A January 20, 2016 Health Affairs Article by Dawn M. Heisey-Grove titled Variation In Rural Health Information Technology Adoption And Use (Health Affairs, no.(2016): doi: 10.1377/hlthaff.2015.0861) examines the differences between different provider groups in rural vs. urban settings.
According to Heisey-Grove, initial adoption levels amongst rural providers was higher than their urban counterparts. “In 2013, 82.3 percent of rural physicians had adopted an EHR system compared to 78.0 percent of urban physicians. Similar differences were observed for nurse practitioners and physician assistants…. and overall, rural registered providers were more likely than their urban counterparts to have achieved meaningful use”. However, “Although initial health IT adoption and meaningful-use achievement was higher among rural providers and hospitals compared to their urban counterparts, these populations were less likely to return in subsequent years of the incentive program”.
A number of potential reasons are cited for this variation including the degree of technical assistance from Regional Extension Centers, the focus on supporting providers to achieve Meaningful Use Stage 1 vs. later stages and other factors such as provider type, specialty and practice size. The drop-off rate was higher in subsequent years of Meaningful Use attestation suggesting an ongoing need for assistance in order to support the use of Health IT in these communities.
In my experience, rural providers are frequently the leaders in adoption of new tools and technologies. In part to compensate for the isolation of smaller communities with immediate access to fewer resources, but also because of the personalities of individuals in rural practice settings. They are frequently (by nature) more self-sufficient and able to make do with less than their urban counterparts and generally provide excellent care to their patients. So, why would they not race to adopt EHRs and then continue to use them more effectively and more completely than urban providers?
I believe that Heisey-Grove highlights some of these factors, in particular the need for a high level of technical support in order to continue to achieve increasingly complex stages of Meaningful Use. However, we also hear from many of the clinicians who contribute their feedback to AmericanEHR that the tools are simply not good enough for the complexity of the care they provide or matched closely enough to their workflow. Do I think this is all the fault of the EHR vendors? Not at all. There are many excellent EHR products in the market. They lack finesse in many cases and by many user’s admissions are difficult to customize to either their specialty or specific work setting. However, in many cases users have also received insufficient training in the use of advanced functions of their EHRs and the level of optimization of each product can vary significantly from one practice to another.
Where do they all fail? In the area of interoperability! The ability to share crucial health information between different systems and providers in order to make the care of patients easier, safer and more efficient. The need for semantic interoperability is crucial such that data transferred from one system to another has the same meaning in the sending and receiving systems alike.
If EHR systems could seamlessly share information that was semantically correct, one of the most significant barriers to adoption and Meaningful Use would be overcome. In time, most providers and practices will find workarounds to systems that are less ‘usable’ than others and in a trade-off, I believe would take interoperability over usability 9 times out of 10. The incentive to use the systems is ultimately related to the value of the data that they can aggregate and present.
Do systems need to get better? Without a doubt. However in a world in which interoperability is the norm, I believe our rural colleagues would win out over urban providers the majority of the time in terms of adoption and use of Health IT. Right now, the barriers are simply too great.