Mid-Columbia Medical Center is a community hospital like many others in a small city serving a semi-rural area, though natives would argue the bucolic region in north-central Oregon along the Columbia River—bulging with cherry orchards and graced by the neighboring magnificence of Mount Hood—is not like other places.

What it has in common with other community hospitals is the particular challenge of how to address the meaningful use objectives of HITECH as a small, independent facility that lacks the deep clinical and IT wealth of both its urban-medical center cousins and hospitals that belong to large healthcare delivery systems.

Mid-Columbia, however, provides an instructive example of how a community hospital with fewer than 100 beds can favorably position itself and reasonably expect to reap the incentives of meeting both ambulatory and acute-care requirements.

The hospital in The Dalles, a city of 15,000 people 80 miles east of Portland, has certain advantages, like a collegial, well-defined community and ownership of its physician practices. But by presciently leveraging the resources available to it—and by extension, available to any "garden-variety" community hospital across the country—it's on track to achieve the clinical quality, patient safety and operational efficiency that meaningful use implies.

Among the key components of its IT approach:

    •    It has proceeded from a mindset that the goal is to build clinical quality and efficiency for the long haul, with meaningful use incentives more of a bonus than a goal by itself.
    •    It has drawn the community's health interests together— physicians, other hospitals, public health department, federally qualified health center—toward much the same EHR and communitywide information- sharing platforms.
    •    It has identified and set loose an IT "evangelist" and an IT-savvy physician champion to lead by explanation and example, both with enthusiasm to burn.
    •    It has treated its status as a small, regional referral center as a plus, exploiting deep ties to the surrounding community to gain cooperation and validation that sometimes eludes more inward-focused large healthcare organizations.
    •    At the opposite extreme, it's porting local plans for information sharing to the state level to get in early on the shaping of health information exchange throughout Oregon.
    •   
"Our Valhalla is to be a true community health resource built around clinical quality and efficiency," said Duane Francis, president and CEO of Mid-Columbia. Francis, who has been CEO since June 2002 and at Mid-Columbia for 20 years, views both the inherent scale and mission of a community hospital as distinct advantages in achieving the goals of meaningful use.

"We see our size as an advantage, including being able to work with a cooperative group of providers that's fairly finite instead of having to deal with 10 or 12 disparate ones. We also have fewer sites," and that makes the job easier, he said. "We're not a rich hospital, but we saw a long time ago the value of investing in IT, so we've invested very scarce resources [starting] seven years ago."

Early to the task
Following the usual battles with physicians over selection of an ambulatory EHR, Mid-Columbia selected a platform from Horsham, Pa.-based Next- Gen Healthcare. It went through sticker shock: The $600,000 set aside seven years ago to begin the conversion to NextGen "turned out to be a drop in the bucket," because of additional "soft" costs beyond the technology itself, said Francis.

Five years after beginning implementation, the organization converted the last physician practice. On the inpatient side, the hospital has invested $3.5 million to $4 million since the mid-1990s in a platform from Westwood, Mass.-based Meditech.

"I'm not worried at all about fulfilling meaningful use because of the human resources, IT and capital investments we've already made in moving to that digital platform," said Francis. "A lot of my counterparts are playing catch-up."

While it was pursuing IT initiatives, the hospital expanded its group of employed physicians and convinced a federally qualified health center to select the same ambulatory platform. The latter gave Mid-Columbia a solid partnership with the local public health department for creation of a health information exchange (HIE) network called Gorge Health Connect, an independent 501(c) (3) organization that will help achieve the community information sharing expected in later stages of meaningful-use requirements. Three critical-access hospitals in the region also are participating.

"We know we have a shot at this thing because we're not on such a grand scale with a lot of disparate systems," said Francis.

Marshalling local capacity
Before the HITECH incentive program came out, Mid-Colombia had already conceived of a community health record (CHR) group to work closely with community physicians, said Erik Larson, vice president and chief information officer. The governing board has doubled nicely as a vehicle to perform analyses of the gaps between current IT capabilities and those required for meaningful use.

The CHR group started up a year ago, meeting biweekly as two subcommittees. CIO Larson oversees a subcommittee for the inpatient side. Heading up the outpatient subcommittee is Brian Ahier, whose formal title is "HIT evangelist" to designate his role as liaison to not only the physicians but also the surrounding healthcare community, including public health agencies, Gorge Health Connect and the state. Other members of the outpatient IT assemblage include the executive director and support staff from the medical group, and the hospital's Next- Gen EHR analyst.

Part of the gap analysis is to inventory available resources to determine, for example, if the hospital should hire someone on staff or retain the services of a consultant to help manage the meaningful- use process. "It's a process that's time and resource intensive" and may require bringing on additional resources, said Larson.

Giving Ahier his role two years ago started the ball rolling for leveraging the community and state resources that are not only available to a small community hospital but are part of its identity, according to Larson. "If you look at the metro area, healthcare organizations work within themselves. In a smaller community we can naturally leverage public health departments and standalone clinics." A community hospital, he said, also must recognize and exploit its relationship with state government: How can the hospital leverage the larger state initiatives that exist?

The task of building relationships near and far falls to evangelist Ahier. "I want him out there as a zealot," said CEO Francis.

Tapping experts with enthusiasm

So far the strategic role with the unconventional title seems to be working. Partly through Ahier's outreach, Gorge Health Connect has forged partnerships with the local community college, Mid-Columbia, Providence Hood River Hospital, a local women's clinic, a surgical specialists practice, Latino health agency, and county and district public health agencies.

After obtaining funding from HRSA, Gorge Health Connect completed a one-year planning process to identify key gaps in information sharing that potentially lead to increased health disparities, increased risk of medical error and higher cost of practice among community health providers. The organization has also conducted a readiness assessment and established the governance framework for HIE and is now poised to implement an integrated rural health network in the four-county area.

Ahier shares leadership in IT adoption with Dr. Tom Nichols, now head of hospitalist physicians at Mid-Columbia while directing its implementation of computerized provider order entry (CPOE). Nichols launched his primary care practice with his wife as office manager after completing medical training in 1989, and almost immediately he was tinkering with automation, generating an electronic record that improved patient flow, medical information flow, health management and even a form of voice recognition.

In 2001 Nichols left solo practice for a six-physician office that acquired the NextGen ambulatory EHR. He realized that IT actually made physicians less efficient on a per-patient basis, but also that automation was a good thing globally— and "at the end of the day, I didn't have a pile of paper." The actual time spent was more on patients and less on administration. Recognizing Nichols as an IT trailblazer, Mid-Columbia tagged him as its physician champion for implementation of its ambulatory EHR.

When Mid-Columbia moved to a hospitalist model in 2006, Nichols joined the new arrangement and brought his clinical IT experience with him, knowledge he found easier to share among the nine-person hospitalist group than it would have been "if we had 40 different [independent] practitioners" who were seeing their own patients in the hospital. Now the physician IT champion within the hospital, the cohesion of the hospitalist group has helped  it become one of the leaders in meaningful use issues like verification, using an electronic medication administration record (eMAR) and CPOE.

Reaching outside the community
Carol Robinson, HIT Coordinator for the State of Oregon in Salem, said she welcomes someone like Ahier with the literal job description of spreading the word about the role of HIE in patient care and population management. In developing a state HIE plan required under the cooperative agreement with the Office of the National Coordinator for Health Information Technology (ONC), the aim from the start was to support communities like The Dalles and Mid-Columbia in planning and executing their own HIE networks like Gorge Health Connect.

Oregon is taking a federated approach, providing core central services built on economies of scale that knit regional efforts together while allowing communities to self-determine strategies with long-term impact, said Robinson. "It's really about creating a belief in the improvement potential of health information technology for patient outcomes and overall population health." Because Oregon is diverse in its population, geography and politics—ninth in state size but with only 3.8 million in population—it has diverse needs and any HIE strategy requires a combination of strategies, she said. Given other burgeoning efforts around the state besides Gorge Health Connect, the state has opted for a market-driven approach that allows communities to develop their own links to providers, hospitals and labs. Mid-Columbia's outreach includes relying on its ambulatory EHR vendor of choice, NextGen, for advice and support. The vendor has already certified its latest version for HITECH and is investing in training users through seminars and classes to execute the nuts and bolts of meaningful use, said Dr. Sarah Corley, the Washington-based chief medical officer for the IT vendor. Local physicians need to be versed in not only meaningful- use measures but also the workflow changes and quality improvements that produce the results—"because in Stage 2 they'll be judged based on outcomes," said Corley. NextGen is also working with regional extension centers (REC) to help automate small primary care offices. "They don't have a lot of resources," she notes, and rural physician practices are especially lacking.

Meaningful use keeps plan on course
Once Mid-Columbia committed to the millions of dollars it will take to set up the necessary IT capacity, the requirements for meaningful use are helping the community hospital and its physicians stay the course, said CEO Francis. "I look at meaningful use, which I fully support, and see a long-needed oasis in the desert. It's badly needed by organizations like ours."

The federal initiative supports "the recognition that we had to move to a digital platform for our doctors in the outpatient sector as well as the inpatient side," he said. That's crucial when costs keep going up because doctors can't see as many patients in the same time frame as they could when practices were managed on paper.

"We're seeing a 10 percent to 20 percent drop in the number of patients, but we look at it as a price you have to pay," Francis said. "We've said from the outset that we're jumping into clinical IT. We will not retreat. So the other aspect of meaningful use is that there's not even an option to retreat, because if you retreat you won't be able to participate."

But the real message in that policymaker's phrase is how IT-enabled processes make the clinician's job of caring for patients easier and better. Dr. Judy Richardson, president of Mid-Columbia's medical staff, recalls just how electronic information sharing improved the care of patients in rural areas by making it possible to communicate over long distances and bring together a big academic medical center with the community hospital.

The Oregon Health and Science University (OHSU), the state's premier health and research center, is a 90-minute drive away, a three-hour roundtrip. That's the trek Richardson would have faced for her very sick 5-year-old, on what was an icy winter night, had she not been able to order an x-ray that was transmitted digitally to a leading pediatric specialist at OHSU for evaluation.

The consultation was critical because prescribing the wrong antibiotic could have been fatal—and having the child's parents drive her all the way to Portland not only would have a danger by itself but would have delayed the much-needed therapy. Instead, Richardson logged on to the hospital's EHR, which by special arrangement is linked to OHSU's EHR, and was able to quite literally get the right drug for the right patient at the right time. The treatment was successful and avoided a costly and potentially traumatic hospital stay.

"I wouldn't have been able to do that six years ago," she said. "That's profound for a rural environment."