Health IT and Rural Healthcare: Embracing Opportunities and Overcoming Challenges

1. Health IT and Rural Healthcare: Embracing Opportunities and Overcoming Challenges Leila Samy, MPH Rural Health IT Coordinator Office of the National Coordinator for Health IT

2. Conflict of Interest Disclosure Speakers have no real or apparent conflicts of interest to report. Leila Samy HHS Office of the National Coordinator for Health IT Stephen Stewart CAH in Henry County Iowa Thomas Klobucar VA Office of Rural Health Bill Menner USDA Rural Development Office of the National Coordinator for Health IT

3. Leila Samy, Rural Health IT Coordinator Office of the National Coordinator for Health IT ONC Initiatives and partnerships to support Rural health IT Office of the National Coordinator for Health IT

4. Learning Objectives • Overall learning objectives • Describe unique challenges and opportunities related to financing, implementing and sustaining the use of health IT in rural communities • Summarize existing federal, state and private-sector programs, tools and best practices for rural providers • Evaluate experiences in participation and use of programs, tools and best practices for rural healthcare providers • Assess gaps in current programs and identify future needs in health IT programs and research for rural healthcare organizations • Session specific learning objectives • Describe ONC Programs for Health IT and their objectives, including collaborations with USDA and VA • Identify ONC resources and tools for rural health IT • Assess experiences with use of ONC programs and resources Office of the National Coordinator for Health IT

5. Rural Rates Compared to Overall Rates for Providers and Hospitals Paid by Medicare or Medicaid Rural professionals are participating in the EHR Incentive Programs at roughly the same rate as the national trend. However, rural hospitals are lagging behind the overall trend. Source: EHR Dashboard on HealthIT.gov as of 11/30/2013

6. Percent of Small Rural and Critical Access Hospitals Paid By Stateas of November 2013 Office of the National Coordinator for Health IT

7. Percent of Rural Physicians, Physician’s Assistants and Nurse Practitioners Paid By State as of November 2013 Office of the National Coordinator for Health IT

8. Percent of Rural Physicians, Physician’s Assistants, and Nurse Practitioners Paid By State as of November 2013 November 2013 July 2013 Office of the National Coordinator for Health IT

9. Hospital Progress Overtime Attesting to Meaningful Use Through November 2013, By Type and Size Note: Large = 400+ staffed beds; Medium = 100-399 staffed beds; Small = <100 staffed beds. Rural = non-metropolitan; Urban = metropolitan. Office of the National Coordinator for Health IT

10. Location of Small Rural and Critical Access Hospitals By Attestation Status Attested Not Attested Office of the National Coordinator for Health IT

11. Hospitals Attested By 2014 Edition Certification Status of Primary Vendor Note: Primary EHR vendors are those whose products are certified to the most 2011 Edition certification criteria in the EHR system (in cases where a provider used certified products from multiple vendors to attest). Source: ONC Certified Health IT Product List (CHPL) 12/31/2013, CMS attestation data 11/30/2013. Office of the National Coordinator for Health IT

12. Hospitals Attested By 2014 Edition Certification Status of Primary Vendor Note: Primary EHR vendors are the vendors whose products are certified to the most 2011 Edition certification criteria in the provider’s EHR system (in cases where a provider used certified products from multiple vendors to attest). Sources: ONC Certified HIT Products List (CHPL) (12/31/2013), CMS Attestation Data (11/30/2013). Office of the National Coordinator for Health IT

13. Hospitals Attested By Size, Type, Location and 2014 Edition Certification Status of Primary Vendor Note: Primary EHR vendors are the vendors whose products are certified to the most 2011 Edition certification criteria in the provider’s EHR system (in cases where a provider used certified products from multiple vendors to attest). Sources: ONC Certified HIT Products List (CHPL) (12/31/2013), CMS Attestation Data (11/30/2013). Office of the National Coordinator for Health IT

14. Rural Health IT Tools and Resources www.HealthIT.gov/RuralHealth Office of the National Coordinator for Health IT

15. ONC Data Brief of Critical Access Hospital Survey Challenges and Opportunities Office of the National Coordinator for Health IT

16. ONC Data Brief of Critical Access Hospital Survey • Challenges and Opportunities Percent Reporting Severe Challenges: Funding, Broadband, Workforce, Technical Office of the National Coordinator for Health IT

17. Collaborating with and Leveraging Partners • White House Rural Council • Streamline programs serving rural America • Technical assistance • Funding , Broadband & Workforce • Serving Rural veterans Office of the National Coordinator for Health IT

18. Expand Funding for Rural Health IT ONC and USDA Rural Development launched an initiative to expand funding for CAHs and rural hospitals. FY 2013 Pilots: Over $38 Million in funding to CAHs and rural hospitals across 4 states. FY 2014: ONC and Rural Development are taking this initiative to scale in additional states. Office of the National Coordinator for Health IT

19. ONC/VA Leveraging Health IT to Improve Care Coordination and Quality for Rural Veterans Project “VICTORhie” The Veteran Initiated Coordination & Transformation of Rural Health Information Exchange • ONC and VA’s Office of Rural Health launched an initiative to leverage Blue Button technology and health information exchange to improve care coordination and quality for rural veterans and highly rural veterans that wish to seek care both within the VHA system as well as at their local rural clinic or hospital. Office of the National Coordinator for Health IT

20. Data driven approach to pilot site selection Office of the National Coordinator for Health IT

21. Office of the National Coordinator for Health IT

22. Bill Menner, Iowa State Director, Rural Development US Department of Agriculture USDA programs and Partnership with HHS/ONC Office of the National Coordinator for Health IT

23. Value Steps Benefits • USDA Rural Development programs provide critical resources to rural hospitals and clinics • USDA Rural Development loans, grants and loan guarantees can assist in the purchase of equipment, network infrastructure, hardware and software for Health IT purposes • USDA Rural Development investments lead to improved health data reporting and quality measures reporting • USDA Rural Development involvement may allow hospitals to use their own resources in alternate ways thanks to resources and savings realized Office of the National Coordinator for Health IT

24. USDA’s Role in Rural Health IT Office of the National Coordinator for Health IT

25. Why is USDA Funding Rural Health IT? • USDA Rural Development is a small mission-area focused on helping create rural communities that are vibrant, self-sustaining and wealth-creating • The Agency has 40 programs that assist in all aspects of rural quality-of-life, from housing to small business to clean water to health care • Strong rural communities help to support American agriculture. Ag producers need small towns for public safety, education, businesses that provide off-farm income, retail and health care, among other things. • Rural residents deserve access to quality health care that does not require a sometimes lengthy trip to an urban center. Office of the National Coordinator for Health IT

26. What Are the Challenges in Rural America? • Lower incomes/wages • Less educational attainment • Larger numbers of elderly • Declining populations • Job loss 11/2012-11/2013 as urban areas gain • Access to capital • Access to high-speed broadband • Greater risk of losing primary care physicians to retirement Office of the National Coordinator for Health IT

27. What Are the Opportunities in Rural America? • Productive US agriculture • Bioeconomy favors rural • Clean water • Work ethic • Service ethic • Quality of life • Excellent schools • High-performing hospitals and clinics Office of the National Coordinator for Health IT

28. Shining the Light on Rural Health IT • President creates White House Rural Council • USDA and HHS secretaries sign MOU • Departments join forces to coordinate and collaborate Office of the National Coordinator for Health IT

29. Iowa Jumps at the Chance! Partners come together to identify new opportunities • Iowa State Office of Rural Health • USDA Rural Development • Iowa FLEX Program – FLEX funding and education • Iowa HIT Regional Extension Center – technical assistance • State Health Information Network - data exchange • Iowa Hospital Association – hospital relationships and support • Iowa Medicaid Enterprise – state incentive and resources Office of the National Coordinator for Health IT

30. Consortium Targets and Educates • ID rural hospitals not progressing toward MU • ID rural hospitals citing financial difficulty for lack of progress • Determine capacity of leadership to move forward • ID local/regional partners • Connect REC, USDA local staff with hospital leadership • Find opportunities to leverage • Promote partnership to key stakeholders Office of the National Coordinator for Health IT

31. Immediate Results • Three hospitals began or expanded work toward Meaningful Use • Conversations with hospitals about funding/loans for equipment were initiated • Rural Health Clinics began stepping forward to EHR/MU • Hospitals & providers were informed and directed to attain incentives • Other discussions commence with USDA for non-Health IT discussions (ambulance, MRI, bricks-and-mortar) Office of the National Coordinator for Health IT

32. USDA Programs to Consider • Community Facilities Loan/Grant (CF) • USDA is the lender. Term may be dictated by Useful Life of equipment. Loan dollars can be 100% of project Grant dollars extremely limited. Population limit 20,000 non-metro. • Rural Economic Development Loan/Grant (REDLG) • 0% 10-year loan via local partner (rural electric coop, rural telephone coop, eligible municipal utility. Up to $2 million per project. Population limit 50,000 non-metro. • Distance Learning-Telemedicine (DLT) • Very competitive program with grants $50,000-500,000. 15% required matching contribution. 20,000 non-metro population limit. Can fund hardware, software and network equipment. • Business & Industry Loan Guarantees (B&I) • An option for for-profit hospitals. Office of the National Coordinator for Health IT

33. Iowa Case Studies Office of the National Coordinator for Health IT

34. Henry County Health Center, Mount Pleasant, IA Office of the National Coordinator for Health IT

35. Partnership with Rural Electric Coop • Community Size: 8,741 • Total Project:  $998,134 including surgical suite • $195,791 will be used for servers, routers, switches, wireless controllers, docking stations and access points.  • USDA provides $798,000 to the local rural electric coop, which passes funds to hospital via ten-year, 0% loan. • Financing allows hospital to use its own reserves for additional health IT investments totaling $165,000 Office of the National Coordinator for Health IT

36. Iowa Specialty Hospital, Belmond, IA Office of the National Coordinator for Health IT

37. USDA Grant Drives Completion • Community Size: 2,348 • Total Project: $440,540      • USDA provides $100,000 Community Facilities grant for purchase and integration of software modules. • Unanticipated Phase Two: Additional hardware needs arise that were not anticipated when the project began. When the project was completed, hospital had spent $190,000 more than they originally planned. Rural Development grant was crucial to project completion. • A very successful project. The hospital has achieved Meaningful Use Office of the National Coordinator for Health IT

38. Pocahontas Community Hospital, Pocahontas, IA Office of the National Coordinator for Health IT

39. Hospital and Municipal Utility Unite • Community Size: 1,744 • Total Project Cost: $1 million • USDA provides $300,000 to Municipal Utility, which passes funds (plus 20% match) to hospital at 0% over ten years. • Project: Implementing a full electronic medical record.  This required some additional hardware components also along with a few new servers. Fully electronic by next fall. • From the hospital administrator: “This would not have been possible without the financial support offered by USDA!” Office of the National Coordinator for Health IT

40. Value Steps Benefits • USDA Rural Development programs provide critical resources to rural hospitals and clinics • USDA Rural Development loans, grants and loan guarantees can assist in the purchase of equipment, network infrastructure, hardware and software for Health IT purposes • USDA Rural Development investments lead to improved health data reporting and quality measures reporting • USDA Rural Development involvement may allow hospitals to use their own resources in alternate ways thanks to resources and savings realized Office of the National Coordinator for Health IT

41. The Big Challenge Office of the National Coordinator for Health IT

42. Stephen M. Stewart CHCIO, FCHIME, FHIMSS, FACHE Chief Information Officer, Henry County Health Center Success Story: Iowa CAH gets USDA financing for Health IT Office of the National Coordinator for Health IT

43. Learning Objectives • Explain what Henry County Health Center (HCHC) did to participate in this project • Partnership with Alliant Energy and USDA • Share the results we gained out of this project Office of the National Coordinator for Health IT

44. The Benefits • HCHC received ~$800,000 interest free loans for “equipment” • We were constructing new surgery center • Have fully implemented EHR • We are a CAH for HITECH reimbursement is on a cost basis • For HCHC 55.23% Medicare Cost share • Plus 20% CAH • 77.23% total reimbursement for CAH for qualifying EHR equipment • Surgery Center required infrastructure to attach to EHR Office of the National Coordinator for Health IT

45. The USDA Grant and Loan Programs and Health IT About Henry County Health Center • Critical Access Hospital-25 Acute beds • 50 LTC beds on Campus • 140 LTC Beds managed under contract • 5 Dialysis Centers • 5 Employed Physicians • 5 Contract ER Physicians Office of the National Coordinator for Health IT

46. The USDA Grant and Loan Program and Health IT Demographics • Iowa Approximately 3 Million People • Henry County Approximately 20,000 • Mt. Pleasant Approximately 9,000 • Located SE corner of state • 25 Miles to Illinois Border • 50 Miles to Missouri Border • 50 Miles from VA Medical Center Iowa City • 60 Miles from VA Medical Center Knoxville Office of the National Coordinator for Health IT

47. The USDA Grant and Loan Program and Health IT • HCHC sought in conjunction with Alliant Energy funding under: • REDL (Rural Economic Development Loan) Program • REDG (Rural Economic Development Grant) Program • RDL (Rural Development Loan) Program • Partnering with Alliant Energy and the USDA advanced HCHC HIT Office of the National Coordinator for Health IT

48. The USDA Grant and Loan Program and Health IT • The results • $855,000 interest free funding for 10 years • HIT expenditures $261,205 • Qualified stimulus reimbursement- $201,728 • Net HIT Investment $59,477 • Gross amount funded interest free for 10 years Office of the National Coordinator for Health IT

49. The USDA Grant and Loan Program and Health IT • What did we acquired • Personal Computers • Printers • Network Fiber Switches • EHR Software Modules • EHR Integrated Central Monitoring System • EHR Integrated Nurse Call System • Wireless Voice communications integrated to EHR Office of the National Coordinator for Health IT

50. The Benefits of this Health IT Project • Clearly in the Technology Step • Electronic Information/Data • Added tools we did not previously enjoy in our Surgery Center • At the end of the day the project enables • Better Care • Better Outcomes • Reduced costs http://www.himss.org/ValueSuite Office of the National Coordinator for Health IT