Indiana's state health information exchange (HIE) program has a goal of driving interoperability by connecting disparate systems into a more cohesive network. One-quarter of funding is devoted to connecting rural and underserved areas to the state HIE infrastructure.

"We've worked specifically in the rural areas to help drive adoption and help organizations navigate the HIE and health IT in general," says Andrew VanZee, MHA, statewide health IT director for the Indiana Family and Social Services Administration.

One focus is helping to offset the costs of connectivity. The state pays critical access hospitals up to $40,000 to offset the cost of EHR implementation. Meanwhile, one national vendor that typically serves rural hospitals cut its interface costs in half when VanZee's team sought out a price compared with the cost presented to a rural hospital. "We said that their pricing was way out of line compared with other vendors. That's a benefit a statewide organization can have in assisting providers. We can advocate on their behalf."

The Colorado Telehealth Network (CTN), part of the Colorado Hospital Association (CHA), also is advocating on behalf of its members for better prices. In their case, the focus is bandwidth. "We're able to offer rural facilities broadband at a price point they wouldn't be able to achieve without our subsidy," says Debby Farreau, CTN project director.

In fact, 201 rural and urban provider organizations are now connected, she says. The mix has a purpose: "Rural facilities want to be connected to urban facilities because they're the ones that perform consultations and provide specialty care. A network without urban care is kind of lopsided. And urban facilities have been really supportive."

CTN offers providers bandwidth ranging from 4.5 megabits up to 100 megabits. Before CTN, many CHA members not only couldn't get broadband at a reasonable price, they couldn't get it at all, Farreau says. Some sites were moved up the priority list during deployment because they had the highest need. For example, it could take hours for the x-ray of a car accident victim from a rural site to make its way to an urban site where a specialist could determine whether that patient needed to be transferred. Now, those types of image studies can be transmitted in minutes, she says.

Many small rural providers in Colorado have IT departments to match—perhaps one person manages IT for the entire hospital. To overcome the staffing barrier, the best way for many of these hospitals to implement an EHR system is through remote hosting.

To do so, they need bandwidth. Facilities require at least 7.5 megabits to remotely host an EHR. Some facilities actually had no IT staff or bandwidth, Farreau says. "A few CEOs of smaller critical access hospitals conveyed that, because of CTN, they were able to provide remote hosting along with other services."

Farreau also heard from a facility with so little bandwidth that they had to stop all other web traffic just to send an image. Another facility's leader was skeptical that CTN could get the hospital 4.5 megabytes. "The staff could barely even communicate with the outside world let alone consider an EHR," says Farreau. That facility is now working on implementing an EHR.

Despite the challenges, rural facilities must continue the transition from paper to electronic records. "From a primary care standpoint, much of healthcare is still in rural America," says VanZee. "We must consider these areas when it comes to policy and technology. Healthcare can't just have a metropolitan delivery model."

EHR Helps Rural Hospital Remain a Player

The federal EHR incentive program helped convince the leadership at Tri-County Hospital to proceed with an EHR implementation, says Kathy Kleen, RN, chief nursing officer for the 25-bed critical access hospital in Wadena, Minn. "Finances are very limited for us." The hospital sought out an EHR system that promised affordability and functionality, she says. The hospital chose the affiliate option of a national vendor's EHR because most of the IT work would be done on the vendor's end and the provider would serve in an end-user support role, says Michael Ritzer, LPN, clinical optimizer. Going from paper to electronic records was a big undertaking, Kleen says. However, the medical staff and hospital board were on the same page when it came to the reason for the switch. "On the one hand we did it for the money, but we also knew that patient care needed a change. The paper world was not doable any longer. Searching for a chart from five years ago is just not a sustainable way of tracking medical information." To overcome the staffing challenge, Ritzer and another "optimizer"—clinic and hospital—were hired six months before the go-live. Kleen calls the positions crucial for a successful transition. The optimizers are full-time, permanent employees who focus on the ongoing EHR optimization. In fact, the hospital recently added a financial optimizer to its roster. Being a small facility posed some unique challenges for the EHR implementation, Kleen says. For example, at a large facility an emergency room physician would probably only need to learn and know one module of an EHR system. At Tri-County, many of the physicians work in multiple departments so they had to learn all of those modules. Despite that, the transition has already paid off, Kleen says. "When we transfer a trauma patient to a tertiary care facility, they can access our records." And when the patient returns to the local community, he or she can go to Tri-County for follow-up care and know that their complete medical record is available to the provider. "We were conscious of the fact that for us to be a player in the future healthcare market, we needed the same EHR as that larger facility," Kleen says. Tri-County owns and operates five rural clinics which each had its own medical records. Rather than acting as five different companies, the EMR has helped the organization become an integrated system. Plus, Tri-County successfully attested to Meaningful Use Stage 1 in November 2011, one of the first critical access hospitals to do so.