Is the New Rural Hospital REC Funding “Intended” to Help All Rural Hospitals?

By Louis Wenzlow, Rural Wisconsin Health Cooperative Last week ONC announced supplemental Regional Extension Center (REC) funding to provide technical assistance to critical access hospitals (CAHs) and rural hospitals with less than 50 beds. According to the funding announcement, this program is supposed to provide RECs with additional staffing and expertise to assist these hospitals in selecting, implementing, and meaningfully using electronic health record (EHR) systems.  This is of course welcome news. The American Recovery and Reinvestment Act (ARRA) identified CAHs and rural hospitals as prioritized providers, but the initial REC program guidance revised ARRA language and definitions to create an exclusive focus on primary care physicians. (See Chapter 5 of ARRA History http://www.worh.org/hit/arra-history/ for more detail on the initial exclusion.) I can only suppose that last week's "supplemental" announcement is ONC's way of recalibrating the REC program to comply with congressional intent.  Many rural advocates are cheering this development, and I would be among them if not for one sentence in the supplemental FOA: "Funds can only be used to assist CAH and Rural Hospitals that the REC intended to serve in their original application." Having watched CMS propose to exclude all critical access hospitals from Medicaid incentives with a slight of hand definition of "acute care provider," I've come to the conclusion that every word and sentence matters. In this case the word we need to focus on is "intended." The questions that this sentence raises are: (1) what signifies "intent to serve" in the application, and (2) which CAHs and rural hospital will be excluded from getting assistance because their REC (if they have one) failed to indicate an "intent to serve."  If ONC is requiring some sort of explicit statement of "intention to serve" in the original application, then many RECs may have failed to make such a statement ... because ONC instructed them not to. According to a transcript of the conference call that provided prospective REC applicants with instructions on how to fill out their applications: "A couple of questions were around critical access to hospitals and what is the expectation to grow the extension center with respect to the critical access hospitals. The emphasis for the extension center program is primary care, so the expectation and the budget that should reflect and the scope of work ... with the critical access hospitals would pertain to support for the primary care docs and would not be the inpatient implementation of an inpatient electronic health record. Its focus is on outpatient on the outpatient aspect." The takeaway from the above quote is that before the initial REC applications were submitted, ONC made clear that CAHs should not be included in the application unless it was for CAH primary care clinic physicians. A minority of CAHs and rural hospitals actually own primary care clinics. So what can ONC be thinking with the "intention to serve" clause? My hope is that they simply used sloppy language to indicate that RECs can only help the CAHs and rural hospitals in their service area. But no one I have spoken to has so far been able to confirm this. If anyone has an answer, please post a comment. I will update this blog as soon as we get clarification.

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