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Rural Delivery: Health Care Lessons from North Dakota

People in rural areas of the United States face unique challenges in accessing health care—challenges that require new ways of thinking and the creative use of resources. Mary Wakefield, Ph.D., R.N., F.A.A.N., a member of The Commonwealth Fund's Commission on a High Performance Health System and director of the Center for Rural Health at the University of North Dakota's School of Medicine and Health Sciences, has spent much of her career exploring strategies for improving rural health. We spoke with Dr. Wakefield about some of the innovations North Dakota has used to improve health care delivery, how these strategies might translate to other settings, and what the next presidential administration must do to ensure health care quality and access for all Americans.

What are some of the special challenges facing health care delivery in rural areas?
Mary Wakefield: Access to services is probably the biggest concern in rural health care. When we talk about access in national public policy forums, we're often referring to health insurance coverage. While that's important in rural areas, too, I'm really talking about geographic access to health care services. It also means access to a health care workforce and access to different sectors—home health care, inpatient acute care, specialty care.

How is North Dakota dealing with these challenges?
Wakefield: One innovation that has emerged in North Dakota—and certainly in other states, as well—is the application of technology to extend the reach of health care providers who might be hundreds of miles away from their patients. For instance, to treat individuals with anorexia, you may need access to psychiatrists. But there are very, very few psychiatrists in rural America. Using tele-mental health, we can use audio and video technology to link the patient to psychiatrists and psychologists.

We can also use information technology to link pharmacists to pharmacy technicians. In many rural communities, there are only pharmacy technicians available. They get their training at a technical college and have a much more limited range of job responsibilities than pharmacists. But, using real-time technology, the pharmacy tech can show the drug to the pharmacist—who, again, may be 100 miles away—and the pharmacist can approve and sign off on it. Consumers also have the opportunity to talk with the pharmacist if they want. If we didn't have that available in our rural communities, in many cases people would have to drive 50 miles to access a pharmacy or a pharmacist in another community. You might ask, 'Is there a potential for a compromise in quality?' But based on data collected so far, using this virtual team our medical errors are actually lower than the national average.

Are these innovations changing the way health care is practiced?
Wakefield: It absolutely changes the way people think about delivering health care services and about health care providers' competencies. I think that we're not doing a great job right now of even thinking about how to educate the next generation of health care workers to deploy technology efficiently in a seamless, coordinated way. We need to step back and ask how we can execute health care services to ensure that they're high quality, safe, efficient, and reimbursed.

Are any of these innovations applicable to health care delivery in urban areas?
Wakefield: Shortages of health care providers are not unique to rural America, although the issue is much exacerbated there. For instance, a community hospital in a medium-sized city may not have a stroke center, but by using these technologies and harnessing the individuals and resources we have available, regardless of their physical location, we can extend the reach of the existing centers. It opens up the opportunity to reach more patients and more communities to provide services.

What kinds of policy changes are needed at the national level to address rural health concerns?
Wakefield: We've got to ensure that good, efficient use of technology receives adequate reimbursement to support those services. If we want to encourage our health care providers to use technology—like e-mail, for instance—we've got to find a way to pay for it. Some insurance companies are now beginning to do that.

We also should be looking at—and this is at the state level—regulatory actions to allow changes in the parameters of how different types of health care providers practice. When we moved to having pharmacists and pharmacy techs work together as virtual teams, it required regulatory changes from the State Board of Pharmacy. Often when you propose changes in scopes of practice, it is a very thorny area because you can get entire professional groups or disciplines rearing up to say no—registered nurses protecting their turf from licensed practical nurses, family practice docs protecting their turf from nurse practitioners, and so on. In our case, it took everybody at the table to agree to this change: pharmacists, the State Pharmacy Association, the State Board of Pharmacy.

What do you think should be the top health care priorities for the next administration, in terms of rural health or health care delivery in general?
Wakefield: First, to reorient the organization of health care and payment policy so they are aligned with each other—to have payment that really motivates and rewards high-quality care and health care delivery systems that are organized to deliver high-quality care. That is unbelievably challenging, extremely difficult. But I think that until we get that right, it's going to be hard to get the changes in organization that we need and use our health care dollars as efficiently as we could and should. In addition, access to health care for the uninsured and driving quality improvement are huge, critical issues.

Can you tell us what you see as the role of the Commission on a High Performance Health System in improving rural health and the health care system overall?
Wakefield: There are many contributions, but one of the greatest is the work of the Commission to inform health care reform at the federal level, and to provide objective, creative, and well-thought-out approaches and solutions to the challenges of compromised quality, decreasing access, and rising expenditures. I think what's particularly helpful is our focus on the organization of health care and trying to drive that agenda forward. It's not just about trying to find ways for the more than 45 million uninsured to have access to health care coverage. It's about reforming the organizations that are providing health care coverage to enhance their efficiency and to ensure consistent, high-quality care.

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