Technological Innovation in Rural Health and Human Services Spaces, with Dan Shane

Organizations and resources mentioned in this episode:

• Rural Policy Research Institute (RUPRI)
  • RUPRI Center for Rural Health Policy Analysis
• National Advisory Committee on Rural Health and Human Services (NACRHHS)
  • Technology Innovation Supporting Access to Rural Health and Human Services: Possibilities and Encouraging Further Investments, Final Committee Report, October 2024

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. Today I'm speaking to Dr. Dan Shane, Associate Professor with the RUPRI Center for Rural Health Policy Analysis. Thank you for joining us today.

Dan Shane: It's great to be here, Andrew.

Andrew Nelson: In early 2024, the National Advisory Committee on Rural Health and Human Services engaged the Rural Policy Research Institute to help analyze how technology can help to provide access to rural health and human services. The research you did resulted in a policy brief entitled Technology Innovation Supporting Access to Rural Health and Human Services: Possibilities and Encouraging Further Investments. It was published in October of 2024. Can you tell us about how you embarked on that process?

Dan Shane: This was a little bit of a curve ball that came our way in early 2024, but the truth is, it ended up being right in our wheelhouse, given all our connections with rural hospital administrators [and] folks who are active in various spaces in the healthcare sector. So, we really embrace this, and I'd like to talk about it, as we went on a listening tour of various constituencies in the rural health space — a lot of rural healthcare administrators of Critical Access Hospitals, folks who are involved with consulting efforts, folks involved on the insurance side of the business with respect to rural healthcare. Just having those conversations, listening with the prompt that we're interested in learning about, "How is technology helping you today, and more importantly, as you look at what your challenges and priorities are for the future, where do you see technology playing a role? Or do you see technology play [a role]?" The short answer is, everybody sees technology playing a role, but it was a fascinating process to learn where the folks are living and breathing in these rural communities, vis-à-vis some of the fancy technology. We're all aware of, "Well, this is going to be great. We're going to make these sweeping changes." But sometimes there's a reality check that we discovered along the way. So, we engaged with these stakeholders prior to the April meeting, and that helped us set the agenda in terms of, "Who do we need to be talking to? Who might be the connections that that will really help these folks?" Ultimately, our goal is to help improve these people's lives, improve their health, help the community in terms of the services that they provide. And I thought we were able to pull together a pretty nice agenda for folks to really engage with these questions.

Andrew Nelson: After identifying some of those groups, you found that many rural health and human services providers and community-based organizations had several specific short-term priorities. Can you tell me about some of those priorities and how technology can be helpful in addressing them?

Dan Shane: Absolutely. In discussions that we had, it probably comes as no surprise that workforce was a topic that came up again and again and again, and for different reasons. First and foremost, it's about access. So, how can these rural health communities — rural hospitals in particular — how can they improve access? And if that means trying to leverage technology to assist that, then that's what they're going to do. So whether that's actually using technology to save time, one of the innovations that I heard multiple times was, "Can we save physicians time?" meaning if they're with a patient, with note-taking or entering in the electronic health record, that's a time sink for these rural physicians.

So that was one of the areas where, if we can save the physician time, that's hugely valuable, that improves access. That's more visits for folks in these rural communities. The other area was thinking about the ways, in terms of leveraging telehealth or existing virtual services, where it might be really challenging to get some specialty services to recruit physicians to work in a rural hospital, right? Ones that came up consistently were gastrointestinal, oncology; those are really going to be challenging. And that's likely an area where they pointed to the virtual services or telehealth services as an area where that's a priority for them. "Give us more." That was the consistent theme when it came to those telehealth services.

Andrew Nelson: You also found that there was an emerging priority, something that hasn't necessarily been a concern for that long, but it's become more and more important in recent years. What was that?

Dan Shane: Cybersecurity. It's probably not on the top of anyone's top five list of important news stories of the year, but when it hits, it can be really, really damaging for a rural hospital. And more specifically, what I mean is the ransomware attacks where these entities come in and essentially take hold, take hostage, their electronic health records, the entirety of their system, and demand compensation before releasing and allowing them to continue to operate as normal. And it's a problem everywhere. But for these rural communities, these smaller hospitals, the risk is just that much greater. Maybe their security systems, the existing security, isn't quite what they need to ward off some of these ransomware attacks. And then bouncing back right from the aftermath of these attacks, it's putting these hospitals in a really difficult financial situation. And they were already, in some cases, in tough financial situations anyway. So, the worry is that this could lead to hospital closures, and that's long been an ongoing concern for the rural healthcare community.

Andrew Nelson: What are some forms of existing technology that have recently been especially impactful in improving health outcomes for rural people? And what are some ways in which we can increase investment in those technologies?

Dan Shane: Great question. And I think the short answer is telehealth. The hospitals, the rural health administrators that we spoke with were very favorable and excited about the telehealth services that they've been able to leverage, and again, telling us, "We want more." And I think it's important to understand that there's barriers to some of these services. So, the community — as we talked about these circumstances — identified that, "Well, who has to be in the room?" So, if you think about telehealth, we're connecting a patient via technology to someone who's in a different location, maybe an urban center, easy. Well, it matters where you are and where the physician is. So, I can't necessarily take advantage of that telehealth service from my home. For the hospital or the physician to actually get compensated, I might have to go to the hospital. So there's opportunities to reduce some of these barriers to improve access to just the existing telehealth services. The hospitals themselves also face some regulatory barriers in some circumstances there needs to be certain people in the room, in the local, the rural hospital, to connect with maybe a GI expert, or an oncology expert, somewhere in a more urban center, or something along those lines. So, it's existing technology, it also relates to questions about, "How good is the connectivity?" So, we need to make sure that the connectivity is good. Hospitals — that's less of an issue if they've got established connectivity — but in some cases, that's another barrier as well.

Andrew Nelson: In the last few years, or recently, have there been any new technologies that stood out to you as being especially valuable in leveraging improved access to rural healthcare?

Dan Shane: I think this is one that has the attention of some of the large tech companies, the Apples and the Googles of the world, is remote monitoring. So, taking advantage of these small mobile devices that can keep tabs on patient characteristics. So, we're already seeing it. If you're out and about, you might see somebody with a device on the back of their arm, [they] might be somebody that is diabetic, and it's real-time monitoring blood sugar levels, et cetera. So, this remote monitoring technology can really take this to another level in somebody's home. And it's folks who might have multiple chronic conditions that might benefit, folks that are in more consistent need of accessing healthcare services.

It requires a pretty hefty broadband to be able to make these work. So that's a real issue. Take two pieces of this: the rural providers, what's their comfort level? And then the patients themselves, what's their comfort level? And it brings up a real important issue, that one of the real concerns with technology that emerged from our conversations was, "Are we taking away a key source of community?" Their visit to their primary care provider or visit to the clinic or what have you, that's a real opportunity for connection and a sense of community. So, it was one of the reservations that was provided to us, that we don't want to lose that, right? We really think that's an important part of our rural community. So there's some trade-offs with some of these new technologies as well, from a community perspective.

Andrew Nelson: Yeah, of course, we want to maximize the quality of care that people have. But for a lot of people, especially as we see rural loneliness in rural spaces is becoming more and more of an issue, having that kind of face-to-face interaction with the provider can contribute to the overall quality of that care.

Dan Shane: Yeah, great point. Loneliness is now a public health emergency, right?

Andrew Nelson: Yeah. Prior to attending the National Advisory Committee on Rural Health and Human Services meeting last April, some of the conversations you had with rural stakeholders allowed you to develop some proposed actions the Department of Health and Human Services could take, and some of those proposals were more urgent than others. Can you talk about some of those?

Dan Shane: Number one was broadband. I think that in this group, it was really important to the group to send the message that the only way that we're going to be able to leverage technology in a successful manner for rural stakeholders is to improve broadband. And the truth is that the Bipartisan Infrastructure Law already has a lot of investment in the pipeline. But I think what was key was to put on the table [was] that, this is a public health emergency, right? This is really important, because maybe the first thing you think about with respect to improving broadband isn't healthcare or isn't human services, but it's vital. So that was one of the key takeaways that the group really wanted to make clear.

Another was, I mentioned telehealth services, and during the pandemic, there were some adjustments in reimbursement, which led to better pay for telehealth services, [in] some cases, pay for the first time for telehealth services, for certain instances of care. And another key takeaway was the vital need to focus and make sure that these services are supported and can support the professionals, right? The providers, the hospital, so that they're getting reimbursed for these services. And as I mentioned, some of these intricacies and some of these logistical hurdles about, "Where do I need to sit as a patient?" versus, "Who needs to be in the room with me?" And those are urgencies that we wanted to make sure were put forward. So those are the recommendations that the group put forward. HHS ultimately is the decision maker. They've taken this information, and they'll move forward as they see fit. But those are a couple areas where it came up again and again during our meeting and during our conversations, broadband and making sure that folks are getting paid for these virtual or telehealth services. In that meeting were also folks representing rural communities in various aspects. So, there was a really broad representation in the NACRHHS meeting. So, when I talk about those conversations, it was inclusive of both the meeting itself, as well as conversations that we had prior.

Andrew Nelson: When you attended the National Advisory Committee on Rural Health and Human Services Conference in April of 2024, it seems like you had some really fruitful conversations with the committee regarding how technology can be leveraged to improve rural health outcomes. After having those conversations, what further suggestions for policy action did you come up with?

Dan Shane: When we say folks are falling behind in terms of broadband connections, the standard keeps getting faster and faster. So that was one of the other points that came out of the meeting, and we can identify what's necessary to establish telehealth services or remote monitoring, but quickly that's going to be outpaced. So broadband came up again and again. Another area where the discussion in the meeting was really beneficial in listening to folks who are living and breathing in the rural communities, [was] understanding the access issues that are at stake, as well as some of the infrastructure issues.

So one of the key points that was made and came out of the meeting was that the rural hospitals often are lagging behind in terms of their digital infrastructure, meaning the technology they're using for their Electronic Health Records is putting them at a disadvantage, compared to a large urban healthcare system, to take advantage of some of the latest innovations. One thing that really came out of this was, "How can hospitals, how can healthcare systems, leverage their own information?" If we can use and mine our data to understand what patient populations are most at-risk, we can get ahead of some of the health issues that pop up. So, one of the recommendations was to find ways to leverage the technology situation with maybe a larger system.

And one of the recommendations was to try to take advantage of what's referred to as a hub-and-spoke model. So, a larger regional hub healthcare organization can be leveraged to assist with smaller rural hospitals that are in their orbit. One of the issues, and one of the opportunities that came up, was having these organizations leverage their relationships with these large digital healthcare organizations to roll out these more advanced digital infrastructures to the rural communities. It's expensive, and there's no easy answer, but that if we want to get those innovations out into those rural communities, we've got to leverage those relationships, those partnerships, those collaboratories was a word that didn't seem like a word, but came up again and again, collaboratories.

And one of the areas that was very interesting, and one of the recommendations that came out, was to use Health and Human Services, the Department of Health and Human Services, as a convener, right? To use the power of a national organization to bring people together to talk about these solutions. Essentially, the meeting itself was so valuable. We were thinking that, well, "Use HHS to bring these large and these regional and these local organizations together to discuss best practices, or better practices, in these situations."

Andrew Nelson: One of the recurring issues that we see in rural healthcare or human service spaces, is the workforce, limited workforce. What are some ways in which technology can help to offset those problems?

Dan Shane: The workforce issue came up again and again, and [that's] an area where I think there's a lot of hope with respect to offsetting or using technology to assist with workforce issues. And I'm going to speak first about physicians. Because the physician shortages are an issue across the country, but they're much more acute in rural America. And to pile onto that, the aging of the physician workforce is a bigger issue. So not only are the shortages greater in rural areas, the average age of physicians is higher. So, it's not only an issue, it's going to become a bigger issue in very short order. The first question that that often came up from rural hospitals and administrators was, "How can we leverage technology to make our physicians more productive?"

These folks were at some of the forefront of testing out what's called ambient listening technologies. So if the physician can just be having a regular interaction with a patient during a visit, and in the background, there's technology that is essentially transcribing everything that's happening, all the discussion, all the information, all the recommendations, and critically, if that can actually then be transported and digitally captured in the electronic health record, that's absolutely gold. And the truth is, it wasn't quite there. I know there's been a lot of improvements in the ambient listening technology, but most of the folks that we talked to said it wasn't quite gameday ready; getting closer, but not quite gameday ready. Because, it's one thing if it just does everything, wraps it up, gets it in the health record, it's coded so that it can be set to billing. We know what happened, we know what was prescribed, all of the above. But if it's in a state, if it's a state where it's essentially just capturing everything, and somebody still has to go in and edit and make sure that we only get the important points out of this interaction between provider and patient, then that's still a lot of work for somebody. So until it can really reduce the time that a physician has to spend on non-patient activities, it won't be the game-changer that maybe folks might hope it is, but it's getting closer. Even at the university hospital that's right across the highway from me, they're piloting that ambient listening technology right now, and I'm hearing mixed reviews.

Andrew Nelson: I've definitely heard from other people how that can potentially really speed up the process of determining the issues a person's facing and figuring out the best course of care for them. How can some of the existing alliances between hospitals, human service providers, and community-based organizations, develop and evolve to better share resources and encourage innovation? In particular, how can larger healthcare systems help to support smaller ones?

Dan Shane: This is a really important aspect of both the conversation that came out of the National Advisory Committee meeting and just conversations that we had with the rural stakeholders. It's never going to be successful if we expect the technology, the innovations to roll out hospital by hospital, it's just not going to be a successful model. So there has to be leveraging of some of the larger organizations and/or the smaller healthcare hospitals, the rural hospitals joining together in order to leverage their resources in a couple different areas. And one might be buying power. Let's take the ambient listening technology, right? So that if there's a vendor that's got a really cutting edge ambient listening technology, it's a much better situation for a group of rural hospitals to essentially be their own buying unit. Maybe in North Dakota and Iowa, South Dakota, Nebraska, there's an actual organization that brings those together and is able to leverage the combined power, the combined resources of those folks and all of the interested parties in order to negotiate a better rate with that vendor. Not only that, but that vendor then is able to roll that out in concert with that regional organization.

The other piece of this is the point I've referenced a couple times, with regard to the digital infrastructure. So, we had conversations with a large healthcare system out west; they were leveraging their relationship with one of the top digital electronic health record vendors and allowing that relationship, essentially giving access to that relationship with the cutting-edge electronic health record vendor for the rural hospitals that were part of their network. And it wasn't an ownership. This was just, "We see an opportunity for a mutual relationship. We've shared resources, so we're going to put you in contact with this electronic health record vendor. We're going to essentially upgrade your digital services and then opportunities to improve the back end of the system, to take advantage of some of the algorithms that can be leveraged with respect to better digital infrastructure." That's what's coming. And that's what a lot of the largest healthcare systems are already making use of. And again, this goes back to mining your own data. How can we use technology, AI algorithms, to look at our own data and tell us who's most at risk? Where do we need to be putting our resources? That only can happen with those large healthcare systems assisting [and] developing those relationships with some of their smaller partners.

Andrew Nelson: Speaking of infrastructure or organizational needs, did you find that human services and healthcare providers have different organizational or infrastructure needs?

Dan Shane: Without question. One of the biggest takeaways was just how difficult from the human services side, how difficult it is to connect across organizations, across services. Despite some of the challenges that I've noted within healthcare, you have the digital health record, right? You have the electronic health record that somebody across the country can immediately access, and the information is there. Everybody can share it, obviously with existing information protections. That doesn't exist on the human services side. If I want to apply for food stamps for food services, if I want to apply for some kind of a long-term care, if I want to think about the issues related to transportation.

One of the biggest points of emphasis was, there really needs to be a common intake form. Collect the information that all patients, all residents, all community folks would need and allow them to connect to any point of service that they might benefit from. So that common point or that common intake form, that was one of the recommendations that we put forward as a committee, was to have HHS really push that, and to make it much more user friendly.

So, another area, another piece under the umbrella of human services is unemployment. And sometimes unemployment can be just amazingly cumbersome. One of the anecdotes that sticks with me constantly is that the application for unemployment in California was something like 240 questions. [It] just evolves over time, and various groups want to be able to collect information, but it just puts an unbelievable onus on someone who's at a difficult stage anyway, to apply for something that by all rights, it would be pretty obvious that they qualify for. So how to make that easier, how to think about making life easier for the folks who can benefit from these services? That was really one of the important takeaways. This isn't fancy technology, this is just taking advantage of existing infrastructure, making it just much easier to leverage what services are already available.

Andrew Nelson: Capital funding can often be a challenge for rural organizations looking to innovate or implement new technologies. What did you learn about capital funding markets and new options that rural providers have to access capital?

Dan Shane: I think that this was an interesting conversation, and this was an area where I learned a whole lot myself from the folks that we had join us at the NACRHHS meeting. Where the focus was on what was termed the middle market for these capital markets, so not the huge folks that are operating in the hundreds or even millions of dollars. It's this middle market of capital that's looking for innovators, was how they termed it. Somebody who's got proof of concept of an idea that can really make a difference in patients' lives and helping that innovator get to scale, get to a place where they're going to be able to be compensated, to get a return on their innovation, to the point where this is going to be a viable business concern.

So, this isn't just a one-off. That situation where we can't get to scale in order to offer these services to a broader part of the community. So, it was fascinating. And there was some really good proof-of-concept examples, one of which was for an investment into an organization that was trying to provide at-home dialysis services in rural areas. So, the availability of dialysis services for folks who need this is a major concern. And it was an example of someone who had a real innovation when it came to at-home dialysis service, which is not easy. What it takes for somebody to be able to help with at-home dialysis is no easy feat. So the technology and connecting the right folks and leveraging the capital to get this to scale was the point of this.

Another was folks with some behavioral or developmental disabilities using leveraging technology to have those folks be still independent for much longer part of their lives. So it's helping social workers and various healthcare professionals, leveraging technology to help them essentially have a broader reach in terms of folks who are living independently. And this was another area where the recommendation was, have HHS be the convener, bring folks together or disseminate these sources of funding that are out there.

The final one that I'll mention, and again, this was a really great learning opportunity for me, was the philanthropic organizations that are out there, that are really looking to make inroads and to assist. And it's just a matter of connecting the folks who have the need with the folks who want to make a difference, and in some cases it's just not happening. So using HHS to be that convener, whether it's a national meeting or whether it's regional meetings or whether there's some kind of state regional sub-organization that can assist with this, that there's more resources out there than I think folks are aware of.

Andrew Nelson: Part of the picture is definitely making sure to get the money that's available to the people in need [of] it the most; where it can have the greatest impact in the years to come. What technological innovations do you think will be the most helpful when it comes to enhancing rural healthcare and services?

Dan Shane: You're not going to be surprised necessarily with what I think are the areas where innovation can really make a difference, given our conversation thus far. But I think really pushing the envelope with respect to the virtual services and the telehealth services in the areas where it's just very unlikely that the rural hospitals or Rural Health Clinics will be able to recruit physicians to fill the existing need. There's a few proof-of-concept ideas that I think will really push this forward, leveraging the expertise available maybe in the large urban healthcare system with the small rural hospitals that are in their orbit — really pushing that out.

And this brings up another element that I don't know that I've touched on — the rural hospitals are very cognizant of not wanting to be put in a situation where they're essentially just going to offshore or outsource their key services. They want a partnership. They don't want to be put in a situation where they're going to give up some of their key revenue generators, for obvious reasons. They're already under financial strains. So they're really looking for opportunities to expand their services and bring the care to their communities, to their folks who don't have access to it. So it's using their hospital as the hub of telehealth.

The other area where I think we're going to see just huge leaps and bounds in the coming years are these wearables and the impact that they're going to have on the connections to the providers, connections to the healthcare services. They're getting better and better. I mean, the watches that we're wearing that have grown by leaps and bounds. They can be the canary in the coal mine for somebody who's experiencing health issues and even with respect to some heart arrhythmias and things along those lines. And I think as the healthcare providers, the healthcare institutions, you sort of make peace with this.

I think we're going to see a big push along those lines as well. And it's going to matter where you live, that if you're within an hour of a large urban metro area, then it's coming. The truth is that in the Iowas and the South Dakotas and North Dakotas where we don't have a huge urban area, urban center — like a Chicago or Atlanta or Los Angeles — it may take a little bit longer for that to diffuse out there, but I think that's an area we're going to see a lot of advance in the next few years.

There's a lot of discussion of AI, the concept of AI. The truth is that, particularly with rural hospitals, they're not there yet. And it goes back to the issue of, the infrastructure's not there, right? They need to get to a point where the blocking and tackling phase needs to be borne out and fleshed out and improved before they're able to take advantage of some of this AI, the algorithm-driven technologies that are starting to roll out.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Dr. Dan Shane, Associate Professor with the RUPRI Center for Rural Health Policy Analysis. Look in our show notes for more information about his work and visit ruralhealthinfo.org for all things pertaining to rural health.