Implementing HIE in rural areas presents a number of challenges, many of which can be directly related to the characteristics of the rural community. The rural population tends to have a very independent mindset. The population is sparse and is scattered over a wide area. There are fewer people to initiate the effort for HIE, and therefore key people need to serve in many roles.
Developing HIE in a rural population requires respect for the region, culture and leadership. However, it may also require time to develop trust with “outsiders” who are brought in to help. That is why it is important to assess the community to understand their specific perspectives of HIE and information needs.
Access to care needs to be understood when working with rural communities. Rural areas tend to have a greater percentage of critical-access hospitals. This means that many critically ill patients are transferred to other, larger hospitals that are frequently a long distance away. Most specialists also are not readily available in the community. This leads to the situation where a patient’s medical records may be scattered over several communities and across long distances. Also, some of the large hospital systems may just ignore the needs of the smaller communities. This drives the needs for better electronic HIE.
Economics also poses a major challenge for the rural areas. Generally, there is a limited source of funding, few major employers, and a lower social economic demographic. Major companies are reluctant to invest in small communities. State and federal governments play a key role in providing startup funding and assistance.
Technology disparities also need to be addressed. Not only may these areas lack a critical mass of technology skills to support HIE independently, but many must start at the very basic levels such as installing communications lines. Many rural communities have limited or no high-speed Internet access, and there is very limited ability to support a full technical HIE architecture. It is important to coordinate HIE development with other efforts, such as federal and state grants. The implementation plans should be flexible. Governance models need to accommodate shared technology, but they should also maintain community autonomy.
The geographic coverage area for the HIE may be hundreds of square miles with a very sparse population. This means that organizers must travel long distances to participate in in-person meetings. The key people for organizing a RHIO may not even know each other at the outset and therefore will need time to build trust and rapport as a team before beginning the difficult work of building a RHIO. Because of the large geographic area and the fact that the HIE effort may be bringing together multiple cultures, it’s important to begin with in-person meetings, at least until the team is formed. Once the teams are formed and the group is working well together, using an online workspace is a good tool to promote collaboration without requiring participants to drive long distances.
So, while rural communities stand to benefit the most from HIE, the reality is that they also face some of the greatest obstacles. These challenges are not insurmountable. It simply requires a collaborative approach designed to leverage the resources that are available to establish a framework of governance, community support and stakeholder engagement.
Laura Kolkman is President of Mosaica Partners (www.mosaicapartners.com), a nationally recognized HIE consulting firm, and Chair of the HIMSS HIE Steering Committee.
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