California State Rural Health Association
Rural Providers and eHealth: The Future is Now
pRoduCed witH SuppoRt fRom tHe CAlifoRniA HeAltHCARe foundAtion And tHe CAlifoRniA ConSumeR pRoteCtion foundAtion
Rural Providers and eHealth: The Future is Now
The use of information technology as a tool to enhance health care quality, improve patient safety, and increase
efficiencies in our health care system has long been a core strategy to strengthen health services in rural areas.
In its seminal 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of
Medicine (IOM) recognized that the use of information technology is a key strategy for transforming the American
health care delivery system.i In its follow-up report published in 2005, Quality Through Collaboration: The Future
of Rural Health Care, investments in information communication technology was one of five key strategies
recommended to enhance health and health care in rural communities over the coming decades.ii Health care
technology has been mentioned as a cornerstone of health care reform in a number of contexts, and is a key
element of the United States Congress and President Obama’s stimulus financing package.
The current term to describe the intersection between technology, electronic communications, and health care is
called “eHealth.” This report provides a summary of the current eHealth environment in California of relevance
to California rural health providers and those that use the rural health care delivery system, identifies the
barriers and challenges associated with rural health providers successfully adopting eHealth technologies, the
opportunities currently available to rural health providers to overcome some of these barriers and a discussion
of the policy implications associated with these opportunities. Lessons learned about successfully adopting
eHealth technologies gleaned from the California State Rural Health Association’s (CSRHA) November 2009 Rural
eHealth Summit are also provided. The appendices include case studies highlighting three successful eHealth
implementations, and specific steps those working on rural health policy issues, including the California State
Rural Health Association (CSRHA), can take to provide leadership in the eHealth policy arena and links to relevant
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This report is the culmination of more than a year’s work by CSRHA and its affiliates examining rural eHealth
issues. The report was prepared for CSRHA by rural health consultant Speranza Avram,1 with support from CSRHA
Executive Director, Desireé Rose, CSRHA Policy Director, Steve Barrow, the diverse community-based rural
stakeholders who participated in CSRHA’s November 2009 Rural eHealth Summit, and the many experts serving on
CSRHA’s Rural Technology Advisory Committee (RTAC), identified in Appendix A of this report. Several individuals
contributed specific information and in-depth review of this report including:
Earl W. Ferguson, MD, PhD
Director, Southern Sierra Telehealth Network;
Director, Telemedicine Outreach and Rural Health care Development
Ridgecrest Regional Hospital
President-Elect, California State Rural Health Association
Director, United Health Group
Senior Policy Analyst for Special Populations, California Primary Care Association
California Telemedicine and eHealth Center
OSHPD, Health care Workforce Development Division
Director, Clinic Services
President, California Association of Rural Health Clinics
Funding for this report was provided by the California HealthCare Foundation and
the California Consumer Protection Foundation.
About the report’s principle author: Speranza Avram has been a leader in the field of rural health technology for close to twenty years. She
has directed several successful regional rural eHealth projects and frequently serves as a national speaker on rural health technology issues.
Ms. Avram works as an independent consultant and also serves as the Associate Director for the UC Berkeley School of Public Health Center
for Health Leadership. For more information, please visit www.speranza.us.
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CALIFORNIA eHEALTH ENVIRONMENT
The current eHealth environment in California is influenced by a combination of multi-year initiatives that are finally
bearing fruit and new financial incentives and resources that are designed to accelerate eHealth adoption. The large amount
of new resources available today, combined with short adoption timelines, have created a sense of urgency to implement
eHealth tools among those organizations who have not been early adopters of eHealth.
Over the past ten years, through funding provided mostly by private foundations, an array of initiatives such as The
California Endowment/Tides Foundation Community Clinic Initiative, the California Telemedicine and eHealth Center,
United Healthcare/PacifiCare Health Technology Grants, and the Blue Shield of California Foundation Health Information
Technology (HIT) Projects, over $100 million has been expended to help safety-net providers, including rural hospitals,
clinics, and other providers add eHealth tools such as electronic health records, telemedicine, and e-prescribing into their
clinical practices. The lessons learned from these initiatives are well-documented (see Appendix D of this document for a
list of resources and links) and share the following common themes:
• The adoption of eHealth technology is less about the technology and much more about the impact of this
technology on the workflow, culture, and operations of an organization. In other words, the installation of a
new eHealth technology is only the beginning of a process, not the end.
• A number of elements need to be in place to ensure a successful eHealth implementation, including:
sufficient financial resources, both short-term and long-term; committed and dedicated clinical and
administrative leadership at all levels of the organization; organizational readiness to change its internal
processes; and sufficient training and technical support both during and after installation to ensure
widespread and deep adoption.
• For most small to mid-size organizations, there are significant benefits to collaborating with other partners,
either on a geographic basis or through horizontal provider networks that span regions or even states.
Collaborating on eHealth adoption projects can offer cost savings through the realization of economies of scale in
purchasing and support costs, built-in peer learning of best practices and peer support, and potential reductions in
information technology (IT) infrastructure and administrative costs.
• The installation of a new eHealth technology alone will not improve health care quality. Data collected by
eHealth tools must be transformed into useful information that clinical providers can use for clinical decision-
making and quality improvement strategies to improve the efficiency, cost-effectiveness and quality of health
services in this country.
• Reimbursement must be restructured to enable and incentivize safety-net providers to fully utilize eHealth
technologies. Doing so will improve patient safety, enhance health care quality, reduce costs, and improve access.
For example, health care providers can use low-cost text-based reminder systems to encourage diabetic patients
to monitor their blood sugars to better control their diabetes and decrease the frequency of hospitalizations and
emergency department visits. Savings to the healthcare system for such activities should be shared with healthcare
providers who document improvements in diabetic care with new technologies.
Health providers in rural communities have additional challenges and barriers to eHealth adoption. Among the most
common cited in the literature are:
• Health IT Workforce Shortage. Rural health care providers face chronic workforce shortages across all health
professions disciplines, including HIT technical support personnel. Many smaller organizations do not have
dedicated IT staff – it is often a job-function shared by several individuals who are responsible for different aspects
of IT management. Sometimes IT functions are provided by clinical staff who manage these activities in addition to
their other duties. Recruiting IT professionals is as challenging as recruiting other types of professionals – most IT
workers prefer to live in urban areas for both lifestyle and economic reasons.iii
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• Limited broadband connectivity. The successful implementation of eHealth requires affordable, high-speed
broadband connectivity. Recent state and federal initiatives are beginning to address this barrier. However, as of
2010, large areas of rural California still do not have access to broadband.iv
• Insufficient access to financing. Most rural healthcare providers are in small, independent practices. Access to
capital financing for the cost of installing eHealth systems and revenue to cover the increased costs associated with
eHealth adoption is more limited for rural health care providers.v
• Loss of productivity impacts financial viability. The time needed for clinical staff to receive training in new eHealth
technologies, combined with work flow changes and the installation of new billing systems often results in “down-
time” that can last for days, weeks, and sometimes months. Most rural health providers rely on timely payments for
services, so any delay in billing can often cause financial strain on smaller providers, and can be a strong deterrent
to implementing eHealth technology.
• Insufficient vendor interest in rural markets. Most eHealth products have been designed for large, urban health
care systems. Affordable, high-quality eHealth products designed for smaller, less complex hospitals and out-
patient settings are limited, and most rural providers have minimal experience working with the eHealth
Despite the promise of eHealth adoption to significantly improve health care delivery and outcomes, adoption of eHealth
technology has not been as rapid as many have hoped, particularly among small and rural practices. For example, a
survey conducted by the California HealthCare Foundation in 2007 found that only 25% of individual physicians in
small and medium-sized practices used electronic health records (EHRs) and just 13% of solo practitioners were using
EHRs, compared to 57% of physicians in large group practices.vii Small and solo practices are the most prevalent types of
physician practices in rural California. A national survey by American Hospital Association in 2006 also noted that EHR
use was most prevalent in large urban hospitals, and that there were clear disparities in EHR implementation in small
and rural hospitals.viii
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NEW FEDERAL AND STATE eHEALTH AND BROADBAND INITIATIVES –
POLICY IMPLICATIONS FOR RURAL CALIFORNIA
There are three converging eHealth and broadband initiatives that have the potential to transform the delivery of health
services and significantly contribute to the economic development of rural communities:
1. Increased eHealth adoption. The push for health reform by the United States Congress and the Obama
administration has resulted in an unprecedented array of new resources, incentives and mandates designed to spur
the adoption of eHealth technology by health care providers.
2. Expansion of broadband connectivity. Federal stimulus funding and other funding is supporting nationwide
expansion of broadband connectivity. This includes the Broadband Technologies Opportunities Program,
the Broadband Implementation Program, and the Calling for 2-1-1 Act, as well as Federal Communications
Commission Rural Health Pilot Projects. This has driven a national push to build out broadband systems to
strengthen homeland security, improve disaster response, and support enhanced social service referral information
systems such as 2-1-1.
3. Use of broadband to expand access to services. The Health Information Technology for Economic and Clinical
Health (HITECH) Act and other ARRA programs are supporting intense federal and state activities to expand
access to services. These include planning efforts for “mobility management” to utilize broadband and new
information technologies to coordinate transportation planning necessary for people – especially low income,
senior and out of work citizens – to travel to health care and other social service support programs. Mobility
Management efforts are being linked with the expanding 2-1-1 system with a goal to provide comprehensive
community-based resource and referral systems to help sustain rural broadband.
Each of these initiatives and associated policy issues are described in more detail below.
At the national level, the Office of the National Coordinator for Health Information Technology (ONC) is coordinating
federal HIT programs. In California, state efforts to maximize the receipt of resources on behalf of California providers
is being coordinated by a new Deputy Secretary of Health Information Technology, with the position currently held by
Jonah Frolich. Under the California’s Deputy Secretary of HIT’s division, the California Health and Human Services
Agency (CHHSA) has embarked on several broad-based and inclusive strategic planning processes, engaging many diverse
stakeholders. The key eHealth initiatives that the state is working on that are of importance to rural providers are:
ElEctronic HEaltH rEcord (EHr) adoption incEntivEs for providErs
Incentive payments will be made by Medicare or Medi-Cal to qualified health care providers who can demonstrate
“meaningful use” of electronic health records (EHR).2 These payments (up to $48,400 for rural providers
choosing Medicare incentives OR up to $64,000 for each rural Med-Cal provider, and a base of $2 million per
eligible hospital, plus additional funding as outlined in the program) are designed to offset some of the costs of
implementing EHRs. The proposed rule released in early January 2010 identified 25 data collection and analysis
elements that encompass “meaningful use.” ix Incentive payments could begin to flow as early as the third quarter
of 2010 and will end in 2021.
rural Health policy implications: As drafted last year, the regulations did not account for the reality that
many rural providers are not as advanced in their planning or financing of EHR, and thus, will be unable to take
advantage of the financial incentives until much later in the process. There was also significant concern about the
lack of inclusion of critical access hospitals (CAHs) in the original meaningful use regulations.
The United States Congress established the meaningful use program within the American Recovery and Reinvestment Act (ARRA) to
promote the utilization of certified EHR technology to advance improvements in health care quality, efficiency, and patient safety.
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As revised, the meaningful use rules provide a bit more time and flexibility to enable providers to demonstrate
meaningful use. There is still concern, however, that small and rural providers who were not “early adopters”
of electronic health records will have a more difficult time reaching the meaningful use criteria in the allotted
time frames. Rural providers are less likely to have the IT staff to help support them in their adoption and
implementation of an EHR. Furthermore, the time required to train staff, implement new workflows and report on
meaningful use will take more than the proposed two years, or one year, depending on when the provider elects to
start the incentive program.
Furthermore, there is confusion about whether CAHs are included as “eligible providers” to receive meaningful
use incentives in the proposed regulations. State and national rural health advocates will be submitting comments to
ONC and will need to advocate for revised meaning ful use eligible provider guidelines to ensure that CAHs are able to
fully participate as “eligible providers” in the federal eHealth programs.
HEaltH it rEgional ExtEnsion cEntErs
In order to support EHR adoption by health care providers around the country, Congress has allocated over
$640 million to fund Regional Extension Centers (RECs) that will provide training and technical assistance to
providers that are eligible for meaningful use incentives. Provider organizations and the State of California have
been collaborating to maximize the number of RECs for California, recognizing both the geographic size of the
state and complexity of the various types of health care organizations that exist here. Cal-REC, a collaboration of
the California Primary Care Association, the California Medical Society and the California Association of Public
Hospitals has received a preliminary funding award notice indicating that its applications for both Northern and
Southern California (excluding Los Angeles and Orange Counties) have been tentatively approved. If this award
becomes final, CAL-REC can expect to receive about $40 million over five years to support EHR adoption for
approximately 7,700 providers, both urban and rural.
rural Health policy implications: A key issue for Cal-REC will be balancing the needs of the various types
of providers who will be participating in this effort, ranging from small providers in rural and remote areas to
complex public hospital systems in urban California. Implementing EHRs and advanced HIT systems for single
and small group practice providers in rural and remote areas is a much more difficult task than it is in urban areas.
This will best be accomplished through strong partnerships between Cal-REC and rural health organizations such as
the newly formed Critical Access Hospital Network (CAHN), the Rural Health Information Technology Collaboration
(RHITC) and other state and regional organizations that are focusing on rural areas.
HEaltH information ExcHangE (HiE)
The Health Information Technology for Economic and Clinical Health (HITECH) Act provides the Office of the
National Coordinator with $2 billion to support the Medicare/Medicaid EHR incentive loan program. The ONC
is directing a portion of this funding towards is Health Information Exchange (HIE). HIE is one of the many
requirements and goals of the Medicare/Medicaid EHR incentive program. Ultimately, all providers will operate
EHRs and will have the capacity to electronically exchange data in their communities, states, and across the
country. Each state, assuming they submit an adequate application, is eligible for an allotment of funding for the
construction of HIE in their state. California is entitled to $38.8 million for its HIE efforts. States are given the
option of applying for the funding directly, or electing a state designated entity (SDE) to apply for the funds on the
State’s behalf. This effort in California is being led by Jonah Frohlich, Deputy Secretary of HIT, within the Health
and Human Services Agency.
After stakeholder meetings began in early spring 2009, the State decided to select a SDE. While the State has not
yet selected their SDE, the State is actively applying for California’s portion of the HIE funding. This process will be
turned over to the SDE, with an independent governing board once chosen. The State continues to utilize a variety
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of workgroups that are creating the HIE operational plan which is required by the ONC for receipt of the HIE
funds. One of the workgroups helping to draft the operational plan is the vulnerable and underserved populations
workgroup, which is co-chaired by the CSRHA Policy Director.
rural Health policy implications: Health information exchange is not a new phenomenon for rural
communities in California. In fact, several leaders in California’s HIE environment have emerged from rural
communities. The lack of resources in rural communities has driven cooperation and the building of agreements
on health information exchange. HIE can reduce the cost of interfaces between the variety of HIT products used,
and so it is critical for rural to ensure that all resources are expended wisely and efficiently. Rural providers who
have participated in the local health information organizations and exchanges should be consulted and shoud provide
input on the State’s operational plan. Rural providers have many lessons to share and can help ensure that California’s
larger HIE infrastructure is robust.
funding for Hit WorkforcE training
The demand for trained HIT workforce will be acute throughout California. A recent report released by the
California Health and Human Services Agency (CHHSA) Health Information Technology Office indicated that
California will need to train an additional 7,000-9,000 HIT workers over the next five years.x In addition, all levels
of California’s existing health care workforce, from front-office to physician providers, will require some amount of
technology training in order to be proficient with the new eHealth applications. Many of these new HIT workers
will be involved in providing this on-the-ground training. However, the time element required to provide the
appropriate level of training to the existing health care workforce is a significant challenge for rural providers who
are notoriously understaffed and underfunded. Health IT management and support is often a job function shared
by several individuals who are responsible for multiple clinical and operational aspects of facility operations, and
must add IT management on top of a crowded work schedule.
Rural providers will be competing with urban providers to ensure that sufficient numbers of new trained IT
workers will be available for rural communities, and also to ensure that existing health workers are able to receive
the training that they need. As with many of the current initiatives, the emphasis will be on developing capacity
and new programs rapidly to meet the demand for new workers and trainers for existing workers. This is an
opportunity for California’s community colleges and universities to be an aggressive and active partner, in HIT
development, especially in California’s poor rural counties.
New funding to train HIT workers is flowing from two federal agencies. First, the Department of Labor, through
funding provided by the American Reinvestment and Recovery Act (ARRA), has already provided funding to
local workforce investment boards (WIB) and community colleges to train new workers in a variety of industries,
including HIT. California, under the leadership of the Northern Rural Training and Employment Consortium
(NorTEC) has applied for $5 million to support HIT training under the leadership of the community colleges.
Under the federal Office of the National Coordinator, funding is being made available to community colleges and
other institutions of higher learning to help them develop curriculum and build capacity to rapidly increase the
number of new HIT workers.
rural Health policy implications: As noted earlier, rural communities face a shortage of all types of health
care workers. It is important to note that, in addition to finding new employees to fill new types of HIT jobs, most
clinical and health care support staff will need training to successfully use eHealth in their practice. Thus, there
will need to be sufficient instructors available to meet this increased need for training. The community colleges, the
primary post-secondary educational institution in rural communities, will need to be a key partner in this effort to
“train-the-trainers” in partnership with the state university system and the University of California.
Much of the funding that will be available to train health information technology workers will be released through
local WIBs. These regional entities are the local point-of-contact for state and federal employment initiatives. They
rely on close coordination with employers to ensure that their training programs meet industry demand and to
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place trained workers. It will be critical for local rural health organizations to engage with their regional WIBs and
build new and expanded partnerships, so that WIBs understand HIT training needs and include HIT in local workforce
In September 2009, the national Rural HIT Coalition and the National Organization of State Offices of Rural
Health co-sponsored a national rural HIT workforce summit.xi The summit’s findings track very closely to
those noted through California’s process, and emphasized the importance of collaboration between employers,
educational institutions, and workforce training entities. California workforce and training organizations are
currently determining a governance structure to coordinate the various HIT training programs that are anticipated
to start shortly. It will be key for rural health advocacy organizations to stay actively engaged in any new health IT
workforce initiatives that are created over the short and long-term.
accEss to Hit financing
Access to HIT financing will be key to the success of implementing eHealth initiatives quickly. Many health care
providers are concerned that there is not enough access to the capital investments needed to purchase and install
eHealth applications. Current key sources of financing appear to be:
• $10 million in new loan funding provided by United Healthcare/PacifiCare specifically for Critical Access
Hospitals. This funding will be available in 2010.
• Up-front incentive payments from Medi-cal to help providers purchase new systems. Details for how these funds
will be released are currently being worked out by the Department of Health Care Services.
• No-interest or low-interest loans from vendors to support the purchase of their products. These can be very useful
if a provider has already determined that a specific vendor’s product is the most appropriate.
• Loans to hospitals from community banks under the Federal Home Loan Bank program. A provision of the
Housing and Economic Recovery Act of 2008 allows the Federal Home Loan Bank of San Francisco (FHLB),
through its member banks, to provide a Standby Letter of Credit. Health care providers could be considered a
“community investment” that would qualify for the program. Health care providers can check with their local
community bank to see if they are a member of the FHLB San Francisco. More can be found at the following
• HELP II Loans. With the California Primary Care Association, California Health Facilities Financing
Authority (CHFFA) is actively exploring the feasibility of creating a new loan program or reconfiguring parts
of an existing loan program to assist providers with the purchase of an electronic health record. This loan
fund would allow providers with the capital to purchase an EHR, enabling them to then participate in the
Medicare/Medicaid EHR incentive loan fund.
rural Health policy implications: During the past year, safety-net programs have already been significantly
reduced due to budget deficits at the state level. The upcoming budget deliberations in California promise to be
among the most difficult ever, with cuts being proposed for core insurance programs. This climate will make it
very difficult for safety-net providers, particularly in rural areas, to consider making new investments in HIT, even
with the incentives. As noted earlier, the impact of provider productivity loss, as well delays in processing service
billings, could result in a temporary loss of revenue for safety-net providers already challenged to survive. Rural health
advocates, in partnership with other safety-net advocacy organizations, need to draw attention to this significant barrier to
eHealth adoption and promote innovative solutions to mitigate the impact of this revenue loss on rural health providers.
Telemedicine generally refers to the provision of clinical services from a distance. The Institute of Medicine of
the National Academy of Science defines telemedicine as “the use of electronic information and communication
technologies to provide and support health care when distance separates the participants.”xii Telemedicine and
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telehealth services continue to expand throughout California, with many new patient sites under development and
many new provider groups entering the marketplace. In addition, major global corporate interests are moving into
the telehealth arena leading to the anticipated expansion of choice in technologies in the coming years.
A decade of telehealth program experience has shown that telemedicine applications applied across the spectrum
of health care services results in substantial improvements in health care access, outcomes and cost avoidance.
For rural health, telehealth is a means of helping to bridge the specialty practitioner shortages, which is a serious
access and workforce issue in rural areas of the state. Nationwide, policy experts, including the National Rural
Health Association, report that telehealth expansion requires supportive policy for reimbursement, licensing and
credentialing. In 2009, the California Telemedicine and eHealth Center (CTEC) released a policy brief identifying
the need for supportive policy for reimbursement, credentialing and coordination of service development as key
factors for optimizing telehealth in California.xiii
rural Health policy implications: Payment policies and covered benefits of insurers and government payers need to
expand to allow for payment and coverage of telemedicine. Payments are currently limited, impacting rural adoption
and availability of telehealth services. Telemedicine adoption would advance with the creation of policy that
broadens and expands service coverage, supports a comprehensive payment structure for services, and addresses
licensure, credentialing and privileging issues for rural and remote providers.
One good example of a sound payment policy that supports eHealth utilization is from Medi-Cal. Medi-Cal
does not require that a patient be in a rural area, but only that a clear barrier to service requires the telemedicine
encounter. Medi-Cal will pay provider visit fees at both ends of the telemedicine encounter (both for the consultant
and the provider requesting the consult, if that provider actively participates with the patient in the encounter),
pays facility fees at both ends of the encounter, and reimburses for line charges. This is in stark contrast to Medicare
telemedicine policy. The federal Centers for Medicare and Medicaid (CMS) will not reimburse for telemedicine
visits unless the patient is located in a rural census tract with a population of less than 20,000, regardless of its
remoteness from needed consultants, and even if telemedicine is the only way for patients to get access to care.
This is denying critically needed care to many clearly documented remote medically underserved areas (MUAs)
and medically underserved populations (MUPs).
There is strong recognition among multiple state and federal sectors that the expansion of broadband for rural communities
will have a profound positive impact on rural economic development. For example, a recent statewide rural economic
development planning process concluded that ubiquitous broadband access throughout rural California is one of four key
policy opportunities that could vitalize rural economies.xiv A number of broadband expansion initiatives are currently
taking place to improve connectivity for the public safety, health care, and social services sectors, including:
california tElEHEaltH nEtWork
In order to address the demonstrated need for broadband expansion nationwide, the Federal Communications
Commission awarded over $417 million in grants in 2007 to support broadband installation across the nation.
California’s $22.3 million award is the second highest in the nation and will bring affordable broadband to over
860 rural and underserved urban health care sites such as rural and public hospitals, community health centers
and public health. The California Telehealth Network (CTN), currently governed by the University of California,
has been in the process of selecting a broadband vendor and organizing itself into an independent non-profit
rural Health policy implications: Critical issues to monitor over the next two years are ensuring that the
installation schedule is responsive to those communities who have the most need for broadband (as opposed to those
that are the easiest and least expensive to serve), and that the business model and fee schedule developed by CTN
clearly facilitates to rural providers.xv
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BroadBand for EmErgEncy and disastEr coordination
Homeland security and disaster planning coordination is conducted by California’s disaster planning and
homeland security agency, CalEMA. This agency was created just over a year ago, combining the State’s Office of
Emergency Services and Homeland Security Agency into one coordinated emergency and disaster-oriented agency.
At the federal level, this agency is coordinated with Homeland Security, Center for Disease Control, the Defense
Department, and the Department of Health and Human Services. Statewide, all law enforcement, trauma hospitals,
9-1-1 systems, disaster relief agencies, and other homeland security-related facilities are tied into this system.
CalEMA is involved with the planning for and coordinating of disaster planning, as well as the planning and
build out of the statewide broadband system, which will be connected with other broadband networks operated
throughout the state. This broadband network is necessary for facilitating a coordinated response when the next
wildfire, earthquake, flood or other natural or man-made emergency hits the state. Broadband is essential for the
State’s federally required comprehensive emergency plan.
In addition, there is a national push to have the 2-1-1 telecommunication system in place to both assist citizens
with accessing appropriate health and human service programs and resources, and, in times of a disaster or
emergency, accessing appropriate shelter, food, health care, and evacuation information. Nationally, Congress has
provided revenue enhancements for the build out of broadband and telecommunication systems for states working
on their 2-1-1 systems. California has yet to receive its share of these enhanced funds for 2-1-1 systems build-out.
rural Health policy implications: Coordination and relationship building between entities responsible for
California’s 2-1-1 system and disaster and emergency planning programs is necessary to ensure the HIT and
telecommunications infrastructure is not disrupted in times of disaster and emergencies. CTN and the Office of
Health Information Technology, CHHS should work to assure that capability for broadband HIT connectivity is
preserved during disasters and emergencies for support of critical health care needs.
BroadBand tEcHnologiEs opportunitiEs program
At the federal level, both the U.S. Department of Agriculture and the National Telecommunications and
Information Agency will be releasing over $7.4 billion to support the installation and use of broadband for a variety
of public purposes. Several rural communities throughout California have organized to submit proposals which
are currently being reviewed at the federal level. A second and final round of funding was released in late January
2010 with proposals due March 15, 2010.
rural Health policy implications: Much of the leadership for broadband deployment at the local level comes
from economic development agencies and/or local telecommunications providers. It is critical that rural health
community stakeholders engage with these local initiatives to ensure that that they interconnect with other regional and
statewide broadband initiatives that are focused on health and/or emergency services.
california puBlic utilitiEs commission programs
The CPUC supports broadband expansion in two key ways. First, through the California Teleconnect Fund,
it provides subsidies to eligible end-users such as non-profit health clinics and hospitals to reduce the cost of
connecting to high-speed broadband.xvi Secondly, it helps pay for the installation of broadband in hard-to-reach
areas through matching grants provided to telecommunications companies.
rural health policy implications: There is currently a vacancy on the California Public Utilities Commission.
The previous Commissioner, Rachelle Chong, was a strong proponent of broadband expansion into rural areas
of the state, and supported both state and federal subsidy programs that kept broadband affordable for rural
communities. The Governor’s Office has the authority to nominate a new commission, who must be confirmed by
the State Senate. Rural health care providers should join with other advocates for rural broadband expansion to ensure
that the other retained Commissioners and/or the new CPUC Commissioner supports rural broadband expansion and
12 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
The current environment brings together many of the elements needed for successfully implementing eHealth projects in
rural communities and there is good cause for optimism. However, pitfalls and challenges remain that could undermine the
potential for success in this current environment. rural advocates can help support successful eHealth adoption by
focusing on the following key policy areas:
➢ EnsurE statE and fEdEral programs rEmain sEnsitivE to uniquE nEEds of rural
HEaltH providErs. Rural providers know that in health care, “one size does not fit all”. What can work
successfully in a dense urban geography may not be successful in remote areas of California where distance and
weather remain barriers to service delivery. Rural providers need to stay engaged and active in state and national
entities that have responsibility for implementing the various new eHealth projects and programs to ensure that
rural interests and concerns are well-represented.
➢ promotE tHE sprEad of rural eHEaltH adoption BEst practicEs. With the truncated time
frame available to achieve “meaningful use” by rural health providers, it is more important than ever to ensure
that the lessons learned by early adopters are spread as widely as possible. Now is no time to reinvent the wheel.
Rather, it is a time to use all of the available networking technologies to encourage connections between rural
health providers who are at the various stages of eHealth adoption: planning, implementation, and optimization.
➢ promotE improvEd rEimBursEmEnt for EHEaltH activitiEs. Unless public and private payers
revise their reimbursement to include payment for service delivery provided in a new eHealth environment,
eHealth will not be sustained beyond the current temporary funding increase and thus, will not fulfill its potential
to transform health care.
Appendix B of this report outlines the specific steps that CSRHA plans to undertake the support the policy
recommendations outlined in this report.
California State Rural Health Association | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | February 2010 | 13
IMPLEMENTING EHEALTH IN RURAL COMMUNITIES – LESSONS LEARNED
With new resources and incentives available for only a short time, rural health providers who have not yet started to plan
for eHealth adoption need to begin immediately if they wish to take advantage of the current environment. Fortunately, as
outlined in Appendix D of this report, there are many resources available to help rural health providers learn from early
adopters who are willing to share their stories and offer advice to avoid common pitfalls.
In its 2006 Report to the U.S. Department of Health and Human Services Secretary, the National Advisory Committee
on Rural Health and Human Services addressed the issue of health information technology.xvii While noting many of the
barriers outlined earlier in this report, they also noted the strengths that rural communities bring to HIT adoption: in
general, rural practices are small, and there are fewer of them in a given geographic area. This reduces the complexity of
eHealth adoption and exchange of health information and also makes it easier to bring all of the relevant stakeholders
together to plan for eHealth adoption.
These strengths are demonstrated in many of the current eHealth projects operating successfully in California today. In
November 2009, CSRHA hosted a rural eHealth Summit entitled “Are you Ready for Meaningful Use? – An eHealth Boot
Camp for Rural Providers.” Summit presenters representing successful rural HIT/HIE implementations from around the state
highlighted the successes and challenges they experienced. Key lessons learned from the conference presentations include:xviii
• The importance of reviewing workflow and changing processes BEFORE installing eHealth technology:
do not automate bad processes!
• Ensure adequate resources for planning and project management during installation and training and technical
support AFTER installation
• Assume the project will take longer and cost more than planned
• Interoperability between different functions within a clinical setting (e.g. lab, prescriptions, x-ray)
as well as between clinical organizations remains a key challenge – ensure that vendor contracts
adequately address this issue
• The end goal is not the installation of the technology – it is the use of this technology to improve
quality and patient safety. Keep this in mind during all phases of project implementation
Appendix C of this report provides in-depth information about three successful rural HIT projects operating in California
today: Southern Sierra Telehealth Network covering a large multi-county service area in rural Southern California, the
Greater Sierra Integrated Health Organization serving Nevada County and Access El Dorado connecting multiple providers
in El Dorado County.
Key success elements in each of these projects include:
• Strong local partnerships that supported significant participation by clinical providers and as a result,
shared agreement on technology products and services
• The ability to attract outside funding to support upfront costs of planning, installation and operation
• The aggregation of needs and resources to develop economies of scale and efficient operations
• Detailed sustainability plans which outline how the eHealth projects will be sustained after external
funding is exhausted
As successful as each of these projects are, they also faced challenges in building their systems including:
• The complexity of finding sufficient financing to match the project’s desired time frame
• Keeping their collaborative partners engaged during long planning processes
• Inconsistent access to broadband connectivity to support technological innovations
14 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
The next few years will offer a narrow window of opportunity for rural health providers to gain access to the tools
they need to successfully use technology to improve health and health services in their communities. Those who
succeed will have strong local and regional partnerships in place, will be able to move quickly to respond to fast-
moving opportunities, will heed the lessons learned from early adopters, and will think carefully about how to
sustain new technologies once start-up funding has ended. CSRHA looks forward to working with its members and
state and national policy makers to ensure that rural communities throughout the state benefit from the current
environment in ways that create lasting health improvements.
California State Rural Health Association | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | February 2010 | 15
CSRHA eHealth Policy Report
APPENDIx A: CSRHA RURAL TECHNOLOGY ADVISORY COMMITTEE ROSTER
Speranza Avram Thomas Nesbit, MD, MPH
Speranza Avram & Associates Graduate Medical Education &
firstname.lastname@example.org Continuing Medical Education & Outreach,
Dorreen Bradshaw UCD School of Medicine
Shasta Consortium of Thomas.email@example.com
Community Health Centers Suzanne Ness
firstname.lastname@example.org Hospital Council of Northern & Central CA
Robert Chilco Nancy Oswald
UC Irvine Redwood Community Health Coalition
Stephanie Couch David Quackenbush
CENIC Central Valley Health Network
John Faltys Tim Rine
PersistentWorldZ North Coast Clinics Network
Earl Ferguson Will Ross
Ridgecrest Regional Hospital Mendocino Informatics, Inc.
Cathy Frey Ezequiel Sandoval
Alliance for Rural Community Health Infinite Consulting Services
Jonah Frohlich Christine Schmoeckel
CA Health & Human Services Office of Health Information
Andrea Gerstenberger Sandra Shewry
UCOP, Health Sciences & Services California Center for Connected Health
Oscar Gomez Paul Snell
Farmworker Health Services, Inc. Re-Think Radiology Consulting LLC
David Harry, PhD Jim Suver
UC Davis Health System Ridgecrest Regional Hospital
Jenny Kattlove Janice Waddell
The Children’s Partnership USDA Rural Development
Patricia Keast, MS Peggy B. Wheeler
UC Davis Health System, California Hospital Associaton-Rural Health Center
Center for Health & Technology email@example.com
Patricia.Keast@ucdmc.ucdavis.edu Melissa White
Ira T. Lott Regional Council of Rural Counties
UCI Health Sciences Telemedicine Program firstname.lastname@example.org
Children’s Hospital of Orange County Michele Yepez
email@example.com DHS- Primary & Rural Health Care Systems
Christine Martin firstname.lastname@example.org
California Telemedicine & eHealth (CTEC) Corrine Chavez
email@example.com State office of Rural Health
Andie Martinez firstname.lastname@example.org
California Primary Care Association (CPCA)
16 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
CSRHA eHealth Policy Report
APPENDIx B: CSRHA’S ROLE IN SUPPORTING RURAL HEALTH TECHNOLOGY POLICY
Recommendations CSRHA has the ability to support its members in rural health technology deployment through three
major activity areas:
• Provide up-to-date information on funding resources, policy updates, and best practices through the use of its
website and social networking media
• Represent rural interests in state and national HIT policy venues to advocate for rural friendly policies
• Facilitate linkages between rural health and other key sectors such as transportation and social services in order to
leverage resources that will sustain technology in rural communities.
The overall goal of these activities is to position CSRHA as the “Go To” organization for rural health providers, policy staff,
and funding organizations needing information about the impact of eHealth on rural provides and rural communities.
Below are some specific steps that CSRHA can take in each of these three areas:
CSRHA has a strong communications infrastructure and can use its website and social media presence to connect its
members to information that can help them with rural health technology implementation. To maximize its ability to use
these resources, CSRHA should:
➢ add a rural health technology section to its website so that resources and policy updates will be easier to find.
➢ post links to state and national resources that provide information specifically to rural providers. This type
of “rural eHealth library” does not currently exist for California. This resource library should be developed in
collaboration with other organizations that provide this type of information, such as the California Telemedicine
and eHealth Center and the Community Clinics Initiative.
➢ promote the sharing of “lessons learned” by california rural health providers through posting of case
studies, facilitation of regional discussions (perhaps at the Rural Roundtables), and sponsoring on-line discussions
of providers working on eHealth projects. CSRHA can promote collaboration between providers by identifying
existing and emerging eHealth adoption projects.
➢ CSRHA can play an important role in educating rural health providers on how to successfully work with
eHealth vendors and can sponsor activities that link vendors with potential customers. Workshops such as now
to negotiate the best contracts and obtain best pricing could be offered via webinars and/or in-person trainings.
CSRHA can encourage members to share request for proposals, contracts, etc with each other to promote the
sharing of knowledge and best practices.
Represent Rural Interests
CSRHA has consistently participated in state efforts to support eHealth and should continue in these efforts, particularly
now that it has expanded policy staff. Specific activities that CSRHA should continue or begin include:
➢ cal-rEc – CSRHA has supported two Regional Extension Center (REC) applications for California. As a part of
the California Safety Net Coalition, CSRHA supported Cal-REC, a collaborative effort of the California Primary
Care Association, the California Medical Association, and the California Association of Public Hospitals. CSRHA
also provided a letter of support for an application submitted by a newly formed Rural and Remote REC. CSRHA
is a member of the California Safety Net Coalition, who will serve as an advisory committee for Cal-REC. CSRHA
will play an important role in ensuring that CAL-REC remains sensitive to rural provider issues.
California State Rural Health Association | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | February 2010 | 17
➢ california telehealth network -- CSRHA has consistently supported CTN and played a leadership role during
the initial application process in 2006 to ensure that the needs of rural health providers remained a central part
of the CTN mission. CSRHA is currently a member of the CTN Interim Advisory Board which will guide the
transition of CTN to an independent entity.
➢ california Health Workforce alliance – The CHWA plans on taking a coordinating role in expanding HIT
workforce training. On behalf of rural health providers, CSRHA should actively participate in the governance of
these statewide workforce programs to ensure that rural communities are able to benefit from these programs.
CSRHA currently promotes this type of collaboration through its Rural Workforce Task Force.
➢ california HiE advisory Board – CSRHA is currently co-chairing a state workgroup on vulnerable populations
and participating on a workgroup on patient engagement.
➢ national rural Hit coalition – CSRHA is not currently a part of this coalition hosted by the Rural
Resource Center. This coalition tracks eHealth policy on a national level and it is vital that California engage
so it can influence how the meaningful use incentive program will be implemented and to address Medi-care
reimbursement for eHealth activities
➢ other organizations – CSRHA should continue to work closely with organizations such as the California
Telemedicine and e-health Center (CTEC) and the new California Center for Connected Health, as well as the
National Rural Health Association, and the American Telemedicine Association, to advocate for improved policies
at the state and national level.
As outlined in this report, there are many opportunities to leverage related programs to help sustain technology investments
in rural communities. CSRHA can take the lead in promoting dialogue between rural health systems and organizations
such as CalEMA, 2-1-1, CalTrans, and others to ensure that their planning and operational efforts are aligned. Mapping out
the relationships and interconnectivity between the various planning groups can highlight opportunities for building in
technical redundancy, reducing operational costs, and maximizing state and federal broadband.
➢ california Emergency management association – CSRHA will help link eHealth policy leaders with homeland
security and disaster planning leadership to explore how these two areas can leverage resources for long-tem
➢ california 2-1-1 – Developing health and information telecommunications call centers in the rural areas of
California will take more coordination between CSRHA affiliates and 2-1-1, including coordination with United
Ways of CA in rural areas, which provide much of the funding for 2-1-1 call centers.
➢ caltrans mobility management systems – These systems will have an impact on how low income, unemployed
and seniors travel to their health appointments and related public and private programs. CSRHA can provide
liaison between leadership teams at CalTrans and within the health sector to help ensure rural health care systems
and providers are kept up to date on the build out of the mobility management systems.
➢ california Workforce investment Boards – These regional entities distribute workforce training funds to
educational institutions and non-profit organizations. Over the next three years, there will be an increased
emphasis on training health information technology workers. CSRHA should engage with these boards at the
state level through communication with the California Workforce Investment Board (CalWIB) and the California
Workforce Association, a state association representing 49 local WIBs and other workforce development
organizations around the state. In addition, CSRHA should sponsor training with its member to assist them in
engaging with their local WIBs to ensure that new funding for health IT workforce training is closely linked with
local employer needs.
18 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
CSRHA eHealth Policy Report
APPENDIx C: CASE STUDIES
Southern Sierra Telehealth Network.
The Southern Sierra Telehealth Network (SSTN), with its rural hub at Ridgecrest Regional Hospital (RRH) has provided
telehealth services since 2001. Its network includes four critical access hospitals (CAHs) distributed over a land mass
covering more than 10% of California. They have worked closely with the Southern Sierra Medical Clinic (SSMC), a small
medical group with a paperless practice since 2002, e-prescribing since 2003 and operating EHR-Lab Interoperability and
Connectivity Specification (ELINCS) for clinical laboratory data health information exchange since 2004. SSMC and RRH
were funded by the California Health care Foundation to develop ELINCS for implementation in rural California.
SSTN plans to leverage its expertise and that of numerous partners to extend services to additional rural communities
east of the Southern Sierra Nevada Mountains. These rural and frontier areas are isolated and medically underserved,
encompassing more than 20% of the land area of California (about 32,000 sq. mi.) with more than 250,000 residents. SSTN
also plans to reach out to non-traditional partners by collaborating with the Veterans Administration Loma Linda Health
Care System (VALLHCS), the Greater Los Angeles VA Health Care System, and Army, Navy, Air Force and Marine medical
facilities in their region to enroll rural veterans in the DoD/VA Virtual Lifetime Electronic Records (VLER) system. The goal
is to enhance chronic disease management using telehealth systems to improve health care access for more than 36,000
civilian veterans in the region. SSTN also support Indian Health Service (IHS) activities – Toiyabe Indian Health Project
in Bishop, Lone Pine, and Furnace Creek in Death Valley National Park by providing telemedicine services for the IHS in
Bishop and Lone Pine since 2002.
Their overarching goal of SSTN is to extend a wide range of cost-effective, cutting-edge HIT and HIE capabilities built on a
foundation of broadband telehealth services throughout their rural, underserved region. SSTN plans to seek grant funding
to specifically focus on outcomes research, leveraging community-level evaluation, performance monitoring and feedback
expertise at the University of California at Irvine and the VALLHCS to implement congestive heart failure (CHF) monitoring
and other outcomes research programs to demonstrate effectiveness of advanced HIT and HIE implementation on chronic
disease management. The program will leverage RRH and VALLHCS home health telehealth monitoring experience and
their experience with Internet monitoring of thoracic impedance (a sensitive index of CHF) of patients with automatic
implanted cardiac defibrillators.
SSTN has been successful because of its ability to aggregate needs and resources over a large geographic area and develop
useful and cost-effective solutions to meet those needs. In 2008, SSTN formed a Business Council that meets regularly and
addresses health care issues related to HIT implementation throughout their region.
The biggest challenges SSTN has faced over the last ten years have been:
• Inadequate broadband connectivity
• The high cost of telehealth solutions
• The lack of capabilities of telemedicine and e-Health technologies.
However, SSTN reports that these challenges are being overcome by broadband connectivity through the CTN FCC grant,
the marked decrease in the expenses of TCP/IP Internet telehealth solutions and marked improvements in technology
capabilities (for example, high definition video and digital stethoscopes) at decreased costs. Cost-effective, high quality
solutions can soon be implemented.
The current challenges SSTN faces are:
• Developing and holding a large regional coalition together while waiting for broadband and other technology
• Developing and implementing sound business, marketing and sustainability plans for supporting advanced HIT
applications in rural communities,
California State Rural Health Association | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | February 2010 | 19
• Getting adequate reimbursement for telemedicine services. For example, Medi-Cal has the most enlightened policy
in the country, reimbursing for services provided by providers present at both ends of a telemedicine encounter,
facility fees at both ends of the encounter, and line/connectivity fees for any encounter with a documented barrier
to service regardless of the patient’s location. Medicare/CMS should change its policy and reimburse telemedicine/
telehealth services if they overcome clearly documented barriers to health care services.
Greater Sierra IHO – Nevada County.
Under the leadership of Sierra Nevada Memorial Hospital (SNMH), Nevada County health care providers are poised to
implement a county-wide shared electronic health record system connecting over 100 physicians, two hospitals, and several
FQHC and RHCs in the county. To date SNMH has been successful in obtaining $761,000 in funding through federal
earmarks and private grants for the Community Connect project.
The health care system in Nevada County, located about ninety minutes northeast of Sacramento, is anchored by two
successful rural hospitals located in the western and eastern parts of the county. Most of the 150 private physicians in the
county are solo practitioners, and have limited resources to invest in new technologies.
The Community Connect goal is to create a community-wide EHR that will be used by all of the health care providers in
the region that will help achieve the following results:
1. Enhance physician recruitment and retention;
2. Improve the quality of care and the patient experience throughout the regional health system;
3. Better manage the health of their patients and as a result improve patient outcomes;
4. Leverage limited health care dollars through a standardized high-quality, low-cost electronic health record
provided to physicians;
5. Eliminate redundant business and clinical practices; and
6. Reduce clinical errors and enhance patient safety.
In recognition of the move toward health information exchange, the Community Connect project has evolved into
the Greater Sierra Integrated Health Organization (GSIHO). GSHIO serves its community providers by facilitating
the implementation of a physician office electronic health record so that these providers will be ready to demonstrate
“meaningful use” and draw down federal EHR inventive payments. From the initial physician office planning through
implementation and hosting of the application, the organization seeks to help physician offices optimize the product to
provide quality health care and maintain financially viable physician office practices. The first providers are scheduled to go
live spring 2009.
In keeping with Centers for Medicare and Medicaid requirements, a participating provider in GSHIO receives the purchase
of the eClinicalWorks PM/EMR license at 15% of cost (85% paid by GSHIO). Additionally, there are four required modules
by GSHIO. These modules are required to insure optimized use of the product and align with GSHIO goals of improvement
of quality of care, data exchange, improved communication with patients and efficient office operations. These required
modules are ePrescribe (eRX), eHealthExchange (eHX), eBusinessOptimization (eBO) and Patient Portal (internet
connection to patients). With the exception of the Patient Portal module (which is a complete stand-alone product), the
initial purchase of these modules is also subsidized 85% by GSHIO funding.
GSHIO provides a full-service electronic health record installation service for its participants. Participants in GSHIO receive
office workflow analysis, training, database setup assistance, physician office hardware/software and Internet connection
assessment, assistance in office hardware and software purchases, office product installation, local vendor product upgrade
assistance, help desk assistance (level 1 and 2) and product hosting at the SNMH Application Service Provider.
Obtaining outside funding to support the development of its county-wide EHR system has been the biggest challenge for
GSIHO to date. Through their strong community contacts, they were able to obtain two federal earmarks, an innovative but
20 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
increasingly difficult strategy to pursue in these difficult budget times. GSIHO’s sustainability plan relies on wide-spread
participation by the county’s health care providers to pay for hosting of the EHR system on the hospital’s ASP. One of the
decision-factors for selecting eClinicalWorks is its relative low broadband bandwidth requirements, making it easier to
deploy in regions of the state that do not current have widespread broadband connectivity, such as Nevada County.
GSIHO has successfully implemented many of the proven strategies for successful community-wide eHealth adoption including:
• Aggregation of provider purchasing power by obtaining agreement to purchase one EHR product for the region’s
health care providers. This task was made more difficult since a few of the area’s private physicians had already
invested in EHR products.
• Reducing the cost of entry for physicians and safety-net providers by using outside funding to subsidize EHR
• Actively engaging physicians throughout the planning and selection process to ensure that they supported the final
• Standardizing installation, training, and technical support across providers results in lower on-going costs.
• Selecting an EHR product that can be used successfully within the limited broadband connectivity that exists in
In addition to bringing all of its county health care providers on-line over the next 12 months, the GSIHO hopes to
expand its lessons learned to other rural regions of California through participation in the California Regional Extension
ACCEL (ACCess EL Dorado)
ACCEL is a community-wide collaborative initiative seeking to create a healthier community, especially within their vulnerable
populations. ACCEL works by identifying specific challenges or barriers to a healthy community and creating systematic
improvements that include all their partners and will serve the entire community. Each of the improvements is designed to
help create a stronger, better-coordinated community health care system for the people who live in El Dorado County.
ACCEL is a partnership between the El Dorado County Health Services Department (Public Health and Mental Health),
Barton Health care System (with affiliated medical providers and rural clinic), Marshall Medical Center (with affiliated
medical providers and rural clinic), El Dorado County Community Health Center, and Shingle Springs Tribal Community
Health Clinic. This partnership includes participants from many disciplines: physicians, nurses, community health
workers, mental health clinicians, and administrators.
ACCEL works in three program areas:
1. Improving access to both primary and specialty care for El Dorado’s uninsured, publicly insured
and underinsured populations.
2. Improving cross agency cooperation and communication for the underserved population of El Dorado County
3. Improving use of Health Information Technology (HIT) between our partnering agencies
ACCEL began organizing in 2002 and in 2005 received funding from County’s Tobacco Settlement funds, First 5, Agency
for Health care Research and Quality (AHRQ), the Blue Shield of California Foundation and The California Endowment
to support the development and implementation of health information technology programs. One of their core programs
is Care Pathways built on a community health linkage model developed by physicians Mark and Sarah Redding and used
by the Community Health Access Project. This model of care focuses on outcomes, not activities, and provides a step-by-
step algorithm for care managers to follow to ensure that patients are linked to the services that they need. Care Pathways
was first implemented without the use of shared technology – but in 2005, ACCEL automated the use of Care Pathways by
multiple providers using a web-based software application called iReach.
California State Rural Health Association | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | February 2010 | 21
ACCEL has developed the organizational foundation and experience to pursue formation of a County-wide clinical health
information exchange (HIE) to increase secure access to health information across multiple settings. They have piloted a
countywide Enterprise Master Patient Identifier (EMPI) that enables sharing accurate demographic data among multiple
providers, as well as developed and implemented a common notification of privacy practices, privacy and security policies,
and technology infrastructure, to link participating agencies in an HIE that shares essential clinical data. This will include
the capacity for disease surveillance, public health communicable disease reporting, and urgent community health alerts.
In late 2008, ACCEL released a comprehensive request for proposals for HIE, but ACCEL did not select a final vendor.
The economic downturn of 2008 challenged all of ACCEL partners’ ability to consider significant investments in the HIE
technology purchase and implementation. At the same time, as both the hospital systems (Barton in South Lake Tahoe and
Marshall on the Western Slope) grappled with internal selection and financing of updated/streamlined health information
technology systems, identifying and selecting an HIE vendor became increasingly complex. The California State budget
crisis has seriously challenged El Dorado County’s ability to deliver resources to the safety net population while the other
partners face reduced reimbursement and increased demand for charity care.
The passage of the American Recovery and Reinvestment Act in February 2009 sparked hope that stimulus funds would
provide the needed bridge to support ACCEL ’s HIE. However, given the emerging clarity of the ARRA HITECH funding
requirements and incentives, ACCEL stakeholders have determined that their highest priority will be investing in
foundational capabilities (EMR/EHR) that will enable effective and efficient clinical data sharing in the long term. ACCEL
will re-visit HIE in the future once each of their key partners has successfully adopted electronic health records.
The lesson learned from ACCEL is the value of taking the time needed to strengthen the ability of the health care providers
to work together before introducing technology as a solution. ACCEL developed strong relationships, built trust, overcame
privacy and security issues, and outlined clear workflow and care pathways that have resulted in tangible improvements in
health outcomes. This strong collaborative foundation served them well in making difficult decisions to postpone forward
motion on HIE so that individual partners can strengthen their internal EHR systems.
22 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
CSRHA eHealth Policy Report
APPENDIx D – eHEALTH RESOURCES
Agency for Health care Quality and Research: Health IT for Small and Rural Communities
A very comprehensive set of HIT tools and implementation guides.
American Telemedicine Association
National association of organizations and individuals working in telemedicine.
There website has many free resources for those interested in telemedicine.
California Center for Connected Health
A new organization that will be focusing on policy recommendations to support
the expansion of telehealth in California.
California DHHS eHealth Home Page
The portal for health information exchange and eHealth planning activities for the
Department of Health and Human Services.
California Telehealth Network
The home page for the $25 million broadband network being built in California to connect
over 860 health care to support eHealth.
California Telemedicine and e-Health Center
One of six federally designated telehealth resource centers, CTEC is located in Sacramento
and has links to other telehealth resources.
Community Clinics Initiative
Lessons learned from the $66 million invested in technology in California’s community clinics.
Community Clinic Voice
A collaborative on-line community of those working in and with safety-net providers,
which includes a robust section on eHealth issues for community clinics.
HRSA Office for the Advancement of Telehealth
Links to the other federally designated telehealth resource centers and has lists of telemedicine programs
around the country.
Rural Health Resource Center Collection of HIT Resources
A comprehensive portal to national rural health IT resources.
California State Rural Health Association | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | February 2010 | 23
CSRHA eHealth Policy Report
Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the
21st century. Retrieved from http://www.nap.edu/openbook.php?record_id=10027&page=1
Institute of Medicine Committee on the Future of Rural Health Care. (2005). Quality through collaboration: The future of rural health
care. Retrieved from http://books.nap.edu/openbook.php?record_id=11140&page=R1#
National Advisory Committee on Rural Health and Human Services. (2006). The 2006 report to the Secretary: Rural health and human
services issue; The national advisory committee on rural health and human services. Retrieved from
California Broadband Task Force. (2008). The state of connectivity: Building innovation through broadband. Retrieved from
Moiduddin, A., & Stromberg, S. (2009). Health information technology in California’s rural practices: Assessing the benefits and barriers.
Retrieved from http://www.chcf.org/documents/healthit/RuralHealthIT.pdf
NORC. (2006). Roadmap for the adoption of health information technology in rural communities. Retrieved from
California Healthcare Foundation. (2008). Snapshot: The state of health information technology in California. Retrieved from
American Hospital Association. (2007). Continued progress: Hospital use of information technology. Retrieved from
For more information on meaningful use criteria, see this summary of the Stage 1 measures: http://api.ning.com/files/Z
MeaningfuluseTableStage1200931217_PI_Table2.pdf or review the entire legislation:
California Department of Health and Human Services. (2009). Draft California’s health information technology and exchange strategic
plan. Retrieved from http://www.ehealth.ca.gov/LinkClick.aspx?fileticket=Mp0sOOr51zI%3d&tabid=72
Rural Health Resource Center. (2009). National Rural HIT Workforce Summit. Retrieved from
California Telemedicine and eHealth Center. (2009). What is Telemedicine? Retrieved from
California Telemedicine and eHealth Center. (2009). Optimizing telehealth in California: An agenda for today and tomorrow:
Major findings and recommendations of the California Telemedicine and eHealth center telehealth optimization initiative. Retrieved from
California Center for Regional Leadership. (2007). 2007 Rural Economic and Health Vitality Policy Agenda. Retrieved from
While state and federal subsidies will help keep monthly service fees for broadband relatively low, these subsidies may end after
a few years. CTN will be engaging in planning for long-term sustainability which will include reviewing the monthly fees it will
charge end users. For more information, visit www.caltelehealth.org
California Public Utilities Commission. (2009). CTF instructions, applications and administrative letters: Making telecommunications
services affordable for schools, libraries, and others. Retrieved from http://www.cpuc.ca.gov/PUC/Telco/Public+Programs/CTF/
Op.cite. National Advisory Committee on Rural Health and Human Services. (2006). The 2006 report to the Secretary:
Rural health and human services issue; The national advisory committee on rural health and human services. Retrieved from
California State Rural Health Association. (2009). 2009 conference: Navigating together through risk and opportunity. Retrieved from
24 | February 2010 | RURAL PROVIDERS AND eHEALTH: THE FUTURE IS NOW | California State Rural Health Association
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