Category: Thought Leadership
May 3 2017
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Oklahoma State University (OSU) is uniquely transforming health care through the establishment of OSU’s Center for Health Systems Innovation (CHSI). CHSI’s mission is to transform rural and Native American health through the implementation of innovative care delivery and information technology solutions.  

America’s health care system is far from perfect – anyone in the industry can tell you that. What many industry professionals are less willing to admit is that one of our health care system’s greatest areas of disparities is in rural America. 

Often, because health care organizations in rural communities are understaffed and separated by great distances, rural residents go without the care they need. By and large, the industry seems to consider the lack of health care in these areas to be low on the list of priorities – a mentality that doesn’t do anyone much good. 

Here’s the thing: If we look at the volume of rural residents nationwide, we’re considering a sizable population of up to 46 million people who likely have limited access to quality health care. That’s a lot of people who could use our help. What’s causing this issue in rural America, and how can practices like open data access help us solve for it?

Rural health care’s supply and demand problem 

In the health care industry, the aging baby boomer population brings some key challenges to the spotlight – especially in rural health care markets. Approximately 76 million baby boomers were born between 1946 and 1964. Until recently, they were America’s largest demographic population (millennials have recently claimed that spot). Of those baby boomers, around 40 million are already aged 65 or older. 

Today, one of the chief economic concerns facing the United States is how to address this shift in demographics and prepare for it. The baby boomer bubble issue affects all industries, but when it comes to the health care industry, we’re affected on both sides of the supply and demand curve. 

As we get older, we develop more age-related, chronic conditions; as our health care needs go up, the demand for health care rises. In the industry, the physicians and other providers that would otherwise be meeting the demands of the health care system are also getting older and retiring. So, thanks in part to a baby boomer population that is hitting retirement age at a rate of 10,000 people a day, the health care industry gets hit twice as hard on both the demand for services and the supply of providers. 

While this trend broadly affects the entire health care industry, the rural market is hit the hardest. In these rural markets, demand for health care is even more critical because the population of rural patients generally carry higher incidence rates than their urban counterparts for many chronic conditions, including hypertension rates, diabetes rates, tobacco use rates, congestive heart failure and more.

On the other hand, primary health care coverage is a significant delivery challenge in rural markets. For instance, in Oklahoma alone, we were short 530 rural primary care doctors in 2013; by 2025, that number will be closer to 830. Nationally, the ratio of patients to primary care physicians in rural areas is only 39.8 physicians per 100,000 people; this is significantly lower than the 53.3 physicians per 100,000 people in urban areas. In rural Oklahoma, there are about half as many primary care physicians practicing as there are in urban areas. This figure doesn’t account for the number of rural primary doctors in Oklahoma that are approaching retirement age; today, 25 percent are over the age of 65, and 50 percent are over the age of 55. 

Additionally, while rural areas are understaffed at a primary care level, there’s also a significant shortage or complete absence of subspecialty level practitioners. In Oklahoma in 2015, for example, while there were 2,856 active rural primary care physicians, there were only 616 active rural subspecialty physicians. This means that if a patient required a specialist’s care beyond what their primary care physician could provide, their options would have been incredibly slim. 

Solving for rural patient populations 

There are several ways we can address the significant challenges of rural health care. We can graduate more doctors, we can increase financial incentives to get doctors to go practice in rural medicine and we can adjust licensure requirements so that providers can deliver health care services at the top of their grade. Today, there are people focused on those solutions, and they will continue to help lessen the burden of those supply and demand challenges that are happening in rural America. 

At Oklahoma State University’s Center for Health Systems Innovation, we’re trying to augment those solutions through a couple strategic initiatives. One part of our center is focused on improving the business of rural health care through improved workflow delivery models and better operational efficiencies. The other part of our center is focused on developing and delivering new information technology solutions and tools to rural health care providers. We want to build layers of forward-thinking technologies – virtual medicine, mobile health, telehealth, predictive algorithms, e-doctor visits and more – into the rural health care system.  

Recently, we’ve concentrated on developing predictive tools that allow rural primary care physicians to manage their patient populations where there is a lack of subspecialists. For example, we know that nationally, about one-third of diabetics will make an annual exam with an ophthalmologist for their annual diabetic retinal eye exam. In the rural market, we can estimate the percentage of diabetics who get an annual exam to be significantly lower, since the number of ophthalmologists will be lower. 

On the other hand, we do know that high percentages of those diabetic patients will go to their primary care physician at least once a year. Without this annual eye exam, diabetics are at an increased risk for diabetic retinopathy, which, when left untreated, can lead to rapid and permanent vision loss. (If caught early, the patient can be treated with an effective laser solution.)

We decided to develop an algorithm that could help rural primary care physicians screen for diabetic retinopathy in their patients without potentially needing a consult from an ophthalmologist. To do this, we took a look at the existing clinical data that a rural primary care doctor might collect – a patient’s demographic information, their comorbidity information and the lab results from a basic lab test. Using this information, we developed a tool that can screen for whether a patient has diabetic retinopathy so that the primary care physician in a rural community can identify those patients and get them the care they need. 

Ultimately, we're developing tools that we can put in the hands of the primary care doctors in rural America to allow them to do more with less – especially in those environments where they don't have all the resources they need. 

Innovative solutions require open data access 

Open data access has let us develop predictive tools – like our diabetic retinopathy algorithm – that we can implement in the rural marketplace. 

Cerner’s Health Facts database has been crucial to our progress. By pulling information from over 2 million diabetic patients with over 6 million encounters out of the database, we were able to draw conclusions and build that algorithm. There's no way we would have enough data to develop a diabetic retinopathy algorithm from our own data sets; there’s not enough volume and breadth in our data.

Like many industries, open data access empowers innovators develop tools to assist their stakeholders. The health care industry is no different. Digitized health information creates a structured collection of health information that helps us develop these predictive tools to implement in rural communities, which helps us solve for the lack of subspecialists and lack of primary care physicians. Ultimately, these same tools can be used in urban and international markets, and will contribute to the progress of care for all patients. 

Do you want more health IT insights? Check out Cerner's Perspectives, a thought leadership publication.

Dr. William Paiva,Executive Director, Center for Health Systems Innovation

Dr. William Paiva Executive Director, Center for Health Systems Innovation Oklahoma State University

@williamdpaiva

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