Physician-Patient

Challenges in Rural America

Today

Communicating in a Technical World:

Copyright Susan M. Wieczorek & The University of Pittsburgh, 2009

Current Healthcare Concern $787 billion American Recovery and Reinvestment

Act.

$30 billion allocated towards health-related, information-technology spending and incentives.

2014 deadline. Physicians who do not implement EMRs will not receive Medicare reimbursements.

Promises to reduce general healthcare spending by over $12 billion dollars over the next ten years.

How might these

changes have

particularly affected the

rural physician?

What is Rural? Definitions are not consistent Areas that lack easy geographic access to the

central areas of metropolitan counties (Improving the Operational Definition of "Rural Areas" for Federal Programs Harold F. Goldsmith, Dena S. Puskin, and Dianne J. Stiles Federal Office of Rural Health Policy 1993 US Dept of Health and Human Resources)

An area with an urban population of 50,000 or less and a population density not exceeding 1000 per square mile (The Bureau of the Census Rogers, JT, 1999). 

An area where geography, population density, weather, distance or availability of professional or institutional resources combine to isolate the [patient] in an environment where access to definitive care is limited The Committee on Trauma (American College of Surgeons)

Basic Research Questions What particular challenges are faced by rural

physicians in adopting Electronic Medical Records (EMRs)?

How do physicians perceive their patient’s computer literacy?

Do physicians think their patients want email access to them, health information on line, and EMRs?

How might EMRs improve physician-patient relationships and care?

How might EMRs improve office efficiency and overall effectiveness?

Two Pilot Studies Case Study of a rural, three-member practice that

had just converted from no computers to EMRs Oral History Interviews. Father, son, female associate, and office manager. Transition from multi-member practice that they left. Only independent for the last 14 months.

Quanitative Survey of 400 Physicians in the Johnstown Region of PA. Paper-Pencil survey sent through hospital currier

service. All physicians admitting to the Conemaugh Health

System. 22% response rate.

The Oral History InterviewsOne hour interviews and multiple follow-up emails

Father, son, female partner, office manager Open-ended prompting for impressions, fears,

ideas, patient care, staff problems, etc. Discussed all matters relating to their use of

technology How it affected their relationship and care with patient How it affected the general management of the office

Results reveal basic satisfaction. All around improved flow of information Cost felt to be worth it and even reduced Strong expression of staff, physician, and patient

satisfaction

Specific Interview Responses & Conclusions Patient said Responses

“Are you listening to what I am saying?” or “Hey Doc you have to look at me.” Patrick agreed adding, “I still think the patient deserves to be looked in the eye when you tell them the bad news. They deserve to be looked in the eye when you are giving them your opinion. They do not deserve to look at the back of a keyboard. That’s the way I feel about it and I think that is simply human decency.”

Gerry who has almost exclusively geriatric patients noted that they “loved to look over my shoulder” reviewing their X-rays and lab results with him and searching the Web for medical information together with him in the office.

According to Tamara, the middle aged patients are often less accepting of the EMRs than the elderly patients either because the latter are more trusting or because they do not notice the absence of the charts

Staff Responses Maggie stated that “we had a lot of patients who were very impressed because when they made a call to

the office, you could pull that chart up immediately and know and see what needed to be done.” Maggie simply summarized, “Since day one, no one complained!”

Physician Responses According to Patrick, “The patient interview is more important than the data, it’s more important than

the record, it’s more important because that is how you build trust and rapport with your patient, not by having wonderful technologies….When we were medical students we were still taught to be doctors first not technicians. I mean at some point there is still an art of medicine; it’s not all science and technology. I think a lot of people forget that. This is still a field where you build…lifelong relationships with your patients.”

Study Two: Survey Hypotheses:

• The more favorably physicians feel towards technology in everyday life, the more favorably they will feel towards technology in medicine. (Supported)

• The more favorably physicians feel towards technology in healthcare and non-work areas, the more often they will use and/or implement office EMRs. (No difference—Felt they “had” to do it and would.)

• The more favorably physicians rate their patient’s use of technology, the more often they will use EMRs overall

• The more favorably physicians feel towards EMRSs overall, the more favorably they will view the effectiveness of EMRs for quality patient care.

• Primary care physicians will be less in favor of EMRs in offices today than will all other specialties. (Refuted—More so due to government mandates and attention towards PCPs.)

Additional Survey Results: Physicians were generally favorable towards

technology on all accounts whether they regularly used the Internet, computers, PDAs, EMRs or not--- personally or in their practice. 53.8% stated that they regularly emailed other

physicians (national average about 63%) 13.8% said they emailed patients (national average is

12%) The more favorable they were towards technology, the

more favorably they rated EMRs (86% in favor) The more favorably they rated EMRs, the more they

felt they improved quality of care (59% felt it improved it)

Primary Care Physicians were just as in favor as other physicians

Conclusions

These are pilot studies. Most national attention on EMR adoption is on urban usage patterns.

Results suggest that physician perceptions of technology directly affects…. Their willingness to adopt, Their perception of their patients’ usage patterns and

needs, Their attitude towards e-communication’s overall

effectiveness

Rural medicine is significantly behind implementation in cities but the technology is the same.

a

The road to electronic rural health care is newly paved. Meeting the challenges of this transition will not be easy. The answers lie in continued research using both qualitative and quantitative means of learning about this complicated and important process.