Oklahoma’s Health Workforce Capacity: The Role of Telehealth / Telemedicine Introduction Previous reports from the Health Workforce Workgroup as part of the Oklahoma State Innovation Model (OSIM) have documented both the landscape for general healthcare providers such as physicians, nurses, and dentists (OSU Center for Rural Health, 2015a) and the gaps associated with employment in these areas (OSU Center for Rural Health, 2015b). In general, these prior reports show the geographic distribution of the Oklahoma healthcare workforce, providing evidence that small and rural areas continue to be proportionally underserved. While workforce supply and demand estimates can vary greatly, the reports document a predicted shortage of nearly 500 primary care physicians in the state by 2030 and conclude that a severe primary care provider shortage persists. This current report focuses specifically on the practice of telehealth and telemedicine across the state, with emphasis on the ability of this technology to mitigate workforce gaps. A large portion of this report deals with documenting existing telemedicine and telehealth practices across the state, including adoption of Electronic Health Records (EHRs) and Health Information Exchanges (HIEs). Policies supporting the use of telemedicine / telehealth are discussed, including those related to the infrastructure required for such programs. Limitations of the technology are also explored. Methodology The overall goal of this section of the report is to describe the role and impact of telehealth / telemedicine on Oklahoma’s health workforce. As such, it uses a variety of data to assess progress and trends across the state while also turning to the academic literature for examples of success as well as words of caution. Specifically, the data in this report are drawn from primary and secondary sources including: the final report on a survey of Electronic Health Records (EHR) / Health Information Exchange (HIE) use performed by the Health Information Technology working group associated with OSIM; a recent (2015) survey of telehealth / telemedicine services among rural hospitals in the state; recent academic literature on telehealth / telemedicine; and an assessment of the current telemedicine-oriented policy environment in Oklahoma. For the purposes of this report, the following definitions are used (Kvedar, Coye, Everett, 2014): Telehealth – the applications of technologies to help patients manage their own illnesses through improved self-care and access to education and support. Telemedicine – the use of technologies to remotely diagnose, monitor, and treat patients.

1

1. Current Telehealth / Telemedicine activity in the state Two specific data sources are used to document the current status of telehealth and telemedicine within Oklahoma. These include the Final Report on EHR / HIE adoption (OFMQ, 2015) which had over 1,400 responses from physician offices, behavioral / mental health facilities, hospitals, and long-term care facilities; and an internal survey run by the Office of Rural Health (2015c) which had 27 responses from hospitals in rural parts of the state. In some cases, these results are compared to earlier surveys or findings from related academic studies. 1.1 OSIM EHR / HIE Survey Final Report (OFMQ Report) The 84-page document provided by the Health Information Technology working group provides detailed information on specifics related to survey methodology, response-by-response analysis, and barriers / recommendations for EHR and HIE adoption and utilization across Oklahoma. Although telehealth and telemedicine are not explicitly tied to EHR / HIE use, the tools are complementary and the standardization afforded by EHR / HIEs is vital to fully recognizing the benefits of telehealth (Waldo, 2003). The OFMQ survey results discussed here are chosen for their relevance to workforce capacity. EHR / HIE adoption The OFMQ survey reports rates (as of 2015) for EHR and HIE adoption across Oklahoma health facilities, as broken out by facility type below. Table 1. EHR and HIE adoption rates by Facility Type Facility Type EHR Adoption HIE Adoption Rate Rate Hospitals 92% 52% Behavioral / Mental Health 75% 21% Long-term Care 64% 34% Physician Office / Ambulatory 94%1 55% Clinic

# Survey Responses 90 243 247 906

Source: OFMQ Survey (2015)

The OFMQ survey also asked specific questions on whether specialized staff were responsible for entering, managing, or analyzing EHR data. 70% of all respondents said yes, including 82% of hospitals and 70% of physician offices. Interestingly, the percentage responding yes to this question was highest when the staff size was relatively low: 78% when the staff size was 2-5, 1

Whitacre and Williams (2015) document Oklahoma practice-level EHR adoption rates of only 43% as of 2011, significantly lower than the 94% reported from physician offices in the OFMQ survey in 2015. The latest nationallevel statistics indicate adoption rates of around 78% in 2013 (Hsiao and Hing, 2014). While some increase has undoubtedly occurred since those years, the exceedingly high rate reported by OFMQ is subject to scrutiny. The Whitacre and Williams data is based off of a comprehensive listing of 2,800 unique practices, while the OFMQ data represents 906 practices and may be subject to self-selection bias. This is because, as the report notes, “it is possible that facilities without an EHR in place were less likely to respond to the survey.” Thus, it seems likely that EHR adoption rates across all Oklahoma practices are less than what is reported in the OFMQ survey.

2

81% when the staff size was 6-10, but only 64% when the staff size was 11 or more. This suggests that with larger staffs, there is more opportunity to ‘fit in’ the EHR work among those already employed. This hypothesis is given more credence by a follow-up question asking for the type of education or qualifications these specialized staff had: 56% were classified as informal, on the job training, while only 10% had IT backgrounds. Only 3% of respondents indicated that they had plans to hire more such staff; however 51% did not know whether or not they would. In terms of HIE adoption, only 14% of respondents indicated that “need more staff” was a reason preventing them from connecting to a HIE, while an even smaller 7% cited this as a reason why they are not using their HIE more effectively (cost and technical challenges were the #1 reasons, respectively). Implementation of EHR systems has been shown to improve efficiency among primary care providers (Pizziferri et al., 2005), but little work has documented their impact on overall employment at specific health facilities. One exception is Hersh and Wright (2008) who find that the amount of IT staff hired varies from 0.08 full-time equivalent per bed for hospitals at the lowest level of EHR adoption to 0.21 FTE per bed at higher levels. However, these were ITspecific staff, and most research has not focused on the impact to primary-care practitioners such as nurses.2 The estimates in Hersh and Wright (2008) suggest that a Critical Access Hospital with 25 beds may have added anywhere from 2 to 5 employees to deal with IT issues associated with EHR / HIE adoption. Larger hospitals across the state (with 100+ beds) could have added 8-20+ employees according to these estimates. One important finding from the OFMQ survey relates to geographic perceptions of workforce barriers to effectively utilize either EHRs or HIEs. Interestingly, urban respondents were more likely than rural to note that they need more staff to help with EHR documentation (21% vs. 15%, p