not a whole lot of healthcare information in the network as we speak,” Deville says. Bunkie also recently launched a clinical and psychiatric telehealth program in conjunction with the LSU Health Sciences Center in Shreveport. The program loads a number of telehealth tools on a rolling cart.

“We call it our computer on wheels,” she says. Aboard the cart are a stethoscope, skin camera and other tools. “They have a doctor in Shreveport and you talk to him. The doctor has a headset and a nurse (at the clinic) has a headset. He can hear the heartbeat in real time and tell the nurse to move it left and right. The skin camera can take snapshots and put it in the electronic health record and magnify it.”

In calmer times, the hospital and its two outpatient clinics draw nearly 20,000 patients. “It is harder for a small hospital,” Deville says, but on the other hand, “you don't have all the politics. It's 'this is what we have, let's work with it.' ”

In the small, central Louisiana city of Winnfield, with a population of about 4,840, folks still call Deano Thornton “mayor.”

“That's one of the nicer things you get called at times,” says Thornton, now CEO of Winn Community Health Center, a federally qualified healthcare center. “I had 27 years in municipal government, 16 years as mayor.”

Thornton says he recognized the need for affordable, accessible care by listening to his constituents. “We own our own electrical system, and people had to make a choice to pay the light bill or pay for medicine,” he says “ 'I couldn't pay the light bill because my son was sick.' I heard it every week.”

The center opened in 2009 with funding from the Rapides Foundation, Alexandria, La. It had a Web-based EHR system in place from developer SuccessEHS on day one.

“We're not big enough to have our own IT person on staff, so we operate strictly online,” Thornton says. “There are 29 FQHC organizations in Louisiana, and well over half of us are on the same software. We can have user-group conferences and talk about our needs. As the data HRSA needs changes, we can implement it together.” The Health Resources and Services Administration requires clinics it funds to file reports online through its Uniform Data System on patient demographics, finances and quality measures, which is much more difficult to organize without a boost from IT.

An EHR also helps the clinic gather data to improve patient outcomes, Thornton says. “With women's health and diabetes, we can track all that and remind the providers what we need to be doing in the exam room itself.” Lab results, meanwhile, “are interfaced into the record so that providers can access it 24 hours a day over their cellphones.”

The Winn clinical staff consists of a family practice physician, two nurse practitioners, a physician assistant and a dentist. About 26% of Winnfield's families—three out of four with children under age 5—have incomes at or below the poverty level. Not surprisingly, more than 83% of its patients are either uninsured or covered by Medicaid, the Children's Health Insurance Program or other public assistance.

“We've applied to put an additional clinic in Grant Parish directly to the south of us,” Thornton says. Winn also received approval to open a clinic in one of the schools, staffed with a nurse practitioner and a behavioral specialist. A bus takes students to the clinic's dentist, he says.

“When only 42% of our children are immunized in a timely manner and we have less than 10% who go to a dentist before age 5, we see the need,” Thornton says.

Follow Joseph Conn on Twitter: @MHJConn