Implementing Clinical Systems in Rural Areas

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Implementing Clinical Systems in Rural Areas (Part 1)

The 2009 Health Information Technology for Economic & Clinical Health Act enacted by the U.S. government aided in progressing the implementation, adoption, and meaningful use of the core clinical system comprising electronic hospital records and electronic medical records in urban and rural regions of the United States. However, the implementation of this core clinical system in rural areas mainly depended on three different themes including 1) Establishing incentives and standards, 2) Starting the process with vendors, teams, and committees and training, and 3) Surmounting difficulties faced by rural hospitals during the implementation process.



The efficient step-by-step implementation of the aggregated clinical core system incorporating electronic medical records (EMRs) and electronic hospital records (EHRs) in rural areas of the United States was contingent on three separate themes, which included:

Additionally, the implementation process was primarily on a site-by-site basis since many rural hospitals initiated their own application schemes.


Executing the core clinical system with electronic hospital records (EHRs) and electronic medical records (EMRs) in rural regions of the United States, which has scattered rural establishments, began with the nation administering federal policies to expedite the process. The country established the American Recovery & Reinvestment Act (ARRA) in 2009 to build a national IT infrastructure. Afterward, the United States passed the Health Information Technology for Economic & Clinical Health (HITECH) Act, which organized the Health Information Exchange (HIE) across the nation to encourage healthcare CAHs, providers, and facilities to apply EHRs in significant ways.

The HITECH Act's main initiative supplied incentive funding through Medicaid and Medicare to advance the adoption of EMR and EHR in rural regions by helping them surmount any financial limitations. Nevertheless, the final goal was to achieve the acceptance of EMR and EHR nationwide. Additionally, the HITECH incentive disbursement authorized grants to associations, educational institutions, and states to intensify the adoption and implementation of HIE, along with extending the security and confidentiality demands of the Health Insurance Portability & Accountability Act (HIPPAA). Some alterations to the HIPAA Act by the HITECH Act involved the security of patients' electronic health information, as well as electronic protection and access. Through these federal policies, the United States government's intention was to create transformative propositions that facilitated superior methods of handling the health data of patients throughout the country (urban and rural settlements).

The Center for Medicare & Medicaid Services (CMS) directed the essential management guidelines for putting the EMR and EHR core clinical system into action in the country's rural regions. These particular guidelines concentrated on enhancing the quality of patient care and teaching the certification process of electronic health records. They also contributed additional guidance for clinical decision-making in sectors embracing HITECH to implement EMRs and EHRs. The CMS also maintained and coordinated monetary payments for rural hospitals and healthcare providers using EHR and EMR to satisfy the standard placed by the federal government. The criterion by the CMS required them to present their EMRs and EHRs to local and state health departments.


The United States' 2009 Recovery Act allocated more than $20 billion in federal incentive payments for doctors and hospitals in the country using EHR and EMR core clinical systems to progress the safety, effectiveness, and quality of care. Also, the HITECH Act granted billions of dollars in direct funding to clinicians and hospitals in urban and rural regions to assist their leaders and administrators in installing EMRs. Furthermore, the ARRA awarded billions of dollars to small physician practices in the nation to promote the use of EHRs. Rural areas collected around $2.5 billion to develop broadband services to permit the adoption of electronic medical record systems. Finally, the U.S. Congress instituted broadband projects by funding up to $7.2 billion for both the National Telecommunications & Information Administration (NTIA) and the Rural Utilities Service (RUS).


Based on authorized national measures by the federal government, hospitals in rural areas launched the process of implementing the core clinical system, including EHR and EMR, by building vendors, committees, and teams. These groups adhered to a distinct hospital's stated criteria. Rural hospitals recognized that the implementation process (EMRs and EHRs) primarily relied upon clinicians and providers utilizing and pointedly employing technology. Therefore, they started by developing and training staff using IT best practices.

Thus, the effective implementation of the EHR and EMR core clinical system in rural regions had two crucial components. One was staff engagement that included establishing essential committees and teams, along with securing stakeholder buy-in. The other was training staff before implementation to guarantee there was a stable shift to brand-new IT-enhanced systems. Hence, the implementation process, following proper consideration of nationally-instituted standards, involved rural hospitals collaborating with staff members to establish committees and provide training, as well as partnering with vendors and consultants to manage the process and produce the required IT tools.

A rural hospital in the country appointed a Chief Information Officer that took part in the EHR and EMR transition at another establishment to supervise its implementation process. As mentioned in a study submitted to the Walden University, the CIO "established a clinical informatics team, permit team, as well as informatics financial team." The individual also conducted organizational training to introduce cooperation IT best practices to help apply EHR and EMR effectively. While selecting vendors to assist in implementing EHR and EMR in rural hospitals, meaningful criteria included cost, ease of use, scope and cultural fit, and how the latest systems interfaced with existing ones.


Some challenges rural hospitals encountered concerning the implementation of the EHR and EMR core clinical system included the following:

Meanwhile, the operational concerns that impacted the implementation of electronic medical record systems in rural regions were cultural circumstances related to:


Throughout urban and rural regions in the United States, the employment of the core clinical system (EMR and EHR) grew by about 46% with the intent of tackling over 98,000 deaths in the country, as of 2013, caused by the scarcity of data documentation along with exchanges between urban and rural clinics.

Also, there has been expanded utilization of the core clinical system (EHR and EMR) in various areas of the United States because of the series of funding possibilities and federally-established standards, which revealed the significance of e-health. Around 87% of hospitals in the nation, including rural ones, used the EHR and EMR core clinical system, as of 2015, to link their patients to e-health systems nationwide. This percentage rose to 94% in the year 2017.

Between the years 2015 and 2017, the average usage of electronic medical records data by rural hospitals to notify clinical practices grew from 5.1 to 5.5 because of the employment of the EHR and EMR core clinical system. Nonetheless, when compared to those in urban regions, this growth symbolized the smallest application of EMR data in the same time frame. The increase still signified the constant adoption of the core clinical system in the United States.

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Implementing Clinical Systems in Rural Areas (Part 2)

The Northern Periphery Programme funded the ‘Implementing Transnational Telemedicine Solutions’ (ITTS) project through September 2011 to December 2013 and was led by the Centre for Rural Health in Inverness, Scotland and was implemented by the six partner countries Scotland, Finland, Ireland, Northern Ireland, Norway, and Sweden during this time period.


The research was conducted through studies from Researchgate,, WHO, and others. Since the implementation took place from 2011-2013, we had to use sources older than 24 months as the details regarding the implementation models were only available through older sources and no new/updated source was available. This was also required to create a robust case study and to include all the required details.



The Northern Periphery Programme funded the ‘Implementing Transnational Telemedicine Solutions’ (ITTS) project through September 2011 to December 2013 and was led by the Centre for Rural Health in Inverness, Scotland. Ten sustainable projects based on video consultation (speech therapy, renal services, emergency psychiatry, diabetes), mobile patient self-management (physical activity, diabetes, inflammatory bowel disease) and home-based health services (medical and social care emergencies, rehabilitation, multi-morbidity) were implemented by the six partner countries including Scotland, Finland, Ireland, Northern Ireland, Norway and Sweden during this time period.

The Norwegian Centre for Integrated Care and Telemedicine at the University Hospital of North Norway in Tromso was the academic research center for telemedicine in Norway. Norway was an early promoter and adapter of telemedicine applications and Norwegian Health Network (Norsk Helsenett, was founded in 2009 in order to provide an electronic exchange of patient information via a health communication network between all relevant parties within the health and social services sectors.


The implementation was structured around five work packages and 10 demonstrator projects across the partnership countries as mentioned below:

  • Work Package 1 consisted of management, coordination, and communication for the project through the subcommittees by developing and implementing a strategy for informing policy across the partnership countries.
  • Work Package 2 created and sustained the International Telemedicine Advisory Service (ITAS) to provide expert advice on the selection, design, implementation, and evaluation of demonstrator projects.
  • Work Package 3 involved detailed planning to produce business cases which identified established and successful best practices, chose sites, estimated costs of implementation and potential benefits, and created progress indicators.
  • Work Package 4 implemented the above-mentioned demonstrator projects across the northern periphery, utilizing the business plans developed in Work Package 3.
  • Work Package 5 then focused on evaluation and sustainability of demonstrator projects using an evaluation toolkit to measure readiness before implementation and the impact of change after implementation. Additionally, it also focused on an analysis of health service activity before and after implementation, interviews with stakeholders, a health economics analysis, surveys of staff and patients, the impact on travel by staff and patients and on carbon emissions, and socio-economic scenarios modeling the impact of further implementation of telemedicine.


The implementation was structured around five work packages and 10 demonstrator projects; Projects 1 to 4 were related to video conferencing consultations, Projects 5 to 7 were about smartphone and Internet-based mobile self-management, and Projects 8 to 10 were about home-based health services.

  • Project 1- Speech Therapy Services: Speech and Language Therapy (SLT) was administered from a video conferencing unit in an urban location to patients located in rural and remote locations.
  • Project 2- Renal Services: Renal services in Norway and in one site in Scotland included links between central and remote local renal units to include more sites and to use video conferencing and provide communication for outpatient reviews and home dialysis.
  • Project 3- Emergency Psychiatry Services: Psychiatric patients are able to receive consultations near their home and have 24-hour access to psychiatric specialists for admissions at remote centers through the use of video conferencing.
  • Project 4- Remote Diabetes Services: The diabetes consultant is delivered in a central or urban location and through video conferencing carried out reviews with patients who had six-monthly or annual appointments.
  • Project 5- Tracking Physical Activity: The majority of smartphones were equipped with miniature accelerometer sensors which could help in monitoring mobility in the form of step count and made the smartphone a viable device to track and monitor physical activity within the adult/adolescent communities.
  • Project 6- Support for Diabetes: Smartphone self-help tools are able to provide the patient to input to their phone food intake, physical activity, and blood glucose measures and goals thereby, allowing them to self-monitor.
  • Project 7- Inflammatory Bowel Disease: An IBD smartphone application was developed for patients to record their symptoms and their adherence to medication schedules.
  • Project 8- Remote Support in Medical and Social Care Emergencies: To assist individuals with various health and/or social needs to live a more independent and safe lifestyle, a range of telecare technologies have been implemented.
  • Project 9- Remote Exercise Classes for Rehabilitation: The physiotherapistare ble to monitor the home patients using equipment such as a pulse oximeter and cab also speak with all the patients and they can interact with each other.
  • Project 10- Home-Based Service Delivery for Patients With Multimorbidity: A touch screen ‘pod’ allows patients to report symptoms, measure oxygen saturation, weight, body mass index (BMI), pulse, blood pressure and responses about general health and send it via wired or wireless broadband to a secure server through a firewall into a computer to safeguard data, or in some cases, directly into the electronic patient records.


The number of outpatient visits and telemedicine consultations in publicly funded Norwegian hospitals grew after its launch in 2013. Over a period of five years from 2009 to 2013, the number of outpatient visits increased by 11.8%, more outpatient visits than in 2009. The highest growth was recorded in Western Norway and Central Norway with rates of 16.8% and 15.8% respectively. The number of telemedicine consultations increased continually during the study period and were six times more consultations compared to 2009 in 2013.