Health Information Technology Value in Rural Hospitals (Iowa)

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Summary:

The national discussion of quality and patient safety has only recently begun to identify and understand the unique quality and patient safety issues facing rural hospitals, as opposed to those of their much larger and far more complex, urban counterparts. Serious questions arise about whether commonly proposed health information technology (health IT) interventions for quality and patient safety issues actually make sense in rural hospitals. Moreover, very few rural hospitals currently have the necessary health IT capacities because of expense, limited in-house health IT expertise, and mismatches among health IT applications. This project was designed to meet the special needs of rural hospitals for assistance with planning health IT enhancements to address patient's safety and health care quality concerns. This project was developed in response to RFA HS-04-012 which states that "AHRQ is specifically interested in...applications that explore the unique barriers faced by rural and small community providers in adopting HIT and opportunities for overcoming these barriers" and "Research areas that are of particular interest to AHRQ include: development and evaluation of toolkits...that can be used by...decision-makers to help them understand the value of health IT and assist them to make health IT purchasing and implementation decisions." First, we documented the patient safety and health care quality challenges unique to rural hospitals. Second, explored the current health IT capacity in rural hospitals, the potential use of health IT by rural hospitals to address their unique patient safety and health care quality issues, and the unique barriers faced by rural hospitals in adopting health IT. Third, measured value derived from health IT in rural hospitals and identified which health IT solutions for enhancing patient safety and health care quality have the greatest potential in terms of generating a positive return on investment. Fourth, created decision-making health IT toolkits to address barriers and provide solutions that are appropriate for rural hospitals. Once the toolkits were developed, we made them available to rural hospital decision-makers. The toolkits facilitate rural hospitals' ability to utilize current and emerging evidence to guide health IT investment and implementation decisions that fit their particular health care environment.

Health Information Technology Value in Rural Hospitals - 2008

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS04-012: Demonstrating the Value of Health Information Technology (THQIT)
  • Grant Number: 
    R01 HS 015009
  • Project Period: 
    09/04 – 08/08, Including No-cost Extension
  • AHRQ Funding Amount: 
    $1,304,478
  • PDF Version: 
    (PDF, 73.75 KB)


Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Summary: Today, hospital-based health information technology (IT) encompasses a wide range of quality and patient safety applications including: electronic medical records, personal health records, e-mail communication, clinical alerts and reminders, computerized physician order entry, computerized decision support systems, hand-held computers, electronic information resources technology, electronic monitoring systems, and telehealth consultative and diagnostic services. However, very few rural hospitals have developed or implemented these health IT capacities because of factors including expense, limited in-house IT expertise and staffing, and the fact that many health IT applications benefit from economies of scale that are unavailable to them. Currently, there are significant gaps in knowledge about the value of health IT in general, but they are especially pronounced in rural applications. There has been little systematic study of whether existing health IT technologies, or investment in the commonly implemented health IT projects, readily lend themselves to quality enhancement in rural hospitals. For a rural hospital with limited resources, there needs to be a better understanding of the fit between actual quality and safety problems and the health IT solutions under consideration. Rural hospitals could benefit substantially from assistance and tools to aid in their health IT decisionmaking.

This grant was designed to address these knowledge gaps, using an in-depth study of Iowa’s 89 rural hospitals with a particular focus on its 80 critical access hospitals (CAHs). A major component of this research was focused on identifying and prioritizing the quality-of-care and patient safety issues facing rural hospitals; this was assessed by surveys, interviews with key personnel, and quantitative analysis. Related to this was the aim of identifying challenges and barriers facing rural hospitals embarking on health IT projects, using research methods including expert panels, case studies, and a literature review. Assessment work also included investigations of the correspondence between various types of health IT technologies and improvements in patient safety, as well as the cost-effectiveness of health IT for rural providers. The information gathered through the project’s research efforts was then synthesized into toolkits for rural providers in Iowa.

Specific Aims

  • Characterize patient safety and health care quality issues in rural hospitals. (Achieved)
  • Characterize the health IT capacity and barriers of rural hospitals. (Achieved)
  • Identify which health IT capacities are most strongly related to patient safety and health care quality issues in rural hospitals. (Achieved)
  • Identify the cost of health IT in rural hospitals. (Achieved)
  • Develop toolkits to help rural hospitals make informed health IT investments. (Achieved)

2008 Activities: With data collection complete, the primary 2008 activities were analysis and dissemination of knowledge products.

Impact and Findings: The Iowa Hospital Association and the Iowa Department of Public Health–Iowa Medicare Rural Hospital Flexibility Program (FLEX) created a workgroup, the Iowa CAH Data Workgroup, of representatives from CAHs to focus on identifying “rurally relevant” patient safety and quality issues. The “rurally relevant” patient safety and quality issues that the Iowa CAH Data Workgroup identified as having the highest priority for Iowa CAHs were: medication errors, falls, appropriate assessment and treatment of chest pain presenting in the emergency department, and births for those hospitals that have obstetric services. They established a Web-based reporting tool for all CAHs to report on these five topics on a quarterly basis for benchmarking within Iowa’s CAHs. The Iowa CAHs have been participating in this voluntary reporting and benchmarking effort since 2005. Quantitative analysis showed that the only Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) for which Iowa was substantially worse than the national benchmark involved maternal trauma during vaginal deliveries. An in-depth analysis of these procedures determined that a number of factors were involved, including maternal risk factors (e.g., higher prevalence of teenage mothers), baby risk factors (e.g., higher prevalence of large babies), and procedure risk factors. This compounding of risk factors occurred more often in rural hospitals and appeared to be related to emergency deliveries in rural hospitals that were not staffed to handle unplanned cesarean deliveries. Analysis of PSIs in rural hospitals before and after conversion to CAH status indicated improvement in indicator rates for prevalent complications coincident with enhanced financial performance. The team also found that the raw in-hospital mortality rate for acute myocardial infarction (AMI) in Iowa rural hospitals (14 percent) was twice the rate of Iowa urban hospitals (6.4 percent). However, AMI patients admitted to rural hospitals were a decade older and were sicker than those admitted to urban hospitals, in part because many AMI patients in rural hospitals are transferred to urban hospitals, and this sub-population of transfers is younger and healthier than those who remain at rural facilities. An instrumental variable approach to control for this trend caused the difference in in-hospital mortality rates to disappear. In a published review of existing literature, the project concluded that to expedite the spread of health IT in rural America, Federal and State governments, along with private payers—who are important beneficiaries of health IT—must make difficult decisions as to who pays for the investment in this technology. They must also drive standards, simplify approaches for reductions in risk, and create a workable operational plan. Toolkits developed included an algorithm to optimize AMI patient referrals, a health IT cost calculator, and online toolkit offering information on health IT implementation and best practices.

Selected Outputs

Allareddy V, Ward MM, Allareddy V, et al. Effect of meeting Leapfrog volume thresholds on complication rates following complex surgical procedures. Ann Surg 2010;251(2):377-83.

Li P, Schneider J, Ward MM. Converting to critical access status: how does it affect rural hospitals' financial performance?. Inquiry 2009 Spring;46(1):46-57.

Li P, Ward MM, Schneider JE. Factors associated with Iowa rural hospitals' decision to convert to critical access hospitals status. J Rural Health 2009 Winter;25(1):70-6.

Bahensky JA, Jaana, M, Ward MM. Health care information technology in rural America: electronic medical record adoption status in meeting the national agenda. J Rural Health 2008;24(2):101-5.

Bahensky J, Moreau B, Frieden R, et al. Critical access hospital informatics: how two rural Iowa hospitals overcame challenges to achieve IT excellence. J Healthc Inf Manag 2008;22(2):16-22.

Chi CL, Street WN, Ward MM. Building a hospital referral expert system with a Prediction and Optimization-Based Decision Support System algorithm. J Biomed Inform 2008;41(2):371-86.

Clabaugh G, Ward MM. Cost-of-illness studies in the United States: a systematic review of methodologies used for direct cost. Value Health 2008;11(1):13-21.

Li P, Bahensky J, Jaana M, et al. Role of multihospital system membership in electronic medical record adoption. Health Care Manage Rev 2008;33(2):169-77.

James PA, Li P, Ward MM. Myocardial infarction mortality in rural and urban hospitals: rethinking measures of quality of care. Ann Fam Med 2007;5(2):105-11.

Li P, Ward MM, Schneider JE. Effect of critical access hospital conversion on patient safety. Health Serv Res 2007;42(6 Pt 1):2089-108.

Roberts LL, Ely J, Ward MM. Factors contributing to maternal birth-related trauma. Am J Med Qual 2007;22(5):334-43.

Wakefield DS, Ward MM, Wakefield BJ. A 10-Rights framework for patient care quality and safety. Am J Med Qual 2007;22(2):103-11.

Jaana M, Ward MM, Pare G, et al. Antecedents of clinical information technology sophistication in hospitals. Health Care Manage Rev 2006;31(4):289-99.

Ward MM, Evans TC, Spies AJ, et al. National Quality Forum 30 safe practices: priority and progress in Iowa hospitals. Am J Med Qual 2006;21(2):101-8.

Ward MM, Jaana M, Bahensky JA, et al. Clinical information system availability and use in urban and rural hospitals. J Med Syst 2006;30(6):429-38.

Grantee’s Most Recent Self-Reported Quarterly Status: This project is complete. All aims have been met and outputs have been developed to help rural providers assess their health IT needs and possibilities.

Milestones: Progress is mostly on track.

Budget: Somewhat underspent, approximately 5 to 20 percent.

Health Information Technology Value in Rural Hospitals - Final Report

Citation:
Ward M. Health Information Technology Value in Rural Hospitals - Final Report. (Prepared by University of Iowa under Grant No. R01 HS015009). Rockville, MD: Agency for Healthcare Research and Quality, 2008. (PDF, 116.6 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
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This project does not have any related resource.

HealthCare Information Technology Capability Survey

This is a questionnaire designed to be completed by administrators in an ambulatory setting. The tool includes questions to assess the current state of enterprise systems.

Year of Survey: 
2005
Survey Link: 
HealthCare Information Technology Capability Survey (PDF, 127.22 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
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Technology: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
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Health Information Technology Value Project: Chief Executive Officer Interview Guide

This is an interview guide designed to be conducted with administrators in an ambulatory setting. The tool includes questions to assess the current state of electronic health records.

Year of Survey: 
2005
Survey Link: 
Health Information Technology Value Project: Chief Executive Officer Interview Guide (PDF, 159.42 KB)
Document Type: 
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Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
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Health Information Technology Value Project: Chief Information Officer Interview Guide

This is a questionnaire designed to be completed by clinical staff in an ambulatory setting. The tool includes questions to assess user's perceptions of electronic health records.

Year of Survey: 
2005
Survey Link: 
Health Information Technology Value Project: Chief Information Officer Interview Guide (PDF, 30.23 KB)
Document Type: 
Research Method: 
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Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
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Employee and Staff Pre Go-Live Expectations and Perceptions Clinical Information Systems Survey: Physician Only

This is a questionnaire designed to be completed by physicians in an inpatient setting. The tool includes questions to assess user's perceptions of computerized provider order entry and electronic health records.

Year of Survey: 
Created prior to 2009
Survey Link: 
Employee and Staff Pre Go-Live Expectations and Perceptions Clinical Information Systems Survey: Physician Only (PDF, 112.8 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Research Method: 
Population: 
Care Setting: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
Location: 

Employee and Staff Pre-Go-Live Expectations and Perceptions Clinical Information Systems Survey

This is a questionnaire designed to be completed by clinical staff across a health care system. The tool includes questions to assess user's perceptions of electronic health records.

Year of Survey: 
2004
Survey Link: 
Employee and Staff Pre-Go-Live Expectations and Perceptions Clinical Information Systems Survey (PDF, 54.64 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Research Method: 
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
Location: 
This project does not have any related project spotlight.
This project does not have any related survey.

Researchers Help Rural Hospitals Get Health IT Boost

Marcia M. Ward, PhDWhen it comes to using information technology (IT) in hospitals, there is no one-size-fits-all approach. This is especially true for rural hospitals, which often lag behind their urban counterparts in adopting health IT.

The reasons for this are varied. Some rural hospitals cannot afford the expense of IT investments and have limited in-house health IT expertise. In addition, many health IT tools are designed with larger hospitals in mind. And while rural hospitals have basic IT systems in place for business applications, they are behind their rural counterparts in adopting technology for clinical use. For example, a survey in Iowa found that more than 80% of Iowa's urban hospitals, and between 30% and 40% of the rural hospitals, reported using computers to collect basic clinical information for potential use in an electronic health record (EHR) and computerized provider order entry (CPOE) system.

To help rural hospitals across the United States make more informed investments in technology, Agency for Healthcare Research and Quality grantee Marcia Ward and colleagues examined barriers to health IT adoption in rural Iowa hospitals. As part of the grant, project leaders wanted to better understand the patient safety and health care quality challenges that are specific to rural hospitals. In addition, the researchers examined rural hospitals' health IT capacity, barriers to using technology, the costs of such technology for rural hospitals and which technologies were most strongly linked to better care for patients. Next, researchers identified which technologies could have the greatest applicability for these hospitals, especially in the state's Critical Access Hospitals (CAHs).

Through literature reviews, surveys and interviews with hospitals in the state, researchers found several roadblocks to IT adoption in rural hospitals. These included high costs related to infrastructure and software, technology that was not ready for a hospital environment, and a lack of reimbursement for the use of technology.

As part of their effort to better understand these barriers, researchers formed the Iowa CAH Health IT Interest Group. The group met several times a year over a three-year period and became the de facto "networking club" for the key people at each hospital who had responsibility for implementing EHRs, says Marcia Ward, the project's principle investigator. The group discussed everything from how to store back-up data and where to get free software to how to write a request for proposals when seeking information from an IT vendor.

Because there is scant research available to guide rural hospitals in implementing health IT, Ward and colleagues also gathered input from the CAH Health IT Interest Group and created Web-based tools to provide hospitals with information that would help them make better Health IT investments. The toolkit included tips from members on how to get multiple Health IT systems to work together, how to train clinical staff to use technology, in addition to:

Research on best practices for Health IT in rural hospitals;

A list of technology vendors that rural hospitals used most often;

Sample Request for Proposals (RFPs) for soliciting health IT bids;

Lists of free or low-cost software;

Tips and federal security requirements for keeping health care data secure;

A hospital referral toolkit to refer patients who have had a heart attack or need coronary artery bypass surgery to the nearest hospital with the best outcomes for that patient; and

A cost calculator to help hospitals estimate the expenses involved in implementing an EMR system.

Ward, Professor and Associate Head of the Department of Health Management and Policy in the College of Public Health at the University of Iowa, says the key to success for this project was bringing so many hospitals to the table to solve a common challenge.

"When you have transparency, and working together, it's just a different place," Ward says. 

This project does not have any related emerging lesson.