Information Technology in the Rural Setting: Challenges and More Challenges

In this issue, Ohsfeldt and colleagues1 estimate the financial cost that would be incurred by all hospitals in Iowa if they implemented computerized physician order entry (CPOE). Small hospitals (defined as fewer than 200 beds) account for 70% of nonfederal, general, short-term hospitals.2 The estimates of Ohsfeldt et al. add to a growing literature describing the financial and administrative burdens incurred when modernizing the information technology infrastructure of the small hospital.3 4 For many of these institutions, lower revenues, higher costs, and poor access to capital combine to make the necessary investment in information systems unrealistic.

The work of Ohsfeldt et al. focuses on the financial burden of implementing CPOE but not the value proposition that motivates the leadership of a hospital to proceed with an implementation. Early adopters of this technology, including community hospitals5 and many other hospitals now poised to make the investment,6 seem convinced that delivering safe and effective care requires information technology to assist clinicians to “do the right thing all of the time.” Nonetheless, even when investments are viewed as important, affordability is a significant barrier, given the many competing demands for capital.

Of necessity, Ohsfeldt and colleagues made several assumptions that influence the extent to which the estimates derived are applicable to every institution. First, the estimation of the presence of clinical systems already in use was of necessity a simplification of the framework that a hospital must employ when considering costs. Second, the estimates of costs were derived from one established information systems vendor and may not be fully representative of the options available to small hospitals in the vendor marketplace. Third, the estimates for small hospitals assume that they can gain economies by forming purchasing cooperatives, but it is not clear whether this option will be available to all these institutions.

The need for capital by small hospitals must be remedied through some combination of loans, regional funding, and pay-for-use and pay-for-performance funding approaches.2 7 8 Group purchasing, mentioned by the authors, particularly when coupled with sharing of expertise is one of several mechanisms to lower overall implementation costs. Small hospitals that are part of integrated delivery systems often benefit from system-wide efforts to deploy comprehensive CPOE implementations.

The simulation model used by Ohsfeldt et al. addresses primarily the technology-related costs and less so the major investment needed in organizational and process change.3 4 Herein lies a further challenge for the small hospital already strapped with resource constraints necessary to maintain financial viability. Individuals with the required implementation process management expertise are either not present in sufficient numbers or are too immersed in other activities to devote the required time. How can the small hospital assemble and organize the relatively large number of professionals required to ensure a successful implementation while at the same time ensuring that these participants' other responsibilities are met? Day-to-day participation by practicing physicians is especially problematic because small hospitals generally lack the complement of available clinical champions, physician administrators, hospital-based practitioners, intensivists, clinic directors, and training directors who often play critical roles in implementing clinical systems at larger institutions. Organizing this effort is akin to changing the wings of an airplane while it is in flight.

Small hospitals in particular require models for implementation that fit their environment and resource availability. A statewide CPOE effort taking shape in Massachusetts, which combines financial assistance with other forms of support, may establish such a model for other areas of the country.9 Selecting vendors with a more “off-the-shelf” approach to software may also be a sound interim strategy for reducing some of the complexity of implementation, but at the cost of limiting functionality in the short-term. Interoperable, standardized systems offer hope in the more distant future.

Without significant commitment by regional or statewide authorities working together with the payors and other stakeholders, many small hospitals will continue to delay or sidestep investments in information technology that could help their nurses and physicians to do their jobs better and to improve the likelihood that their patients receive a consistently higher standard of care. Predominantly rural states will be particularly underserved because they rely on local, usually small, community hospitals for much of their care.

The Critical Access Hospital Program provides more favorable Medicare reimbursement for rural hospitals that meet particular qualifying criteria and expresses a national commitment to sustain local hospital care. Now similar recognition—backed up by aggressive, multifaceted programs in the region, state, or through other affiliations—is needed if these local health care providers are expected to deliver care at the high level of quality and safety that their communities expect.

The financial challenges documented by the work of Ohsfeldt et al. remind the reader of the even greater challenge faced by physicians practicing in small, independent practices. Most physicians are self-employed, and 60% of them work in practices with two or fewer other physicians.10 The issues raised when addressing the small hospital may very well pale in comparison with the transformation required for CPOE (and other clinical system implementation) within small physician practices. Affordability—both money and time—is a major barrier to implementing systems in the small practice setting. Without similar strategies for financing, consolidation of expertise, and support for workflow transformation, the increased level of care provided by hospitals adopting CPOE will not be paralleled in the physician practices where patients obtain most of their care.

Small physician practices and small hospitals are a critical foundation of our health care system. The costs that these organizations face when contemplating necessary information technology seem formidable to the point of not being affordable, especially if each organization must work alone to address its critical needs. If society expects to address the nation's health care quality challenges,11 12 it can ill afford to leave this vital sector unequipped to achieve this goal.13