Rural Life Expectancy Policy Brief

1 May 2023

Prioritizing the expansion of electronic medical record interoperability

software to rural health care systems

Authors: Dennis Boynton

, Morgan Block

, Madeline Merwin

, Anjali Chandra

, Eneka Lamb

Brian Doerr

, and Ada Pariser

Affiliations:

Michigan State University College of Human Medicine, Grand Rapids, MI, USA

Community Hospital Corporation, Plano, TX, USA

Introduction

The transition from paper to electronic medical records (EMR) has modernized and improved health care

delivery systems by enhancing the management of medical data as well as communication between

hospitals, insurers, patients, and clinicians. Recognizing the benefit of EMR software, federal funds were

distributed for the digitization of patient records through the HITECH Act of 2009.

This transition brought

about a myriad of EMR platforms, with hospitals across the country often utilizing differing EMR software,

creating new technology challenges. The advent of a vast number of EMR platforms has led to the

fragmentation of patient data across multiple platforms, making records difficult to access, as one EMR

system may not communicate with another. The lack of communication between different EMRs led to

the next revolution in health care data management through implementation of EMR interoperability

software. This allows providers to access patient records from outside health systems, as well as share

important information with providers at other practices. All data sharing is facilitated by the software

and can be done regardless of the EMR a practice utilizes (such as Epic, Cerner, etc.)

In 2016, the 21st Century Cures Act was passed, mandating that the Centers for Medicare and Medicaid

Services (CMS) prioritize the expansion of EMR interoperability software.

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With EMR interoperability,

clinicians more effectively manage patient care with information coming from both inside and outside

their health system. It has been shown that both providers and patients benefit from EMR

interoperability, as workflows are improved and patient care is optimized.

In one medium-sized hospital,

implementation of EMR interoperability in one aspect of patient care increased safety and revenue by a

margin of $370,000 within the first eight months.

Utilizing EMR interoperability software to its full

potential reduces errors in patient care and costs of duplicate testing through better inter-health system

communication, while improving preventative screenings and vaccine administration.

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Particularly for rural communities, EMRs are instrumental in delivering quality care to patients and

ensuring smooth transitions of care when patients seek treatment outside of their home community. Given

limitations posed by the small scale of rural health care systems, patients must often travel to larger

urban or suburban health systems that may utilize a different EMR platform. When rural patients seek

care at these larger institutions it is critical that their local providers can access a comprehensive review

of the care they received. Rural hospitals report more challenges in exchanging and receiving data with

health systems using various EHR platforms when compared to hospitals with more resources.

With

more than 46 million Americans living in rural areas,

hospitals in these regions serve many patients.

Despite their critical role in providing access to care, rural health systems consistently find themselves in

financial distress, with many struggling to keep their doors open.

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Already facing this burden, hospitals

serving rural communities often find it unfeasible to purchase the technological infrastructure necessary

for EMR interoperability. Beyond cost, implementation of EMR interoperability software is hindered by

2 May 2023

barriers such as poor integration with older EMR platforms, lack of staff training to solve software and

data issues, and concerns over data privacy and security.

Analysis

The struggles imposed by lack of EMR interoperability directly affect small, rural clinics in a very personal

way. A small family medicine clinic in Escanaba, Mich., has been facing these challenges for the last year.

During the transition to a new EMR system, clinic staff found they were deficient in appropriate training,

on-site assistance, and ability to transfer old records to the new EMR platform. During the initial rollout

period, they were responsible for the “backloading” of all patient medical charts into the new system, but

without adequate preparation time and no third-party application to transition the records, the clinic still

has not been able to complete this task. According to a nurse coordinator, “If we do not take it upon

ourselves to manually look up in an ‘old system’ when a patient’s last PAP, low-dose CT, mammogram,

or colonoscopy was done, then we miss opportunities to catch abnormalities and due dates for

screening.” Navigating past records slows clinic efficiency especially when clinics face staffing shortages,

causing existing staff to have more responsibilities (K. Vandeville, personal communication, Feb. 10,

2022).

Improving rural EMR interoperability is more than implementing the EMR system. In a 2017 data brief

from the Office of the National Coordinator for Health Information Technology, only 27 percent of rural

hospitals and critical access hospitals reported having the ability to participate in the four domains of

EHR interoperability: sending, receiving, finding, and integrating summary of care records. This is

significantly less than the 41 percent of hospitals that reported having similar capabilities nationwide.

Additionally, despite some allocated federal funding from CMS and demonstrated benefits of

interoperability, only 24 percent of health care systems use application programming interfaces (API) to

scale, while 90 percent believe that interoperability would be helpful.

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When health care teams discuss a

shared patient, they prefer leveraging longitudinal data from an EMR for efficient, timely

communication.

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The National Rural Health Association (NRHA) recognizes the important groundwork

states have laid out to encourage interoperability among health information systems through health

information exchanges and other mechanisms. However, with a multitude of EMR platforms, accessing

patient data is often burdensome and inefficient, causing significant stress for providers trying to manage

care. Moreover, with the increased fragmentation of patient data over disparate platforms, suboptimal

and compromised patient care due to poor transitions is becoming more common.

Ineffective care

transitions have been implicated in increased hospital readmission rates, contributing to unnecessary

spending.

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NRHA agrees with health information exchange experts: “Complete participation and achievement of

interoperability is a key element to improving provider care quality and population health

management.”

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CMS has also expressed their support for enhancing interoperability by releasing their

EMR Incentives Program to the Medicare and Medicaid Promoting Interoperability Programs in April 2018.

This program recommends and, in some cases, requires payers to utilize API to improve the

interoperability of their preferred EMR. It has been argued that the implementation of API will improve

various aspects of patient care and medical office efficiency by reducing administrative roles for prior

authorizations and claims.

Policy recommendations

• Establish requirements for EMR vendors to enact a common language or share existing APIs

between EMR systems to ensure interoperability.

3 May 2023

• Promote the allocation of funding to resource-poor rural hospitals, community health centers,

rural health clinics, and other rural health providers for the purpose of upgrading and purchasing

infrastructure that allows EMRs to fully utilize API interfaces and become interoperable.

• Support federal legislation that enforces standardized security measures for all electronic medical

record software.

• Establish and train an IT staff member at each regional hospital dedicated to the maintenance

and optimization of API and EMR interoperability software.

Recommended actions

• Develop requirements for EMR vendors to enact a common language or requirements to share

existing APIs between EMR systems to ensure interoperability.

• Allocate funding to rural health systems to implement these technologies within their frameworks

through federal and state grant funding, as well as Medicaid programs.

• Allocate funding to resource-poor rural hospitals and health systems for hiring experienced EMR

specialists to train physicians and staff on how to better use their EMR.

• Develop a federal language regarding security standards for EHR interoperability to enhance

security of personal health information through the Office of the National Coordinator for Health

Information Technology.

Conclusion

Many rural health systems currently do not have any EMR interoperability software or are not utilizing

such software to its full capacity. Studies have shown that this lack of utilization poses unique challenges

for rural facilities. A review of the literature shows that this issue may stem from lack of resources or

training from an EMR specialist. Therefore, we advocate for NRHA-sponsored legislation creating a

stimulus that allocates funds for rural hospitals to better utilize EMR interoperability software. Studies

have shown that through proper utilization of EMR interoperability software, patient care and safety can

be improved and unnecessary use of resources will be reduced, thereby reducing costs for hospitals.

4 May 2023

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