Health Information Technology in Rural Healthcare
Health information technology (HIT) is an important tool to improve the quality, safety, effectiveness, and delivery of healthcare services in rural communities. HIT can connect rural patients and providers in remote locations to specialists in urban areas. Implementing, maintaining, updating, and optimizing HIT can be an ongoing challenge for rural facilities and providers with limited resources and expertise.
HIT uses technology to store, secure, retrieve, and transfer protected health information electronically within healthcare systems and community settings. Key components of HIT can include:
- Electronic health records (EHR) for patients, instead of paper records
- Secure digital networks to send and deliver up-to-date records whenever and wherever the patient or clinician may need them
- Electronic transmittal of medical test results
- Telehealth applications to increase access to providers
- Telemonitoring applications that allow patients to transmit vitals or diagnostic information to providers remotely
- Confidential and secure patient health portals for patients to access their personal health information online
- Electronic communication between healthcare providers, as well as patients
- Electronic prescribing and ordering to help avoid medical errors
- Decision support systems to provide clinicians with information on best practices and treatment options to improve quality of care
- Mobile devices and tablets to update patient records in real time and document at the point of care
Frequently Asked Questions
- Are there HIT resources specific to rural facilities?
- How can HIT improve healthcare delivery and the quality of care in rural facilities?
- What are considerations for rural facilities when implementing and upgrading EHR systems, including working with vendors?
- What is the relationship between HIT and telehealth?
- What are some HIT funding opportunities for rural providers?
- To what extent have rural hospitals adopted EHR systems?
- What are some HIT workforce issues in rural facilities?
- How have rural HIT networks contributed to their members' success in implementing HIT?
- What is HIE and how does it work?
- How do rural providers exchange information with other providers?
- How do we ensure the security and privacy of our electronic information?
- How can providers engage patients in electronic health information?
- Why is broadband important for HIT? How can we tell if broadband is available in our community?
- We have limited broadband in our area. What are our options?
Are there HIT resources specific to rural facilities?
Yes, there are many rural specific HIT resources available, including:
- The Office of the National Coordinator for Health Information Technology (ONC), within the U.S. Department of Health and Human Services, provides a Health IT Playbook that acts as a guidebook for healthcare professionals on using HIT. It includes a section on Rural Health Resources that provides information on the benefits of HIT in rural areas, barriers to HIT adoption and implementation resources, and tools and resources for Critical Access Hospitals (CAHs) and other rural hospitals.
- The National Rural Health Resource Center (NRHRC) provides an online HIT section of their Resource Library that lists upcoming events and a searchable list of HIT resources.
- The Agency for Healthcare Research and Quality (AHRQ) maintains an online Tools and Resources section, as part of their Digital Healthcare Research section, that provides resources for planning, implementing, and evaluating HIT.
- The National Rural Health Association (NRHA) maintains a listing of HIT resources that provide information and connections for HIT implementation, use, and support for rural areas.
The Federal Office of Rural Health Policy's Rural HIT Workforce Program grantees developed rural HIT workforce curriculum resources. These courses can be used by rural-serving community, vocational, and technical colleges in preparation for HIT certifications and to provide guidance for instructors. Educators are welcome to adapt and build on these training materials. The grantees' training programs were designed so that others can adapt and build on these training materials to fit their program's needs.
For rural project examples that have demonstrated success, see RHIhub's Models and Innovations under the topic of HIT.
How can HIT improve healthcare delivery and the quality of care in rural facilities?
HIT works to ensure efficient, coordinated, and secure healthcare information exchange for patients who receive healthcare services from multiple providers or in multiple locations.
A 2018 article, Health Information Technology Continues to Show Positive Effect on Medical Outcomes: Systematic Review, found over 80% of the reviewed literature shows positive effects of HIT on the efficiency and effectiveness of medical outcomes.
HIT allows patients the opportunity to engage in the provision of their healthcare by tracking health conditions, accessing provider visit notes, and test results. However, broadband access for rural residents can be a barrier to engaging with their health records. The Federal Communication Commission’s (FCC) 2020 Broadband Deployment Report notes that in 2018, approximately 22.3% of rural residents and 27.7% of Americans in tribal areas did not have access to fixed broadband services that met the FCC’s minimum speed benchmark. The 2018 Journal of Rural Health article, Differences in Access to and Use of Electronic Personal Health Information Between Rural and Urban Residents in the United States, reported rural residents had less regular access to the internet and were less likely to manage personal health information online or email healthcare providers.
The Rural Monitor article, Making the EHR Work: Rural Healthcare Organizations Use Data Extraction to Improve Patient Care, discusses how rural organizations are using their electronic health record (EHR) data to address population health issues. Kentucky's White House Clinics, for example, used their EHR to identify an increase in cancer screening rates after the implementation of a new intervention program.
Quality data tracked and reported with HIT is an important component of value-based payment models such as Accountable Care Organizations (ACOs), Medicare Shared Savings, and the Quality Payment Program (QPP) as well as state Medicaid programs. RHIhub's Rural Healthcare Quality topic guide discusses quality and quality measures for rural healthcare facilities and provides additional resources and funding opportunities to address rural healthcare quality.
What are considerations for rural facilities when implementing and upgrading EHR systems, including working with vendors?
Considerable planning is necessary to ensure a good fit and optimal use of an EHR system. There are many considerations for rural facilities when selecting and implementing EHRs. Section 1 of the ONC Health IT Playbook includes information and resources and highlights EHR adoption and implementation steps:
- Selecting a vendor
- Contracting with a vendor
- Implementing and adopting an EHR
- Using your EHR
- Optimizing or replacing your EHR
ONC describes barriers rural hospitals experience related to EHR implementation that are unique to providing healthcare in a rural setting paired with related rural-specific HIT resources.
What is the relationship between HIT and telehealth?
HIT and telehealth are related and complementary activities. Both use technology to improve efficiency and the delivery of healthcare services in a healthcare system in different ways. ONC defines HIT as a broad term encompassing a compilation of technologies and programs to analyze, house, and share health information. Examples of HIT include electronic health records (EHRs), personal health records (PHRs), e-prescribing, online communities, and online patient and provider communications. The Health Resources and Services Administration (HRSA) Office of the Advancement of Telehealth (OAT) defines telehealth as:
using electronic information and telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, public health, and health administration.
For more information on telehealth, review RHIhub's Telehealth Use in Rural Healthcare topic guide.
What are some HIT funding opportunities for rural providers?
Funding specifically aimed to assist with HIT is limited, but many grant and loan programs focus on issues and initiatives that interplay with HIT, such as healthcare quality, access to healthcare, healthcare workforce, improving efficiency, broadband access, capacity building, and network development. Some funding opportunities may be able to pay for HIT as part of a bigger initiative.
Several federal organizations and agencies offer grant opportunities that support HIT:
- Agency for Health Research and Quality (AHRQ)
- Health Resources and Services Administration (HRSA), including the Federal Office of Rural Health Policy and Bureau of Primary Health Care
The U.S. Department of Agriculture (USDA) has loan and grant programs that will fund HIT initiatives, including:
- Community Facilities Direct Loan and Grant Program
- Distance Learning and Telemedicine Program Grants
- Rural Economic Development Loan and Grant Program
Other funding opportunities supporting rural providers and HIT exist. For example, the Universal Service Administration Company (USAC) Healthcare Connect Fund provides assistance to healthcare providers for eligible expenses related to broadband connectivity at a flat discounted rate of 65%. For more information on broadband funding opportunities, see We have limited broadband in our area. What are our options? If you have questions about whether or not a funding opportunity supports HIT, you can contact the agency or organization sponsoring the funding opportunity or program and ask if the opportunity supports HIT initiatives and expenditures. Some funding opportunities and programs may support HIT efforts with spending restrictions, such as what can and cannot be purchased or what the overall percentage of the budget or allotment can be used for HIT expenditures.
RHIhub maintains a list of federal, state, and foundation funding opportunities for HIT in rural healthcare. You can contact us at 800.270.1898 or firstname.lastname@example.org to request a list of funding opportunities specific to your project and location.
To what extent have rural hospitals adopted EHR systems?
Although nearly all rural hospitals have adopted EHR systems, according to the ONC's Health Information Technology Data Brief 42, Variation in Interoperability among U.S. Non-federal Acute Care Hospitals in 2017, only 27% of rural hospitals and CAHs were able to participate in all four domains of EHR interoperability—sending, receiving, finding, and integrating summary of care records—compared to 41% of all hospitals nationwide. In 2018, the national average rose to 48%. Additionally, the percentage of rural hospitals that indicated they lacked the technical ability to exchange patient health information to outside providers or organizations, experienced a cumbersome workflow to send EHR information, or had challenges exchanging information across different EHR platforms, was significantly higher than the national average.
|Rural Hospitals||Critical Access Hospitals||National Average|
|Source: Variation in Interoperability among U.S. Non-federal Acute Care Hospitals in 2017, ONC Data Brief 42, November 2018|
What are some HIT workforce issues in rural facilities?
A 2015 article, Health Information Technology Workforce Needs of Rural Primary Care Practices, surveyed rural primary care practices from 13 states to assess their EHR and HIT workforce resource needs. The survey identified the top five major workforce-related barriers to EHR/HIT use as:
- The prohibitive cost of consultants and vendors who understand the HIT needs of rural facilities
- Limited resources available for EHR and HIT training (this includes funds and time set aside for training)
- Difficulty finding and connecting with qualified candidates
- Trouble retaining qualified staff with EHR and HIT skills and knowledge due to a competitive market
- HIT career steps are not clear cut, which reduces interest in EHR and HIT training and education
As with any leadership role, succession planning for HIT leaders is an important exercise. Consideration should be given to how HIT activities would continue if HIT staff leave due to retirement or other reasons. Facilities might consider training and career ladder programs to prepare the next wave of HIT leaders or look to outsource some of their HIT management in the event they lose their internal capacity.
The HIT workforce is limited in rural areas and there has been a lack of adequate HIT workforce development in rural communities. A 2015 WWAMI Rural Health Research Center policy brief, Access to Health Information Technology Training Programs at the Community College Level, identified two barriers for recruiting rural students to community college HIT training programs:
- HIT job opportunities are limited in rural areas
- Potential rural students find it difficult to relocate or commute to on-campus programs
Rural Health Information Technology Workforce Curriculum Resources provides planning and educational programs to train rural HIT workers, including an inventory of curriculum resources that includes detailed course descriptions and training materials.
How have rural HIT networks contributed to their members' success in implementing HIT?
Networking can help rural hospitals and healthcare facilities manage HIT implementation. Rural HIT networks can provide many benefits, such as shared HIT staff, volume purchasing for software and training, health information exchanges (HIEs), and data analytics services. NRHRC provides a Health Information Technology Network Readiness Assessment, a self-assessment tool for healthcare leaders interested in forming a HIT network.
The Rural Health Information Technology Network Development (RHITND) Program, a three year pilot program funded by the Federal Office of Rural Health Policy from 2011 to 2013, helped to develop rural health networks that support the adoption of EHRs and HIT. Recipients of RHITND Program grants included the Health Care Coalition of Rural Missouri, which established electronic medical and prescription records, telemedicine capabilities, and HIT training for providers in rural West Central Missouri. Other RHITND Program grantees included Rural Health Partnership of North Central Florida and the Louisiana Emergency Response Network and the Louisiana Health Information Exchange. The RHITND Sourcebook provides an overview of every RHITND Program grantee.
Rural Health Innovation's 2018 Network Spotlight: Northeast Kentucky Regional Health Information Organization describes a rural HIT network, highlighting how it supports its members and overcomes challenges in a rural area.
What is HIE and how does it work?
HIE as sharing electronic health information that
allows health care professionals and patients to
appropriately access and securely share a patient's medical information electronically. ONC describes three
forms of HIE:
- Directed exchanges utilize secure messaging to send and receive information between known parties, usually healthcare providers or healthcare facilities
- Query-based exchanges initiated by a question or request of personal health information uses a data repository or record locater to find patient EHRs
- Consumer-mediated exchanges stem from a patient engaging in the delivery of their healthcare services by communicating pertinent health information
HIE allows providers to discuss, plan, share, and coordinate patient health information and care between multiple healthcare facilities. ONC identifies multiple HIE benefits for both patients and providers. The National Rural Health Resource Center's (NRHRC) HIE Toolkit provides information and resources on guidelines and requirements for HIEs.
In July 2019, the Centers for Medicare and Medicaid Services (CMS) announced Data Point of Care, a pilot API (application programming interface) program designed to provide physicians with historic claims data to fill in gaps in patient histories. Data Point of Care expands MyHealthEData, a government-wide initiative announced in 2018. MyHealthEData is a digital patient health information platform that allows patients access to their full healthcare records and the ability to control and make decisions on how their healthcare data is used. The MyHealthEData initiative is being led by the White House Office of American Innovation in coordination with multiple divisions of the U.S. Department of Health and Human Services (HHS), including CMS, ONC, National Institutes of Health (NIH), and the U.S. Department of Veterans Affairs (VA).
How do rural providers exchange information with other providers?
The electronic exchange of protected health information between providers is achieved in a number of ways. Traditionally, information that was carried or couriered in a paper or film format can now be sent to another provider in a digital format via HIE, EHR, or media, such as a USB memory stick. Information that was initially communicated through mail or fax can be shared via a HIE or EHR as a PDF or in a structured data file through Direct Secure Messaging. Just like in the paper-based process, all parties involved in the exchange of protected health information need to agree on the method and format of the data being sent and received.
Some rural hospitals contract out specialty services or other healthcare services not available at their facility. In these instances, imaging or other patient health information is exchanged electronically via a VPN (virtual private network) point-to-point connection. With advances in broadband connectivity in rural areas, images or test results can be sent much faster, which results in a faster turnaround time, ultimately improving patient care and safety.
How do we ensure the security and privacy of our electronic information?
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 created regulations to provide a minimum standard for compliance with privacy and security of health information. One of the requirements of the HIPAA Security Rule is to perform an annual risk assessment. This risk assessment should look at all of the administrative, physical, and technological risks your organization faces. It recommends a third-party be involved in the risk assessment to act as another set of eyes to identify any risks. Many agencies and organizations provide information and resources for providers, hospitals, and others to provide guidance on conducting security and privacy assessments:
- ONC provides a Security Risk Assessment Tool, SAFER Guides, and other resources on Privacy, Security, and HIPAA
- NRHRC has a Cybersecurity Toolkit for Rural Hospitals and Clinics
- AHRQ provides a Health Information Security and Privacy Collaboration Toolkit
- Health Industry Cybersecurity Practices: Managing Threat and Protecting Patients from the U.S. Department of Health and Human Services 405(d) Task Group includes practical cybersecurity guidelines for small, medium, and large health care organizations to cost-effectively reduce cybersecurity risks. Technical Volume 1 of this report is dedicated to cybersecurity practices for small health care organizations.
- The 2017 Report on Improving Cybersecurity in the Health Care Industry from the Health Care Industry Cybersecurity Task Force provides several small and rural hospital specific recommendations to address cybersecurity challenges
- The U.S. Department of Health and Human Services Cyber Security Guidance Material provides resources for HIPAA-covered entities on how to respond to cyber-related security incidents
- HIMSS provides multiple toolkits and resources related to privacy and security
- The American Hospital Association (AHA) offers a What's Your Cyber Risk Profile? 12 Considerations for CEOs fact sheet and other cybersecurity and risk advisory tools and resources
A 2017 Rural Monitor article, Cybersecurity: How a Rural Alaska Hospital is Safeguarding Its Patients' Information, identifies security and privacy concerns in rural communities and describes how healthcare providers in rural Alaska are protecting their patients' information.
How can providers engage patients in electronic health information?
HIT has significant potential to help patients engage more fully in their own healthcare. A 2019 ONC data brief, Electronic Capabilities for Patient Engagement Among U.S. Non-Federal Acute Care Hospitals: 2013-2017, found 60% of CAHs, 70% of small non-CAH hospitals with fewer than 100 beds, and 73% of rural non-federal acute care hospitals provide their patients the ability to electronically view, download, and transmit their health information. Patient engagement can happen at every interaction, both inside and outside the point of care. Online patient portals can be used to schedule appointments, review test results and immunization schedules, and request prescription refills. The factsheet, Using Secure Electronic Messaging to Support Patient and Family Engagement, lists many benefits secure electronic messaging can have for both patients and providers.
Two final rules were issued in 2020 to improve interoperability and provide patient access to their personal health data. The ONC Cures Act final rule implements the interoperability provisions of the 21st Century Cures Act to promote transparency in healthcare and patient control over their own health information. The Interoperability and Patient Access final rule establishes policies to allow patients to better access their health information and increase the exchange of healthcare data between providers, patients, and payers.
However, it is important for rural providers to be aware of challenges their patients might encounter in accessing their information. The NORC briefing paper, Understanding the Impact of Health IT in Underserved Communities and Those with Health Disparities, identifies challenges for underserved populations that are due to community and population-related factors, including:
- Limited health and technological literacy
- Language and cultural factors
- Comfort level in interacting with the healthcare system
- Access to technology and the internet
ONC's Patient Engagement Playbook is a resource for providers, hospital and practice staff, and others to learn successful strategies and best practices to increase patient engagement.
Why is broadband important for HIT? How can we tell if broadband is available in our community?
A January 2019 Congressional Research Service report, Broadband Internet Access and the Digital Divide: Federal Assistance Programs, defines broadband as high speed internet access, cable, fiber, satellite, mobile and fixed wireless, and other advanced telecommunication connections and services that give users the ability to exchange data at adequate volumes and speeds to support their information technology applications in a variety of fields, including distance education, public safety healthcare, and more.
The Federal Communications Commission (FCC) set a benchmark for a fixed service provider providing advanced telecommunications capability as a download speed of 25 Mbps and an upload speed of 3 Mbps. According to a 2019 Congressional Research Services report, 73.6% of Americans living in rural areas had access to fixed broadband services meeting the FCC minimum speed benchmark of 25 Mbps/3 Mbps in 2017. Broadband is integral in connecting rural healthcare providers using HIT applications to healthcare professionals, patients, and healthcare facilities.
Information on broadband availability in tribal areas is less certain. Government Accountability Office (GAO) reports published in 2018, Broadband Internet: FCC's Data Overstate Access on Tribal Lands, Tribal Broadband: FCC Should Undertake Efforts to Better Promote Tribal Access to Spectrum, and Tribal Broadband: FCC Should Undertake Efforts to Better Promote Tribal Access to Spectrum, share insights regarding the actual availability of broadband access in tribal areas.
The FCC map, Residential Fixed Internet Access Service Connections per 1000 Households by Census Tract, shows the number of residential internet service connections per 1,000 households. To determine the availability of fixed 25Mbps/3Mbps broadband deployment and broadband speed in your community, as well as other locations across the country, you can search by city and state, ZIP code, or a street address in the Residential Fixed 25 Mbps/3 Mbps Broadband Deployment map and the Residential Fixed Broadband By Speed map. Another broadband mapping tool, the Broadband Search Tool, is available from USDA Rural Development.
We have limited broadband in our area. What are our options?
There are a number of programs healthcare facilities or their local telecommunication provider may be able to use to expand broadband access in rural areas, including:
FCC's Rural Health Care Program,
administered by the Universal Service Administrative Company (USAC), provides funding to healthcare
telecommunications and broadband services for the provision of healthcare services. The purpose of this
program is to improve the quality of healthcare for patients in rural communities. Two separate funding
opportunities make up the Rural Health Care Program:
- Healthcare Connect Fund (HCF) Program provides a 65% discount on eligible expenses related to broadband connectivity to individual and consortium rural healthcare providers.
- Telecommunications Program offers healthcare providers a discount on telecommunication expenses based on the urban and rural price differences in your area.
The USDA also provides information and resources on investments in rural broadband and e-connectivity. A 2018 USDA document, e-Connectivity @ USDA: Broadband Resources for Rural America, offers a resource matrix highlighting 27 programs to serve as a guide for planning, researching, and implementing e-connectivity activities and projects. USDA offers many funding opportunities to expand telecommunication and broadband services, including:
- Rural Broadband Access Loan and Loan Guarantee Program furnishes loans and loan guarantees for the costs of construction, improvement, or acquisition of facilities and equipment needed to provide broadband services.
- Community Connect Broadband Grant Program provides funding to support the development of broadband services in rural communities.
- Telecommunications Infrastructure Loans and Loan Guarantees provides financing for the construction, maintenance, improvement, and expansion of telephone and broadband services in rural areas.
- Distance Learning and Telemedicine Program Grants provide funding to promote and improve telemedicine and distance learning services in rural areas using telecommunications, computer networks, and related advanced technologies. Grant funds can be used to purchase equipment and capital assets, including broadband transmission facilities.
Other funding programs and grants can be found on RHIhub's list of funding opportunities related to broadband, which includes federal, state, and private foundation funding opportunities.
Last Reviewed: 9/11/2020