This business case is a healthcare scenario framework that can highlight a set of facets for consideration by providers, policymakers, payers, and other stakeholders when evaluating the potential efficacy of initiatives and investments in non-urban settings.
Healthcare Scenario Framework for Rural / Underserved / Remote Settings
The healthcare and technology assumptions, expectations, considerations, implementations, and operations of rural and underserved regions are sometimes different than their urban/suburban and well-served counterparts. Scenarios are often developed by relevant stakeholders that help clarify those distinctions, teasing out not only the health information technology distinctions, but other aspects that impact the healthcare process as well. If well-formed, the requirements expressed by these scenarios can be compared, contrasted, categorized, and merged within a framework. Those requirements can then be prioritized, funded, implemented, measured, and updated. Short- and long-term roadmaps can also be envisioned by stakeholder groups that will better meet the needs of the rural and underserved populations and of their solution providers.
The authors propose a facet-based framework for specifying well-formed scenarios within rural/underserved/remote settings such that access to healthcare services becomes more equitable to their urban-based counterparts.
Significant facets of non-urban healthcare services include: population, payment, technology, access, service, regulation, education, condition, economics, and special interest groups.
Figure 1: Rural Health Scenario Facets within the Framework
Figure 2: Population-based Facets
How many people live in U.S. rural/underserved/remote settings – and who are they?
According to the United States Department of Agriculture, the number of people living in non-metropolitan counties in 2014 stood at 46.2 million — nearly 15% of US residents spread across 72% of the nation's land area. According to the National Rural Health Association (NRHA), the people aged 65+ constitute 18% of the population versus 15% in urban settings.
Populations are characterized by multiple determinants, such as residence, stage of life, family status, gender status, economic status, and cultural status; these determinants may affect healthcare availability and choice. Healthcare services based on a person’s stage of life (e.g., a college student, a new employee, or a newborn) differ significantly. Consider a person’s residence: how can a bill be mailed to a homeless person? Can an email be sent to a person who does not have Internet access?
Figure 3: Payment-based Facets
How many people are insured in rural/underserved/remote settings – and to what degree are they covered by insurance?
According to a report done by the Kaiser family foundation, 20% of the uninsured in the United States lives in rural areas. However, in states like Montana and Maine, over 70% of the uninsured are from rural areas. Since many within the rural population tend to earn their livelihood via small businesses, a wider variety of healthcare insurance benefit coverages exists – including non-coverage. Consequently, Medicaid picks up some of that slack by offering a prevalent degree of healthcare coverage in rural communities.
Figure 4: Technology-based Facets
How does technology affect care in rural/underserved/remote settings?
Technological infrastructure, though developing and improving over the past several years, still remains a challenge for rural healthcare communities. For example, telehealth, which can be a very attractive method of care in rural communities, is still often unavailable due to technological barriers (such as a lack of high speed Internet access) and regulatory barriers (such as non- face-to-face consultation reimbursements).
Most rural healthcare institutions have an electronic health record system, but still struggle to fit their workflows and processes to existing technology. Additionally, access to the most current technology – and the cost of that technology – remain barriers for smaller healthcare delivery settings, and thus, play a vital role in health decisions.
Figure 5: Access-based Facets
How accessible is healthcare in rural/underserved/remote regions?
Smaller communities may have difficulty accessing specialized and/or affordable care in an efficient manner. Workforce shortages, geographic and transportation barriers, health literacy needs, and cultural and social barriers are all major factors to consider when dealing with healthcare issues in a rural community. Local, close-knit, cultural-affinity aspects are often an advantage when promoting and developing solid healthcare network support in rural settings. Health literacy needs may also be different based on local dialects and languages. To reach the nearest healthcare facility, a family may first need to consider factors, such as convenient public transportation, choice of specialist, and availability of neighbors who can provide logistical support.
Figure 6: Service-based Facets
How do healthcare services differ in rural/underserved/remote settings as compared to urban settings?
According to the policy brief for Healthy People 2020, mental health, substance abuse, and dental health services are the most important services that impact rural healthcare. Unfortunately, only 15% of rural residents have ready access to mental health services, according to Smalley (et al) and users of mental health services in rural communities are sometime stigmatized. Fluoridated water is not always available in rural settings, giving rise to an increase in oral health conditions. Additionally, accesses to dental professionals – and the ability to pay for those services – are also factors. Various types of substance abuse (i.e., underage drinking and tobacco use) are sometime more prevalent in certain rural areas and community acceptance of the behavior as a social norm can inhibit the desire to seek care.
Figure 7: Regulation-based Facets
How are laws, regulations, and policies different for rural/underserved/remote settings than for urban settings?
Facilities that are deemed “rural” may have different regulations (e.g., cutoff points for funding) than those of urban settings. Regulations may also impact the availability and level of funding for alternate services, such as telemedicine. Also, there might be special formulas for calculating funding that are based on the patient’s income, location, population density, and level of infrastructure. Rules may also exist for specially defined demographic populations (e.g., Indian Health Services, veterans’ services, or disparity-based service offerings).
Figure 8: Education-based Facets
How are education requirements and services different for rural/underserved/remote settings than for urban settings?
Healthcare providers may need specialized education in order to become acclimated to the social, behavioral, and cultural norms of patients within rural settings before tailoring and offering healthcare and wellness services. For example, a clinician may desire to use mobile technology to meet a requirement to teach a newly expectant father and mother about the various stages of pregnancy.
Figure 9: Condition and Impact-based Facets
How might the care for certain health conditions vary in rural/underserved/remote settings versus urban settings and what is the impact of such care?
The same disease/injury/condition that occurs in a rural setting may have different overtones than if occurred in the urban setting. For example, the considerations for a widowed elderly woman with a broken hip who lives on a farm is different than if that woman lives in a city and has ready access to public transportation, nearby neighbors, emergency transportation services, care-giving facilities, and pharmacies.
Consider also the care-related impacts for a person with a chronic condition who lives in a rural setting and who can’t easily acquire weekly medicine refills (due to the distance of the pharmacy), or who needs to visit a dialysis machine every other day, or who needs a bandage dressed at regular intervals, or who needs insulin injections by a visiting nurse who must travel great distances.
Figure 10: Economic Investment and ROI-based Facets
How do relevant stakeholders weigh risks / rewards for deployments in rural/underserved/remote settings versus urban settings?
The relevant stakeholders of an existing, well-established, expensive urban-based health IT system may be able to tailor (or re-engineer) certain services to gain clients in remote regions. The hope is that a small, short-term investment / loss will be eventually followed by a handsome profit.
Next, consider the relevant stakeholders of new app-for-that targeting rural settings who might make a medium-level investment with the realistic expectation that the service will become obsolete within a few years, but which has a good likelihood of making a modest profit.
Finally, consider the relevant stakeholders who weigh the risks/rewards of building an application that targets rural settings where a consistent profit cannot be expected without the addition of sustained government subsidies (such as a public health –related application).
Figure 11: Special Interest Groups-based Facets
Why do some special interest groups focus on rural healthcare settings?
Even though certain caregiving organizations may break even or lose money, they may decide to establish healthcare services or facilities in rural settings for the “greater good” of society. Caregiving organizations need to consider the types and numbers of people who might be covered by special interest operations in rural settings. Furthermore, potential patients need to be aware a priori of the nature and location of specialized services that may be offered in rural settings.
Let’s use a common situation to illustrate how this framework can help design and implement healthcare services and policies in rural settings.
Scenario: A woman is eight months pregnant with triplets and requires her next regularly-scheduled ultrasound examination/review, but the nearest clinic setting is a good distance away. The following facets should be considered when attempting to envision a set of healthcare services to meet such needs:
Population: Does the rural facility offer a full suite of services that targets pregnant women? Or does it need to collaborate with other service providers in order to cover the special requirements for handling triplets? Do the woman and her provider share a common language – or must a translator service be engaged?
Technology: Can the pregnant woman use home-based, remote-access technology to provide data to the provider, perhaps from a home medical device or a mobile fetal scanner) to provide raw data or to communicate (via audio and video) with members of her care team? Does the facility serve as a remote station for a large, well-equipped host provider – perhaps via telehealth consultations? Is the proposed technology too expensive for the rural service provider?
Access: Does the pregnant woman – and specific members of her caregiving team – have a means of being transported to the care facility? Is there a cultural expectation that care will only be offered by a female caregiver? What if a religious constraint prevents the key caregiver from traveling to the care site on a particular day (whereas as alternate caregiver can more easily be identified and engaged in an urban setting)?
Payment: Does the woman’s insurance carrier cover face-to-face care differently than for a telehealth consultation. Can she pay for the service out-of-pocket? Does the provider have a full suite of means by which payments can be accepted remotely (such as a bit coin or cash)?
Service: Does the caregiver offer auxiliary services (such as a visiting nurse)? If the woman has a problem with alcohol, does the caregiver provide counseling services?
Regulatory: Are telehealth services reimbursable to the provider, and therefore, more available to the pregnant woman – or will the woman be expected to cover such services costs out-of-pocket? What if those telehealth services cross county or state boundaries? Do regulations prohibit the provider from accepting measurements from home-based healthcare measurement devices (such as the collection of daily weight via a bathroom scale) and disallow billing for such services?
Education: Does the healthcare provider need specialized training for providing care through the use of mobile technology when teaching a newly expectant father and mother about the various stages of pregnancy?
Condition Severity/Duration and Impacts: Might the woman need childcare service assistance for her other children while she visits her caregiver. What is the impact of the loss of one (or more) day’s wages to the woman and her family if she needs to receive care at a remote facility?
Economic: Are the number of women that can be served in a remote ultrasound facility sufficient for the solution be deemed economically viable? Or is a mobile ultrasound vehicle linked via telecommunications to specialists needed/ would an increased use of telehealth solutions mitigate the lack of access to care in remote regions and is such a service economically viable for the caregiver?
Special Interest Groups: Are grants available that can help purchase mobile ultrasound vehicles? Are special programs available and accessible to pregnant women (e.g., WIC (Women, Infants and Children) Nutrition Program) in remote settings? Does the woman have the knowledge and ability to secure ancillary services (e.g., to use communications technology to locate the nearest available midwife)?
This framework should help when solution requirements are being envisioned or gathered, when policies and regulations are being analyzed and formulated, when a solution is being re-engineered, or when a solution is be evaluated for possible sun-setting (e.g., to accommodate a new architecture). Not all facets are likely to apply to each category of healthcare scenario.
Finally, though this framework includes a fairly complete set of facets, it is also designed to be extensible (e.g., perhaps including additional facets that address information retention, natural / manmade, interruptions, relative costs versus return-on-investment, or synergistic infrastructure-related opportunities). The framework may serve as a healthy, cogent approach for addressing healthcare in non-urban settings.
John Ritter, Healthcare Standards Architect; HIMSS Program Director (Western Pennsylvania), volunteer with HL7, ISO TC215, HIMSS, and ONC S&I Framework.
Kalyani Yerra, MBA, MHA, PMP, CPHIMS, Sr. Technical Architect, Premier, Inc. HIMSS Health IT for Rural Health and Underserved Work Group member
Gora Datta, Chairman & CEO CAL2CAL Corporation, HL7 International Ambassador & Co-chair HL7 Mobile Health, Vice-Chair, IEEE Orange County Section
Special thanks to the HIMSS HIT for Rural Health and Underserved Work Group Volunteers
- Chairperson – Gora Datta, Chairman & CEO CAL2CAL Corporation, HL7 International Ambassador & co-Chair HL7 Mobile Health, Vice-Chair IEEE Orange County Section
- John Ritter, Healthcare Standards Architect; Volunteer at HL7, ISO TC215, HIMSS, ONC S&I Framework.
- Kalyani Yerra, MBA, MHA, PMP, CPHIMS, Sr. Technical Architect, Premier, Inc.
- Roger Shindell, MS, CHPS, Founder, President, CEO, Carosh Compliance Solutions
- W John Gachago, e-Health Consultant, JWG Global Ltd.
- Larry Rine, CEO, Intersect Healthcare Systems
Ian E. Hoffberg, Manager, Healthcare Information Systems (HIS), HIMSS North America
If you have comments, please contact Ian E. Hoffberg at firstname.lastname@example.org