Becker's Hospital Review

22 Executive Briefing Sponsored by: I n the shadows of large, urban hospitals and academic medical centers, small to midsized community hospitals in rural America can increasingly feel left behind. Some challenges they face are unique to their markets' economic, social and geographic factors. Other threats are universal — felt by hospitals small and large, in town and country — but especially daunting for rural hospitals, considering their thin margins and limited resources. While they may not have the largest footprint, small to midsized community and critical access hospitals play a crucial role in the U.S. healthcare system. Fourteen percent of Americans, or approximately 46 million people, live in rural counties, according to the Pew Research Center. The U.S. population is aging nationwide, but rural areas have a higher share of adults age 65 and older than urban or suburban counties, meaning they also see higher prevalence of chronic disease, a higher disability rate, lower prevalence of healthy behaviors and a growing gap in life expectancy compared to the nation as a whole, according to population health researchers. "Just because you're a rural, small- to medium-sized hospital doesn't mean you don't have people who are as sick as can be," said Paul Black, CEO of Allscripts. "They have dietary problems, anxiety problems, cardiac problems — people with those health issues don't just live in big cities." Since 2012, Mr. Black has led Allscripts, a trusted partner to many leading healthcare organizations and thousands of clinicians around the world for its EHR, population health, patient engagement and revenue cycle management services. In October 2019, Allscripts hosted a private summit in Chicago at the Becker's Hospital Review 5th Annual Health IT + Revenue Cycle Conference for leaders from hospitals with 100 or fewer beds across the country to discuss opportunities and challenges in the rural healthcare landscape, including innovation, clinician burden, population health and variation in clinical care and practice. What follows is an abbreviated summary of that gathering. 'You are their last hope' Small to midsized community hospitals in smalltown America face distinctive economic, social and geographic disparities that can challenge healthcare delivery and limit access to care. People who live in small or rural communities are less likely to receive the basic healthcare they need, and physical distance from care is a primary reason. Consider rural residents who live on farms and must travel long distances to reach a healthcare provider. The time they must take off work to make an initial or follow- up appointment causes many to delay or forgo care. This dynamic can make rural hospitals' population health efforts especially difficult. "We can talk about precision medicine, consumerism, telemedicine and all those wonderful things," said Mr. Black. "But I think about what you do day in, day out, 99 percent of the time when people come to your emergency room or your critical access hospital. You are their last hope. They don't want to go to the big city." To complicate things, small and midsized community hospitals are encountering another major threat on a regular basis that counters their very mission: cyberattacks. All hospitals make attractive targets for cybercriminals due to the increasingly interconnected nature of their operations and IT, but smaller hospitals are more susceptible to cyberthreats like ransomware since they are less likely to possess robust cybersecurity policies and resources and more vulnerable to the financial impact, according to Moody's. "There's a hot place in hell for people doing cybersecurity attacks on hospitals, and a lot of you are vulnerable to that," said Mr. Black. "You didn't do anything to deserve it, but it's a real, live issue in this world today. Having an infrastructure in place with a shield against that is not impenetrable, but more effective than what's probably happening each and every day at your hospitals." Many rural hospitals have minimal operating margins with little room for financial loss. In fact, 21 percent of U.S. rural hospitals are at high risk of closing unless their finances improve, according to a 2019 analysis from management consultancy firm Navigant, which assessed hospitals' operating margin, days cash on hand and debt-to- capitalization ratio. One determinant Navigant specifically cited for at-risk hospitals is their lack of capital to invest in updated, innovative technology. Innovation to transform healthcare: It takes a village Thousands of hospitals, health systems, community practices and pharmaceutical companies rely on Allscripts to build open, connected communities of health through its EHR, financial management tools and population health systems. Better Outcomes: The Deciding ROI for Community Hospitals' Technology Investment

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