November 24, 2008

Unique Rural HIE Challenges
By Laura Kolkman
For The Record
Vol. 20 No. 24 P. 6

ARCHIE bunkers down in Arizona.

Sparse populations distributed across wide geographic regions. A shortage of primary care providers, specialists, and tertiary care hospitals. Limited technology infrastructures and even more limited financial resources.

For rural communities, some of the very characteristics contributing to the disparities in care that health information exchange (HIE) can overcome also present the greatest obstacles to organizing the regional health information organizations (RHIOs) and other initiatives that make HIE possible.

The Challenges: Population, Economics, and Technology
Consider the characteristics of the rural population. There are fewer people to provide the initial impetus for HIE. Further, those who typically take the lead in RHIOs and other initiatives tend to wear multiple hats. This can make it difficult to identify the “power centers” critical to getting an initiative off the ground.

The remote nature of rural populations also makes it difficult to achieve the critical mass of skill sets necessary to manage all aspects of an initiative—including technology skills.

On the economic front, rural communities are generally made up of a lower socioeconomic demographic than their urban counterparts. There are typically few (if any) major employers and even fewer major sources of potential funding for HIE initiatives, as major companies are often reluctant to invest in small communities.

Technologically speaking, most rural communities have little or no high-speed Internet access and a limited ability to support the full technical infrastructure that HIE requires. That means most initiatives must start at the most basic level: installing communications systems.

Even the geographic coverage area presents unique problems when it comes to organizing for an HIE. Achieving a critical mass of participants and patients often requires that coverage areas encompass hundreds of square miles, necessitating long-distance travel to participate in organizational meetings. This can impact the ability of organizers and participants to establish the trust and rapport necessary for a successful initiative.

Strength in Numbers
These are all challenges with which the organizers of the Arizona Rural Community Health Information Exchange (ARCHIE) are familiar. With the help of funding through the Federal Communications Commission’s (FCC) Rural Health Care Pilot Program and a RHIO Planning Grant from Arizona’s Government Information Technology Agency, ARCHIE is working to establish an information exchange that will link healthcare providers in four rural Arizona counties and, eventually, tie into other HIEs across the state.

Before even reaching the point of knowing what they wanted to accomplish, a group of champions (who would eventually become ARCHIE’s core leadership) spent five years evaluating the regional landscape to determine where the healthcare system was in terms of technology adoption. It also worked closely with the state of Arizona, federal agencies, and initiatives in other areas of the country to understand the impact policies may have on the need for HIT and to identify the key stakeholder relationships necessary for the organization to gain a foothold in the targeted coverage area.

As a result, ARCHIE encompasses a wide range of stakeholders, including five hospitals (three of which are critical-access facilities), provider groups, consultants, and a variety of governmental agencies, including workforce development, aging, and social services.

This kind of collaboration is often necessary for rural initiatives to achieve the critical mass of expertise and resources required to attract funding opportunities and support HIE infrastructures. And though such diversity can lessen competitive issues, it also increases logistical challenges.

“Running a rural network is like herding cats because everyone has a full-time job and two or three other areas of responsibility. The initiative is not their primary focus,” says ARCHIE Executive Director Julie Schourup, MD, MPH. “Getting everyone in the same room is also a challenge due to the small populations and large geographic distances. All of our hospitals are separated by at least 30 miles.”

Technology has helped ARCHIE overcome some of the more significant logistical issues. The group is now making use of Central Desktop, a Web-based collaboration tool that allows it to hold webinars and online meetings and keep participants up-to-date through blogs and other online communications tools.

Getting to the point where online collaboration was possible for ARCHIE is a powerful illustration of just how significant the technological, financial, and human resource challenges can be for rural communities.

Schourup notes that when ARCHIE first launched, one hospital had no Internet or e-mail capabilities and was functioning with an extremely outdated computer system. By pooling its knowledge base, the initiative was able to find a vendor willing to work with the facility to revamp its entire IT infrastructure, bringing it to a level where the hospital could become an active participant. It will also allow the facility to connect into the exchange once it is up and running.

“Many times, it’s not just financial considerations; it’s actually finding the people who can take care of things,” Schourup says. “Some members have contributed financially to get things like the FCC proposal done because we needed technical help. Others have contributed time and expertise, as well as things like photocopying and making their facilities available for meetings.”

In the eyes of ARCHIE’s leadership, in-kind contributions count just as much as cash. As such, they track the value of all contributions to keep the playing field level between all stakeholders. It has also helped encourage the involvement of key stakeholder groups whose participation is critical but who may not have the resources to contribute financially.

“One of our basic operating principles is to be completely open and transparent, so everyone can see what is going on and anyone can initiate a conversation,” Schourup says. “We let each organization participate at whatever level they can. This way, there are fewer opportunities for conflict. We nearly always reach a consensus and look for common points of interest. It’s clear to everyone that we will all benefit. It just has to be built first.”

A Tailored Approach
While every rural community is unique, the approach taken by ARCHIE highlights several key strategies rural initiatives can deploy to overcome the logistical and organizational issues that can stop even the most enthusiastic champions. They include the following:

• Conduct community assessments to understand the landscape in which the exchange will operate and to determine the right mix of stakeholders to ensure progress.

• Seek out other initiatives that have undertaken similar projects to learn what did and did not work and why.

• When financially feasible, enlist the services of a consultant with a strong track record of working with rural communities to launch HIE projects.

• If a consultant isn’t in the cards, take advantage of a number of resources available to help guide rural initiatives through the organizational stage.

• Take full advantage of the resources and funding opportunities available through state and federal governments.

• Maximize internal resources by coordinating with other local and state efforts and by giving equal weight to in-kind and financial contributions to encourage more active stakeholder participation.

• When regular in-person meetings are geographically impossible, utilize online workspaces to promote community and collaboration.

• Ensure that the focus remains on accomplishing the HIE’s goal for the benefit of the community it will serve.

The reality is that rural communities stand to benefit the most from HIE but face some of the greatest organizational obstacles to getting exchanges funded and operational. These challenges are not insurmountable, however. They simply require an approach that begins with understanding the environment in which the HIE will operate, followed by the establishment of a framework of governance, community support, and stakeholder engagement. These elements come together to create the solid foundation rural communities need to make HIE a reality.

— Laura Kolkman is president of Mosaica Partners, a health information exchange (HIE) consulting firm, and chair of the HIMSS HIE Steering Committee.