Division of Health Policy, Office of Health Information Technology
PO Box 64882
St. Paul, MN 55164-0882
651-201-3589
Minnesota e-Health Brief: Rural Providers
Introduction
E-Health is the adoption and effective use of electronic
health record systems (EHRs) and health information
exchange to improve health care quality, increase patient
safety, reduce health care costs and improve individual
and public health.
Minnesota has been a national leader in e-health for
many years and has established the e-Health Profile, an
effort to uniformly collect and routinely share progress
of Minnesota’s health and health care providers toward
integrating health information technology, as prescribed
by Minnesota’s 2015 interoperable mandate. The
assessment information is used to:
• Measure Minnesota’s status on achieving state
and national e-health goals.
• Identify gaps and barriers to enable effective
strategies and efficient use of resources.
• Help develop programs and inform decisions at
the local, state and national levels.
• Support community collaboration efforts.
This brief presents e-Health Profile assessment results
focusing on rural health care providers1 in three settings:
ambulatory clinics (2012 data), hospitals (2012 data),
and nursing homes (2011 data). Data for local public
health (2010) are provided where applicable, but without
rural/urban distinction.
Common barriers to adoption among these health care
settings include: costs to implement, staff to design and
customize an EHR, trainers, computer / IT personnel,
and staff to prepare the EHR for use. Rural settings
were less likely to report cost concerns or support from
administration and/or providers.
About two-thirds of nursing homes have installed EHRs.
Adoption is lower among rural nursing home compared
to their urban counterparts, at 64% and 74%
respectively. For nursing homes with no EHR system
the largest implementation challenge was cost to acquire.
Effects on workflow was the largest challenge for
nursing homes in process of getting an EHR. Staff and
education training was the overall largest challenge for
nursing homes with an EHR.
Figure 1: Adoption of Electronic Health Record Systems
among MN Health Care Settings
Rural
Urban
95%
Hospitals (N=136)
97%
80%
Clinics (N=1,180)
79%
Adoption of EHRs
Adoption of EHRs is at a very high level for hospitals
and ambulatory clinics (Figure 1). Nearly all Minnesota
hospitals have implemented EHRs, with little variation
between critical access hospitals (CAH) and non-CAHs.
Among clinics, EHR implementation is strong in both
rural (80%) and urban areas (79%). Utilizing the ruralurban commuting area (RUCA) definitions we see
adoption rates are comparable across large rural, small
rural and isolated clinics (data not shown).
1
Geographic categories in this brief are defined by the rural-urban commuting
area (RUCA) classification system. For hospital comparisons, rural is defined
as critical access hospital (CAH) versus non-CAH.
64%
Nursing Homes (N=316)
74%
0% 20% 40% 60% 80% 100%
Percent of provider settings
with EHRs installed
While local health departments do not have certified
public health EHRs available, 95% (68/72) have
implemented an electronic health record systems (data
not shown in chart). Of these 68 departments the most
commonly-used systems include CHAMP (33), PH-Doc
(24), and CareFacts (7).
Minnesota e-Health: Rural Providers
page 2
EHR Utilization
Effective use of EHRs is an important activity to
improve the quality and safety of health care. EHR tools
that support quality and safety include clinical decision
support, electronic prescribing, and computerized
provider order entry.
Clinical Decision Support
Clinical decision support refers broadly to providing
clinicians or patients with clinical knowledge and
patient-related information, intelligently filtered or
presented at appropriate times, to enhance patient care.
Figure 2 shows key clinical decision support tool
indicators in hospitals, clinics, and nursing homes. The
number of hospitals and clinics using these tools has
increased since 2010, and previous gaps between urban
and rural rates of implementation exist but have declined
in magnitude. For example, in 2012, 45% of rural clinics
were routinely using more than three clinical decision
support tools, up from 34% in 2011. Common
challenges to effective use among rural clinics were
staff/provider training to use the tools and availability of
these tools in the EHR software.
E-Prescribing
The second indicator of effective use of EHRs is
electronic prescribing or “e-prescribing”, meaning
secure bidirectional electronic information exchange
between prescribing providers (prescribers), pharmacists
and pharmacies, and payers or pharmacy benefit
managers. E-prescribing improves the quality of patient
care because it enables a provider to electronically send
an accurate and understandable prescription directly
from the point-of-care to a pharmacy.
Figure 3 shows that e-prescribing rates are high among
Minnesota clinics and pharmacies, while hospitals and
nursing homes are lower. Statewide, 93% of pharmacies
e-prescribe and there is no difference between urban and
rural pharmacies. Rural clinics e-prescribe at a slightly
lower rate than urban clinics, particularly among clinics
that do not have EHRs (e-prescribing can be
accomplished using a non-EHR computerized system).
Figure 3: Electronic Prescribing among MN Health Care
Settings
Rural
Figure 2: Clinical Decision Support Tools Used Routinely
by MN Health Care Settings that have EHRs Installed
Hospitals (N=130)
Medication guides or alerts
Clinics (N=935)
Medication guides or alerts
Nursing Homes
(N=217)
Rural
Medication guides or alerts
Clinical services
reminders/alerts
Clinical guidelines
Urban
59%
75%
66%
45%
76%
86%
36%
48%
94%
93%
Pharmacies (N=1,058)
64%
83%
85%
56%
60%
Clinical guidelines
50%
60%
Clinical guidelines
44%
58%
Clinics* (N=1,180)
Nursing Homes~ (N=316)
44%
Care services reminders/
alerts
Preventive care services
reminders/alerts
Hospitals (N=130)
Urban
60%
64%
43%
51%
41%
45%
0% 20% 40% 60% 80%100%
Percent of Minnesota Providers
Using EHR CDS Tools
0% 20% 40% 60% 80% 100%
Percent of Minnesota Provider
Settings e-Prescribing
* Clinic data includes those that do not have an EHR installed and instead are
using a non-EHR e-prescribing service.
~ Includes nursing homes that planned to e-prescribe by mid-2013.
Computerized Provider Order Entry
Computerized provider order entry (CPOE) is the direct
entry of medical orders into the EHR. Used alone or in
combination with CDS, CPOE can reduce errors and
optimize care coordination. Figure 4 shows rates of
CPOE utilization across settings. About half of CAHs
have fully implemented CPOE, and about another onethird have partially implemented CPOE. CAHs’ rate of
full CPOE implementation is lower than for non-CAHs,
but CAHs show strong progress toward full
implementation. Key barriers to CPOE implementation
May 2013
Minnesota e-Health: Rural Providers
page 3
for CAHs include staff and/or provider training,
resistance to implementation, time required to build
orders into the system, resources required to
build/implement and/or maintain orders, and provider
preference to use handwritten or paper orders.
urban clinics are exchanging health information with
unaffiliated settings. Common barriers to exchange
include competing priorities, limited or nonexistent
capacity of others to send and receive information, and
privacy and security concerns.
Most clinics are effective users of CPOE, defined as
using these tools for 80% or more of all orders.
Effective use among rural clinics is slightly less than
among urban clinics; common challenges for rural
clinics include staff training, provider preference for
paper orders, and limited time during patient encounters.
Nursing homes with EHRs are not using the system for
CPOE at a high rate. Twenty-eight percent of rural
nursing homes reported use of CPOE for medication
orders, compared to 22% among urban nursing homes.
Figure 5: Health Information Exchange among MN Health
Care Settings that have EHRs Installed
Figure 4: Use of Computerized Provider Order Entry
among MN Health Care Settings that have EHRs Installed
Rural
42%
82%
Nursing homes able to
exchange
52%
60%
22%
49%
35%
40%
0% 20% 40% 60% 80% 100%
28%
22%
0%
56%
Percent of Minnesota Provider Settings
Exchanging Health Information
72%
79%
Nursing Homes Using CPOE
for medication orders
38%
Clinics exchanging with
any setting
13%
Clinics' use of CPOE for 80%
or more of orders
84%
98%
Hospitals exchanging
with unaffiliated settings
38%
Hospitals partially
implemented for CPOE
Urban
Hospitals exchanging
with any setting
Clinics exchanging with
unaffiliated settings
Urban
Hospitals fully implemented
for CPOE
Rural
20% 40% 60% 80% 100%
Percent of Minnesota Provider Settings Using CPOE
Health Information Exchange
Health information exchange is the secure electronic
exchange of clinical information between organizations
using nationally recognized standards. The goal of health
information exchange is to help make health information
available – when and where it is needed – to improve the
quality and safety of health and health care. Figure 5
provides a summary of exchange activity among health
care providers in the state. Hospitals have high rates of
exchange, with 84% of CAHs and 98% of non-CAHs
exchanging health information. However, rates of
exchange with unaffiliated providers, hospitals and other
entities are much lower.
Just over half of rural clinics (52%) exchange health
information, compared to 60% of urban clinics, and as
with hospitals there is less exchange with unaffiliated
health settings. Just 22% of rural clinics and 49% of
Conclusions
These findings suggest that, across several health care
settings, rates of EHR adoption in rural areas of the state
are strong. Effective use of these systems has increased
statewide, but rural providers still underutilize EHRs
compared to their urban counterparts. Exchange of
health information is a challenge for providers across the
state, with a need to expand the capacity of all providers
to engage in health information exchange. Despite these
utilization shortcomings, providers have made great
strides to achieve interoperable EHRs and are expected
to continue to make progress.
Data sources
Data are from assessment activities of the Minnesota Department of
Health, Office of Health Information Technology, available at
http://www.health.state.mn.us/e-health/assessment.html. Data used
in this brief are from the 2012 clinic and hospital surveys, 2011
nursing home survey, 2010 lab and local health department surveys;
and pharmacy data are provided by Surescripts (2012).
For more information, contact:
Karen Soderberg
Office of Health Information Technology
[email protected]
www.health.state.mn.us/e-health/.
May 2013