Technology-facilitated care coordination in rural areas: What is needed?

Monday, July 6th, 2020 | Rory | No Comments

Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics. 2020 May;137:104102.


Comments by the lead author – Dr. Emily Gill from Opōtiki


People who live in rural areas have poorer health than their urban counterparts, and for those with multiple, complex medical needs, this is impacted by health IT systems.  This research suggests US rural settings may contend with more unaffiliated electronic health records (EHRs a.k.a. PMSs), than urban settings.  The equivalent in NZ is that rural areas that border between DHBs are more likely to see patients from outside their own DHB, and this poses challenges of accessing and exchanging electronic information (e.g., electronic referrals) with unaffiliated DHBs.  Policy regulations should require that health information be exchanged between all health services, from pharmacy to private hospital to allied health providers, in a way that is ‘useable’ (e.g., user-friendly; without the need to login to multiple other platforms).  An important way to evaluate whether health IT systems are improving health is to focus on care coordination activities: for patients who see multiple health providers due to their complex, chronic needs, how easily can the patient and all the health providers involved access and know pertinent health information, especially when changes are occurring frequently? 

More details:

To provide coordinated care, health information needs to be frequently transferred across settings such as primary care clinics, acute care hospitals, and community health services. The U.S. government made a major financial investment in health information technology with the aim of improving improve care coordination and provided incentives for healthcare organizations to electronically exchange information in a more efficient and accurate process.  Given the increased health needs of the rural population, this research project sought to understand the experiences of healthcare providers in exchanging information during or in response to a transfer of care.


The interviews and surveys conducted through this research described numerous gaps between the necessary care coordination activities for patients with complex needs and the capacity for technology to facilitate the process. Healthcare professionals described low confidence in the integrity of the information they receive, and the effort required to gather needed information, including challenges with arranging real-time communication with other providers caring for the same patient.  Providers described care plans, a potentially useful tool in care coordination, as being regulated to such an extent that they are not used in routine decision making. In exchanging information between organizations using different Electronic Health Records (EHRs), most systems could not automatically incorporate the new information into the existing patient record. This lack of interoperability explains the large quantities of information the providers described faxing and scanning in.  Finally, rural healthcare professionals described the compounding impact of poverty on coordinating care for their patients. Not having transportation to specialist appointments; being geographically located between multiple larger health systems, which amplifies the number of external EHR systems in use; and the lack of access to specialty services all accentuate the challenges of information exchange during care transitions.

Both the U.S. and New Zealand should continue to focus on policy that drives the development of technology standards for how health information is exchanged.  In addition to promoting EHR systems that can receive and incorporate information automatically, standards should guide the usability of digital health data, and how it is aggregated across settings to create useful longitudinal care plans. Policy in both countries should encourage further research to define meaningful measures of how coordination technology tools impact population health.

Dealing with chest pain – a pathway protocol.

Friday, July 3rd, 2020 | Rory | No Comments

Miller R, Young J, Nixon G, Pickering JW, Stokes T, Turner R, et al. Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations. Journal of Primary Health Care. 2020;12(2):129.
open access link

The study protocol for an observational study examining the safety a novel chest pain pathway that uses point-of-care troponin.

Chest pain pathway’s are used throughout the country but largely rely on laboratory based troponin assays, which are not available for a considerable proportion of the rural population.[1] This will be the first large study that examines a rural and/or primary care population.

Enrolment has been more difficult (and slower) than anticipated, but in more than 300 low risk patients (and preliminary analysis), there have been no missed Major Adverse Cardiac Events in the first 30 days after presentation. This is in line with other chest pain pathways that use the new high-sensitivity assays.

very preliminary analysis of the primary end-point 

If you have access to point-of-care troponin and aren’t involved as a study site then please get in touch with me, and if you are already contributing – thank you!! and think of entering patients with chest pain into the data collection tool!


  1. Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.  ↩

People falling over in the South.

Tuesday, May 26th, 2020 | Rory | No Comments

Merrett A, Keys J, Crane C, Gwynne-Jones D. Non-resident orthopaedic admissions to Dunedin Hospital 1997 to 2017 and Southland Hospital 2011 to 2017. The New Zealand Medical Journal (Online). 2020 May 8;133(1514):41-5.

An interesting audit of orthopaedic injuries in the far South published in a recent NZMJ. One of the authors is the current Chair of the Division of Rural Hospital Medicine (Jennifer Keys). The authors found that overseas visitors cost the DHB a lot of extra money when they fall off or over things. It would be interesting to examine the extra workload these injuries have on the rural health services closer to the ‘action’.

Suspect on balance the tourist dollars in far outweigh any extra health costs incurred – as I think we are finding out!



The purpose of this study is to audit the numbers of non-residents requiring orthopaedic admission to Dunedin and Southland Hospitals and determine the effects of increasing tourist numbers on healthcare resources.


All non-resident orthopaedic admissions to Dunedin Hospital from January 2005 to December 2017 and Invercargill Hospital from January 2011 to December 2017 were analysed with respect to country of residence, mechanism of injury, primary diagnosis and case weights consumed. The results were combined with figures from 1997–2004 to give a 21-year series for Dunedin Hospital.


There has been a significant increase in the number of admissions and case weights (CW) over the past 21 years at Dunedin Hospital (p<0.001). The most common mechanisms of injury were snow sports at Dunedin Hospital and falls for Southland Hospital. Between 2011 and 2017 there were on average 50 non-resident admissions per year (92.9 CW/year) to Dunedin Hospital and 74 admissions (120.7 CW/year) in Southland.


Increasing tourist numbers have resulted in an increase number of orthopaedic admissions to Dunedin Hospital over the last two decades although it remains a small proportion of the total workload. Southland Hospital is relatively more affected. These patients represent an annual cost in excess of $1,000,000 to Southern DHB.


Rider unknown. Too much hair for Garry…

image credit:

Pandemics and rural generalist doctors: A West Coast comment.

Saturday, May 16th, 2020 | Rory | No Comments

Brendan and Laura discuss the effect (and need) of rural generalists spanning primary and secondary care on the Coast – especially in the time of a pandemic – in this letter, which is Open Access in the NZMJ.

Marshall B, Aileone L. COVID–19 pandemic and rural generalism: the West Coast’s rural workforce solution. The New Zealand medical journal. 2020 May 8;133(1514):90.


“The current COVID–19 pandemic only strengthens the need to move to a more flexible workforce rurally, where clinicians can flex across services, maximising skill sets and ensuring the workforce is utilised effectively. This is something specialty workforces cannot do effectively, as they lack the training to deliver care in other areas. When the elective work is removed, as is happening within this COVID–19 environment, a ‘specialist’ workforce is often unable to respond to urgent service needs.”

“The opportunity a crisis has provided to do better for patients cannot be squandered. This would see the coast develop a more resilient SMO workforce, while delivering care at a responsible price. In the long term, this would see a combination of local and Christchurch-based specialists working collaboratively with a team of rural generalists to provide the right care for patients into the future.”

Changing the model: Ashburton’s experience

Friday, April 24th, 2020 | Rory | No Comments

Withington S, Kiuru S, Wilson S, Lyons J, Feberwee A, Lander J. Transition of the medical model of care at Ashburton hospital over 10 years: the perspective of rural generalists. Transition. New Zealand Medical Journal. 2020 Apr 3;133(1512).

NZMJ – will become open access after 6 months

Finally something non-COVID. A great viewpoint article in the previous edition of the NZMJ from the team in Ashburton. In this article they describe their transition to a rural hospital generalist model with resident medical officers (house officers and registrars), away from a specialist model. They report their drivers for change and the inevitable challenges.

Interestingly, even with a reduction in the number of beds, reduction in total FTE and double the  number of annual presentations (+106% cf. 2008), there were similar number of admissions and bed days. Transfers increased but not nearly by the same amount as the number of presentations (12% increase in transfers versus 106% increase in presentations [152% increase in Triage 1 & 2 presentations])

Anticentralisationarianism [neologism] in the UK. Viva la generalist!

Tuesday, March 3rd, 2020 | Rory | No Comments

Vaughan L, Edwards N. The problems of smaller, rural and remote hospitals: Separating facts from fiction. Future Healthcare Journal. 2020 Feb;7(1):38.

Open Access link

UK small hospitals are not small by NZ standards but this is still a very relevant summary of the literature that challenges the assumptions health planners make about the merits of centralisation and specialisation. I recommend this paper to all of you in clinical leadership or management positions. For everyone else at least read the sections on ‘The unrecognised problems of closure’ and ‘smaller hospitals and social justice’. Rural hospitals are not just little urban hospitals and they have quite a distinct role in the social and economic fabric of the communities they serve. This follows on nicely from Kati’s recent paper in the NZMJ (Open Access full text available in 6 months time)

Comment by Associate Professor Garry Nixon

This article comes from a themed edition of the Future Healthcare Journal. It is open access.

Take home points

Moreover, while doctors and managers frame arguments about services in terms of quality, safety, cost and efficiency, patients and other community stakeholders have entirely different sets of concerns.

Instead, they view local access to hospital services as a ‘self-evident good’, and consider that most problems could be solved with appropriate resources.

They are clear about the burdens imposed by increased travel time and isolation from friends and family. The role of the hospital in the community is also critical – not only were hospitals frequently the largest employer in the area, but they were imbued with substantial political and symbolic power of the importance of the area in the wider context.

These and other arguments about the disbenefits of hospital closure are rarely discussed in the medical context

Hospital or service closures do not remove risk, but rather transfer the risk from the healthcare system to patients and their families.


Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems – cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

Call to action: American Heart and Stroke association on rural health

Friday, February 21st, 2020 | Rory | No Comments

Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, Hipp J, Konig M, Sanchez E, Joynt Maddox KE. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation.:CIR–0000000000000753.

Open Access

An interesting read from American Heart and Stroke Associations. Key points below – some of which will sound familiar, although in a vastly different health and political (thank goodness) environment!

  • There is no single definition of rural in the United States.
  • Rural population: older, lower population growth, more impoverished, less ethnic diverse, but higher percentage of indigenous populations (living close to or on their homelands)
  • Health outcomes significantly worse (and worsening) cf. urban areas
    • 40% higher prevalence heart disease
    • 30% increased stroke
    • higher maternal mortality rates

y axis = deaths; rural = orange line

  • Hospital care is increasing more difficult and further away (10.5miles cf. 4.4 miles)
    • Worsening as hospitals close (>100 rural hospitals closed since 2010; especially if state did not extend Affordable Health Care act (Obama Care))
  • Harder to access ambulance services
  • Some evidence of worse cardiovascular outcomes in rural v urban hospitals (evidence in NZ coming soon)

“In addition, it is hard to measure and track outcomes of rural hospitals for many conditions because volumes are often sufficiently low so as to preclude any conclusions from being drawn about performance for any individual site.”

  • Patient satisfaction higher cf. urban hospitals’
  • 9% of US physicians practice in rural area (despite 20% of population)
    • 77% of rural areas = Primary Care Health Professional Shortage Areas


  • Supply of clinicians need to be addressed
  • Rural specific team based care models
  • Scope of Practice Laws facilitate rural workforce development
  • Telehealth and digitally enabled health care
  • Rural-specific care delivery sites
  • Regionalisation fo care
  • Sustainable funding
  • Flexible payment models
  • Improvement health insurance coverage
  • Broader economic development in rural areas
  • Research!

“The AHA is committed to leveraging our reach and assets and to working with strategic partners to develop solutions to improve rural health in America.”


Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association’s pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association’s commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.


Thanks to Mayanna Lund (Cardiologist @ Middlemore Hospital) for passing on this paper 

Light em up. Or not?

Tuesday, February 18th, 2020 | Rory | No Comments

IG Stiell, MLA Sivilotti, M Taljaard, et al. Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial Lancet, 395 (2020), pp. 339–349 EZ Proxy link

Papers on managing acute AF have been popping up a bit recently. This one shows that the strategy of procainamide infusion followed by shock was equivalent to shock only strategy (≥200J for the shock). It also showed that pad position (secondary analysis and also randomised for those who got shock) didn’t make a difference.

My interpretation of the study results. Conversion to sinus rhythm was not significant.

Not sure that procainamide infusion is used in our hospitals very much but shock only seems to do the job.

No mention of the recent NEJM study which showed that doing nothing was similar at 48 hours to doing something there and then…

Pluymaekers NA, Dudink EA, Luermans JG, Meeder JG, Lenderink T, Widdershoven J, Bucx JJ, Rienstra M, Kamp O, Van Opstal JM, Alings M. Early or delayed cardioversion in recent-onset atrial fibrillation. New England Journal of Medicine. 2019 Apr 18;380(16):1499–508.

So leave then shock? – what do you think? 

Need a study into long term outcomes for rate v rhythm control after acute AF



Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug–shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion.


We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at, number NCT01891058.


Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug–shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0–9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug–shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68).


Both the drug–shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.


Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.

Good care closer to home!

Monday, February 10th, 2020 | Rory | 2 Comments

Blattner K, Stokes T, Rogers-Koroheke M, Nixon G, and Dovey S. Good care close to home: local health professional perspectives on how a rural hospital can contribute to the healthcare of its community. New Zealand Medical Journal. Vol 133 No 1509: 7 Feb 2020 Link – NZMJ articles are open-access 6 months after publication

This paper from Kati illustrates the unique and special place that Hauora Hokianga has within NZ medical system. The four main themes: “Out context”, “Continuity of care”, “Navigation”, and “Home” encapsulate how many of us would like to view our health services.

Tino pai Kati

“Yes—observation. The medical intervention is quite a small part of medical treatment, isn’t it, often? It’s about being able to observe, have a place of safety, and have a place of recovery as well.”



Hokianga Health in New Zealand’s far north is an established health service with a small rural hospital, serving a largely Māori community. The aim of this study was to gain insights into the wider roles of one rural hospital from the perspective of its staff.


Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health, eight with past and current medical practitioners, three with senior non-medical staff. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the Framework Method.


Four main themes were identified: ‘Our Context’, emphasising geographical isolation; ‘Continuity of Care’, illustrating the role of the hospital across the primary-secondary interface; ‘Navigation’ of health services within and beyond Hokianga; and the concept of hospital as ‘Home’.


Findings highlight the importance of geographically appropriate, as well as culturally appropriate, health services. A hospital as part of a rural health service can enhance comprehensive and continuous care for a rural community. Study findings suggest rural hospitals should be viewed and valued as their own distinct entity rather than small-scale versions of larger urban hospitals.

Kati also pointed me toward this article from this article by Glen Colquhoun. In it he describes a country of many Hauora Hokianga’s.

“The role of a health system is not to bounce patients away from it. It is to help, to open its arms and surround with care. It is to be the embodiment of nurturing – our mother’s wide open arms.”

Broken? Postgraduate medical education

Tuesday, January 21st, 2020 | Rory | No Comments

Hutten-Czapski P. The ‘Brokenness’ of postgraduate medical education. Can J Rural Med [serial online] 2020 [cited 2020 Jan 21];25:3–4. Available (open access) from:

Seem familiar?

“There is a disconnection in all Canadian postgraduate programmes, from both the medical school mission and community needs’ standpoint.”

A nice editorial that outlines issues familiar to us in NZ. The lack of a coordinated pathway (? is there a better term ?) to rural generalist practice. We eagerly await the results of the survey into the first 10 years of the rural hospital medicine training programme, but this programme only addresses one aspect of rural practice – what about rural general practice? what about rurally based academics?

“Not surprisingly, a longitudinal residency that takes place entirely, or mostly, in rural generalist settings (typically between 4000 and 30,000 population and 150–1000 km distant from a city of over 100,000) is associated with rural practice at an odds ratio of 3.9.”