MITRE and Partners Closing Gaps in Rural HealthOctober 2016
Topics: Environment, Communications Technology (General), Public Health (General)
Rural health systems face different challenges than those in urban or suburban areas. Rural patients often must travel long distances for hospital or even primary care. They have poorer overall population health, with a significantly heavier burden of disease, such as higher rates of hypertension and cerebrovascular disease, including strokes.
They also have a higher prevalence of mental-health issues, including suicide. Yet while 20 percent of the U.S. population resides in rural areas, they have access to only about 10 percent of U.S. physicians.
These problems can't be solved overnight, but they can be improved. That's why a rural health innovation partnership led by MITRE is working with the Billings Clinic and other partners, both medical and academic, to understand rural health challenges and pilot solutions. Located in Billings, Montana, the Billings Clinic provides acute care for an area the size of California, including large swaths of six states.
By delving into the key issues in one region, the team hopes to find recommendations to enhance rural health across the country. A larger group (see "Choosing Areas for Greatest Impact," below) narrowed down the areas to tackle, ultimately focusing on four: cybersecurity, decision-making about patient transfers, increasing provider capability, and using technology to engage patients in their own care.
Keeping Critical Systems Safe
It's no secret that hackers have targeted hospitals across the country trying to obtain sensitive patient information. Although no such attacks have occurred at the Billings Clinic, it pays to be prepared. So for the cybersecurity component of the initiative, Dr. Nick Wolters, CEO of the Billings Clinic, requested a vulnerability assessment of key data systems.
A MITRE team led by Armand Kinslow made recommendations for further protecting the clinic's data systems, and Billings is currently implementing them.
Improving Patient Transportation to Improve Treatment Options
In many rural settings, there are a few major hospitals and smaller Critical Access Hospitals (CAH) located throughout large geographic areas. Patient transportation may be required between clinical sites. For example, in Montana, a patient may need to travel more than 300 miles due to limited local healthcare resources to get a simple diagnostic test that in other places could be obtained locally.
"Patient transportation can be very expensive," says John Piescik, MITRE's director of health strategy. "In many cases it's over $30,000 for one trip and not fully covered by many insurance programs. And sometimes transfers simply aren't possible. In Montana, roads become treacherous during the winter and then patients can only be transported by air, weather permitting.”
There are some general national guidelines for transferring patients, but they often do not address the unique challenges of rural health systems. MITRE's Les Servi is analyzing patient transportation records and indications of clinical outcomes to derive data-based guidelines on whether to transport a patient based on necessity and level of risk. Making the right decisions can save lives and is also expected to reduce overall costs.
In a hospital setting, the level of risk of deterioration for a patient can be assessed with a Modified Early Warning Score (MEWS), based on patient vital signs. MEWS helps doctors determine whether a patient needs escalated care. The MITRE team is trying to create a similar set of metrics for risk assessment in an outpatient setting to help medical facilities maximize their resources.
"Les is working on an analytics project to help determine if a patient should be transferred," says MITRE's Sybil Klaus, principal scientist in neuro-technology and informatics and innovation-area leader for MITRE's health research portfolio. "We want practical guidelines, similar to MEWS, to determine the level of risk and potential benefits of either moving the patient or having them stay put."
Backing Up Primary Care Providers Through Telehealth
Another part of MITRE's research will investigate whether healthcare providers can expand capabilities at a specific location using video teleconferencing and other telehealth technology for coaching and training. The team is researching how to use physician assistants, nurse practitioners and paramedical professionals in remote areas to provide a wider scope of care without increasing risk or violating professional licensing.
"We're looking at ways to expand healthcare capability at remote locations," Klaus says. "If, for example, you use physicians to advise primary care providers out in areas nearer to the patient, then the patient doesn’t have to travel all the way to a major hospital for treatment.
"Training like this can help develop provider’s caring capability over time to be more extensive. It can also help prevent unnecessary and potentially costly transportation to a major hospital."
Getting Patients More Involved in Their Own Care
"One of the many challenges rural patients face is making sure they’re actively engaged in their care when providers are spread out across large distances," Sheridan says. "We’re doing a research study on using technology to improve that engagement."
Patient Toolkit is an app originally created for the iPad and geared toward patients with chronic illnesses. The team will perform a study in which chronically ill patients begin using the app and assess the impact on the workflow and communication between the patient and the provider. Patient Toolkit also allows patients and their providers to view information that shows any trends or patterns.
"We're hoping to improve that communication process," Klaus says. "The second phase of the study will look at ways to integrate the app into the electronic health record. We hope that when providers have more accessible and up-to-date information, it will help them make more informed treatment decisions."
What Works for Montana Can Work Across the Nation
Another part of the project aims to develop an overall rural health framework, which structures how the multiple pieces of a health system interact and work together. The framework would provide tools to analyze a given region's health needs and available healthcare resources and offer ways to apply the rules of a general model to improve care in that specific rural region.
The challenges faced by the rural health system in Montana exist in many other areas. The team identifies priority areas in which to find solutions that apply across multiple rural regions. Retaining providers is another challenge because rural areas often have limited cultural and educational opportunities. Physicians, physician assistants, and nurses may feel isolated from their professional communities.
"One way to address that is to make sure healthcare providers in rural areas feel supported," Klaus says. "The studies we're doing and analytics we can provide will hopefully give them more information to work with.
"We also want to empower primary care physicians with tools to make sure they can offer the best care for their patients and feel connected to the resources of a regional health system."
This research can help find solutions that could be extrapolated to many different parts of the United States and even internationally. There is also a significant veteran population in rural areas. Klaus says lessons learned in the rural health innovation partnership can be applied to help rural veterans as well.
"We really want to make a difference in the lives of rural residents," Klaus says. "Although the population is smaller, their challenges are just as real."
—by Emily Ready