Department  of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

AREA HEALTH EDUCATION  CENTERS

A Role  in Enhancing

the  Rural  Practice  Environment

#J SERWCE3 
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Inspector  General 
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0EI-01-93-O0570  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared  under the direction of Mark R. Yessian, Ph.D., Regional Inspector 
General, and Martha B. Kvaal, Deputy Regional Inspector General, Boston Region, Office of 
Evaluation and Inspections.  Participating in this project were the following people: 
Boston  Headquarters 
Russell W. Hereford, Ph.D., ProjectLeader  Alan Levine 
Dana L. Miller 
For additional copies of this report,please contact the Boston regionalo~e 
/y telephone at (617) 565-1050, or by fax at (617) 565-3751.  Department  of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

AREA HEALTH EDUCATION  CENTERS

A Role  in Enhancing 
the  Rural  Practice  Environment 
v+ -  $ ? 
$  JUNE GIBBS BROWN

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a  Inspector  General

73 
%++ 
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>
0EI-01-93-O0570  EXECUTIVE  SUMMARY

PURPOSE 
The  purpose  of this inspection  is to assess the  role  that  Area  Health  Education 
Centers  play  and  can play in providing  support  services  to enhance  the  practice 
environment  for health  care  practitioners  in rural  areas. 
BACKGROUND 
The  goal  of the  Area  Health  Education  Center  (AHEC)  program  is to link health 
professions  education  with service  delivery  in underserved  areas  by bringing  together 
the  academic  resources  of a university  health  sciences  center  with local  clinical 
resources.  The  FY  1994 appropriation  of $22,203,000  supports  19 basic  AHEC 
programs  and  13 model  State-supported  programs.  The  FY  1995 appropriation  is 
$24,625,000. 
During  our  background  work  on this inspection,  we met  with  staff from  the  Division  of 
Medicine  within  the  Public  Health  Service  (PHS)  to discuss an inspection  focusing  on 
AHECS  provision  of continuing  education.  They  expressed  a desire  that  we broaden 
the  focus  of our  inspection.  Consequently,  we expanded  our  inquiry  to include  library 
resources  and  telecommunications,  and  to consider  ways in which AHECS  could  play a 
lead  role  in helping  rural  health  professionals  practice  in a changing  health  care 
system. 
Our  methodology  uses AHEC-reported  information  from  four  primary  data  sources: 
(1) funding  applications  submitted  to the  Bureau  of Health  Professions  (BHPr)  from 
13 AHEC  programs  for a 3-year  period  ending  in 1994 and  from  10 model  AHEC 
programs  for FY  1994; (2) data  on continuing  education  activities  from  all AHEC 
programs,  submitted  to BHPr  for FYs  1991-92 and  1992-93; (3) telephone  interviews 
with  directors  of 19 AHEC  programs;  and  (4) site visits to 4 AHEC  programs  in 3 
States,  during  which we met  with more  than  30 rural  practitioners. 
FINDINGS 
MIEC3  are enhancing rural practitiontm  access to health care information by linking 
them with medical  library rtxou.rtw. 
.	 AHEC-provided  library  resources  include  professional  staff, computer 
equipment  (both  hardware  and  software)  for data  base  searches  and  document 
distribution,  practitioner  training,  and  books, journals,  and  audio-visual  tapes. 
.	 As special  incentives  to attract  community-based  faculty  for their  students, 
AHECS  provide  additional  training  on using data  bases,  free  use  of medical 
library  resources,  and  computer  hardware  and  software  to access  these  resources. 
i  AHEC3  are responding to the need  of many types of practitioners for continuing 
education  on clinical topics. 
.	 AHECS  continuing  education  courses  cover  a wide range  of topics  in the  health 
care  field. 
	 In developing  their  continuing  education  agendas,  AHECS  try to be  particularly 
responsive  to community-based  practitioners  in order  to encourage  their 
involvement  with AHEC-affiliated  students  and  residents. 
.	 On  average,  more  than  two-thirds  of participants  in AHEC-sponsored 
continuing  education  programs  in 1993 were  nonphysician  practitioners, 
including  nurse  practitioners,  physician  assistants,  nurses,  and  allied  health 
professionals. 
For the most pati,  howeve~ AHEC3  are inking  opp~  to educate practitioners 
about innovatkms  h  health care delivery, such as cliiukal practice guideliiaes or managed 
care. 
.	 Although  clinical  practice  guidelines  are  intended  to help  practitioners  make 
clinical  decisions  about  patient  care,  most  AHECS  have  not  included  these 
topics  in their  continuing  education  courses. 
.	 Despite  the  potential  impact  of managed  care  on rural  practice,  most  AHECS 
have  not  included  courses  on this topic  in their  continuing  education  programs. 
MZEC3  are beginning to use telecommunications  to provide  supprt  to isolated 
practitioruxq  but they are not yet taking advantage of the jhll potential  of thzk technology. 
.	 AHECS  most  common  use of telecommunications  is to provide  additional 
education  for professional  advancement  of local  nurses.  Except  for this 
purpose,  however,  few AHECS  utilize  regularly  scheduled  telecommunications 
programming. 
	 Constraints  on greater  AHEC  use of telecommunications  include  AHECS  lack 
of ownership  of the  technology,  its capital  and  operating  costs,  and  lack  of 
practitioner  familiarity  or comfort. 
OPPORTUNITIES:  LOOKING  TO  THE  FUTURE 
AHECS  are  well positioned  to help  practitioners  address  emerging  issues  that  impact 
health  care  delivery  in rural  areas. 
We recommend  that the Public Health  Service strengthen the role of AHEC3  by 
facilitating  their abi@  to fxus  support services on three areas:  clinical practice 
guidelines+,munaged care, and telecommunicatiom. 
ii    Clinical practice guideliiaes 
AHECS  could  facilitate  adoption  of clinical practice  guidelines  in rural  practice  by: 
 Including  guidelines  aspartof  continuing  education  courses 
 Ensuring  guidelines  areavailable  intheir  medical  libraries 
o Helping  adapt  guidelines  to rural  conditions 
The  PHS, working  through  the  Agency  for Health  Care  Policy and  Research,

could  encourage  guidelines  adoption  by:

 Involving  AHECS  in the  development  of guidelines

 Encouraging  AHECsto  disseminate  guidelines

 Assessing  rural  practitioners  concerns

 Examining  theuseof  guidelines  in rural  areas

  Managed  care 
AHECS  could  inform  rural  practitioners  about  managed  care  by: 
 Sponsoring  informational  spposia  for rural  practitioners 
o Assisting  practitioners  in negotiating  contracts 
 Participating  in State-level  planning 
The  PHS  could  assist AHECS  in this effort  by: 
 Disseminating  information  on managed  care 
o Taking  advantage  ofitsongoing  communications  with AHECs 
  Telkcommunicatins 
AHECS  could  lead  efforts  to take  greater  advantage  of telecommunications 
potential  to facilitate  rural  practitioner  access  to information  by: 
 Actively  participating  in State  telecommunications  initiatives,  such  as those 
involving  State  offices  of rural  health 
- Training  practitioners,  students,  and  primary  care  residents 
The  PHS  could  facilitate  these  efforts  by: 
 Encouraging  the  Federal  NECProgram  andthe  Federal  Office  of Rural 
Health  Policy to work  closely together 
- Considering  theextent  of NECcollaboration  with telecommunications 
networks  in its review  of funding  applications 
.
111  COMMENTS  ON THE  DRAFT  REPORT 
We  received  comments  on the  draft  report  from  the  Public  Health  Service  (PHS)  and 
the  Assistant  Secretary  for Planning  and  Evaluation  (ASPE)  within  the  Department. 
We  also received  comments  from  the  National  Organization  of AHEC  Program 
Directors  (NOAPD).  We  include  the  full text  of all comments  in Appendix  A.  Below 
we summarize  the  comments  of the  respondents  and,  in italics,  offer  our  responses. 
PHS Comments 
The  PHS  concurs  with our  recommendations.  The  agency  identifies  a plan  of action 
that  it will undertake  to implement  those  recommendations. 
.  The  PHS  plans  to convene  a work  group  with staff from  HRSA  and  AHCPR  to 
address  our  recommendation  on the  use of clinical  practice  guidelines. 
.  The  PHS  has  already  established  a task  force  within  HRSA  to identify  steps 
that  could  be  taken  to assist its customers  and  constituents  in responding  to the 
growth  of managed  care  throughout  the  nation. 
.  The  PHS  notes  that  HRSA  will undertake  efforts  to increase  interaction 
between  the  AHEC  program  and  the  Office  of Rural  Health  Policy as one 
approach  to strengthening  development  of telecommunications  systems, 
We appreciate  the positive  response  from  PHS,  and  we are encouraged  by the plan  of 
action  that  the  agency  has  adopted  in response  to our recommendations. 
ASPE  Cmmnents 
The  ASPE  generally  agrees  with our recommendations,  particularly  those  that  address 
clinical  practice  guidelines  and  managed  care.  However,  ASPE  suggests  that  we might 
wish to emphasize  grantee  involvement  in efforts  to explore  the  use  of telecommu
nications.  We agree that  thk  is an  emeWng field  in which  a consensus  has  not yet  been 
reached  on  how  to take ji.dl advantage  of advanced  technology.  Howeve~  we believe  that 
an  indication  that xlHECs  are exploring  telecommunications  would not  be sufficient  for 
assessing  their  actual  involvement  in that field.  Lvstead,  we have  revised  the  language 
suppomng our recommendation  to emphasize  that  the Federal  AHEC  program  could 
consider  the extent  to  which AHECS  are involved  in linking  with  State  ejforts  to develop 
telecommunications  in its rating  of applicants  for AHEC  jimding. 
NOAPD  Comments 
The  NOAPD  made  a number  of technical  and  editorial  comments.  The  one  area  of 
particular  concern  to NOAPD  is our  recommendation  on clinical  practice  guidelines. 
The  NOAPD  questions  whether  these  guidelines  are  pertinent  topics  for continuing 
education  in communities  where  local practitioners  have  not  requested  such 
information.  We uge  AHECS  not  only  to take  advantage  of existing  oppo~nities  to 
educate  practitioners  about  the  information  contained  in these guidelines,  but  aho  to play 
a proactive  role  in making  practitioners  aware  of their potential  use.  In addihon, one 
important  thrust  of our recommendation  is to involve  the  expertise  residing  in AHECS  to 
make  these  guidelines  more  relevant  and  usefil  to rural practitioners. 
iv  TABLE  OF  CONTENTS

PAGE 
EXECUTIVE  SUMMARY 
INTRODUCIION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

FINDINGS


Medical  Library  Resources  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

 
Continuing  Education  Courses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6


Missed  Opportunities..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

.  Telecommunications  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

OPPORTUNITEW  LOOKING  TO  THE  FUTURE 

Strengthening  theAHECRole  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13

  Clinical  Practice  Guidelines  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13


Managed  Care.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  15

.  Telecommunications  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16

COMMENTS  ON THE  DRAIW  REPORT  . . . . . . . . . . . . . . . . . . . . . . . . . . ...17

APPENDIX 
ATextof  Comments  on the Draft  Report  . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-1

B.  AHECSupport  Services  in Three  States:  Case  Descriptions  . . . . . . . . . . . . .  B-1

CI  Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..C-l
 INTRODUCTION

PURPOSE 
The  purpose  of this inspection  is to assess the  role  that  Area  Health  Education 
Centers  play  and  can play in providing  support  services  to enhance  the  practice 
environment  for health  care  practitioners  in rural  areas. 
BACKGROUND 
.  The  Area  Health Education  Center Program 
Recruiting  and  retaining  health  care  practitioners  in rural  areas  remains  a vexing 
national  concern.  The  &ea  Health  Education  Center  (AHEC)  program  repres&ts 
one  strategy  that  the  Federal  government  has adopted  to address  this concern.1  The 
goal  of the  AHEC  program  is to link health  professions  education  with service  delivery 
in underserved  areas  by bringing  together  the  academic  resources  of a university 
health  sciences  center  with local  clinical resources.  This linkage  facilitates  recruitment 
and  training  of health  professions  students  for work  in underserved  areas,  and  it helps 
to retain  health  professionals  practicing  in those  areas  by enhancing  the  rural  practice 
environment  through  continuing  professional  education  and  support  services. 
The  primary  mission  of AHECS  is to support  training  for medical  students  and 
medical  residents.  Under  the  Federal  program,  funding  is provided  directly  to an 
AHEC  project,  a cooperative  arrangement  that  operates  through  a medical  school. 
The  AHEC  project  oversees  an effort  encompassing  multiple  AHEC  centers  at sites 
remote  from  the  medical  school.  Each  AHEC  must  maintain  preceptorship 
educational  experiences  for health  sciences  students.  At least  10 percent  of all 
undergraduate  medical  clinical  education  must  be  conducted  in an AHEC  or in 
AHEC-sponsored  sites.  AHECS  must  also maintain  or be  affiliated  with  primary  care 
residency  programs  for a minimum  of four  residents  in each  year.  Each  AHEC 
project  must  be  responsible  for a program  for training  physician  assistants  or nurse 
practitioners,  and  for at least  two programs  involving other  health  professions,  such  as 
dentistry  or mental  health  practice. 
The  Federal  government  has supported  the  AHEC  effort  since  1971.  The  Federal 
AHEC  Program  is operated  by the  Division  of Medicine  in the  Bureau  of Health 
Professions  (BHPr),  Health  Resources  and  Services  Administration  (HRSA),  within 
the  Public  Health  Service  (PHS).  The  FY  1994 appropriation  of $22,203,000  supports 
19 AHEC  projects  under  the  basic program  and  13 projects  funded  under  a new 
model  State-supported  AHEC  program  that  includes  at least  a 50 percent  State 
match.2  The  FY  1995 appropriation  is $24,625,000.  More  than  100 AHEC  centers 
now operate,  including  both  those  that  are  supported  currently  with Federal  funding 
and  those  that  have  graduated  from  Federal  AHEC  support  and  rely on State  funding. 
Since  the  Federal  programs  inception  in 1971, AHECS  have  operated  in 35 States. 
1  The  Federal  government  also supports  other  efforts  to encourage  the  development  of 
health  delivery  capacity  in rural  areas.  One  such effort  is HRSAS Federal  Office  of 
Rural  Health  Policy (ORHP).  The  ORHPprovides  funding  forinditidual  State  offices 
of rural  health  and  funds  a Rural  Health  Outreach  Grant  program  that  supports 
innovative  strategies  for delivering  health  care  in rural  areas,  such  as mobile  clinics for 
prenatal  care  and  development  of telecommunications  systems. 
  The  Role  of Support  Services in Enhancing the Rural Practice Environment 
In this inspection,  we use  the  term  support  services  to describe  three  types  of 
activities: 
	 Medical  Iiirary resources  that  provide  rural  practitioners  with  access  to 
journals,  data  bases,  and  document  delivery  services. 
F	 Continuing education  courses that  share  clinical information  with community-
based  practitioners  (such  as updates  on new diseases  and  treatments);  that 
assist  practitioners  to provide  care  in a changing  practice  environment  (such  as 
skills needed  to practice  in a managed  care  setting);  and  that  enhance  the 
educational  process  of health  professions  students  (such  as courses  to improve 
community-based  practitioners  ability to be  preceptors  for medical  students). 
F	 Telecommunications  technologies  that  link rural  practitioners  with  clinical 
resources,  such  as those  available  at the  academic  health  center.  These 
interactions  include  computer-based  information  exchange  to foster  consultation 
and  long distance  educational  courses  for isolated  practitioners. 
These  support  services  are  only one  facet  of AHECS responsibilities.  Other  important 
AHEC  activities  include  educating  medical  and  other  health  professional  students, 
maintaining  primary  care  residency  programs,  and  carrying  out  recruitment  programs 
for the  health  science  professions  among  minority  elementary  and  secondary  school 
students  from  medically  underserved  areas. 
AHECS  use these  support  services  for two basic  purposes.  First,  they  seek  to  enhance 
the  knowledge  base  and  skills of community-based  practitioners  by providing 
information  that  will be useful  in the  local  setting,  in response  to the  needs  of those 
practitioners.  Second,  AHECS  use  support  services  to help  recruit  community-based 
practitioners  who  teach  AHEC-sponsored  health  professions  students  and  residents. 
AHECS  consider  their  principal  overall  mission  to be basic  education  of health 
professionals.  Recruiting  and  retaining  high quality  preceptors  and  faculty  in 
community-based  settings  is an ongoing  task  for AHECS.  By focusing  their  support 
services  on these  faculty  and  affiliated  staff in their  practice  settings,  AHECS  are  able 
to provide  some  additional  benefit  to these  faculty,  many  of whom  practice  in isolated 
or other  underserved  areas. 
2

  Despite  medical  education  programs  such as AHEC,  initial  practitioner  training  and 
recruitment  appear  to be  only partial  solutions  to assuring  their  ongoing  availability  in 
rural  areas.  A  1994 study by the  General  Accounting  Office  states  that  although  the 
number  of primary  care  physicians  providing  patient  care  rose  75 percent  between 
1975 and  1990, the increased  supply  did not  improve--and  even  slightly exacerbated-
the  uneven  distribution  between  urban  and  rural  areas  that  already  exists.3  The 
Congressional  Office  of Technology  Assessment  (OTA)  notes,  health  professionals 
may be  dissuaded  from  choosing  a rural  practice  location  due  to either  a perceived  or 
an actual  lack  of professional  opportunities  and  benefits  [such as] opportunities  for 
career  advancement  and  ability to meet  continuing  education  requirements  for 
recertification.4 
The  OTA  captured  the  implications  of this problem  when  it noted  that  rural  primary 
care  physicians  may infrequently  treat  many  conditions,  and  rural  technical  personnel 
may find it difficult  to maintain  competence  in skills they rarely  practice.  . . .  Many 
rural  health  professionals  do not  have  easy access  to professional  colleagues, 
consultations  and  second  opinions,  medical  libraries,  or continuing  education.s 
Because  of their  link between  health  sciences  centers  and  community  practitioners, 
AHECS  are  in a unique  position  to provide  ongoing  support  services  to rural 
practitioners.  The  director  of one  AHEC  summarized  this task when  he noted, 
AHECS should  examine  their  current  models  of support  for life-long  learning.  Models 
that  bring relevant,  timely  information  closer  to the userh point  of need  should  receive 
priority  attention.  AHECS  are  ideally  positioned  to address  the  need  for individualized 
learning  and  self-directed  inquiry.  Such information  delivery  systems  could  become 
the  foremost  criteria  by which AHECS  will be judged  in the  years  ahead.b 
FOCUS  OF  THIS  STUDY 
During  our  background  work  on this inspection,  we met  with staff from  the  Division  of

Medicine  to discuss an inspection  focusing  on AHECS provision  of continuing

education  services.  The  PHS  staff expressed  a desire  that  we broaden  our  inspection

beyond  continuing  education,  Consequently,  we expanded  our  inquiry  to include

library  resources  and  telecommunications  services,  and  to consider  ways in which

AHECS  could  play a lead  role  in helping  rural  health  professionals  practice  in a

changing  health  care  system.

This inspection  assesses  support  services  provided  by all AHECS,  both  those  receiving

current  Federal  AHEC  support  and  those  not  receiving  such support.  Consequently,

we do not  intend  for this study to report  on the  use of Federal  AHEC  funds  only.

Even  among  those  AHECS  that  currently  receive  Federal  AHEC  funds,  this support

may comprise  only a small portion  of their  budgets.  Other  AHECS  are  no longer

dependent  at all on Federal  funding.

3
 METHODOLOGY 
our  methodology  relies  upon  AHEC-reported  information,  drawn  from  four  primary 
sources: 
1)  We  reviewed  funding  applications  submitted  to BHPr  for  13 AHEC  programs  for a 
3-year  period  ending  in 1994.  Each  application  included  reports  on AHEC  activities 
for the  prior  year.  We  also reviewed  applications  for funding  from  10 model  AHEC 
programs  submitted  in FY  1994. 
2)  We  analyzed  data  on continuing  education  activities  from  all AHEC  programs  that 
had  been  submitted  to BHPr  for FYs  1991-92 and  1992-93. 
3)  We  conducted  telephone  interviews  with directors  and/or  staff from  19 AHEC 
programs. 
4)  We  conducted  site visits to four  AHEC  programs  in three  States.  Each  site visit 
included  discussions  with  staff and  practitioners  at the  AHEC  program  and  at AHEC 
centers.  During  these  site visits, we met  with more  than  30 rural  practitioners,  in 
addition  to AHEC  staff members,  We  selected  these  sites based  on our  review  of the 
AHEC  program  files and  discussion  with staff from  the  AHEC  Program  Office  in 
HRSA.  We  chose  programs  that  had  been  operating  for at least  three  years.  In 
Appendix  B we describe  the  support  services  of these  AHECS  in detail.  These  sites 
were: 
Arkansas  AHEC  Program,  University  of Arkansas  for Medical  Science,  Little 
Rock,  Pine  Bluff AHEC  Center,  and  Fayetteville  AHEC  Center; 
South  Texas  AHEC  Program,  University  of Texas  Health  Science  Center,  San 
Antonio,  and  Lower  Rio  Grande  Valley AHEC  Center,  Weslaco; 
Nova  Southeastern  University  AHEC  Program,  North  Miami,  and  Central 
Florida  AHEC  Center,  Apopka;  and 
North  Florida  AHEC  Program,  University  of Florida  Medical  School, 
Gainesville,  and  Big Bend-AHEC  Center;  Tallahassee. 
We  conducted  this study in accordance  with the  Quality Standards  for  Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
4
 FINDINGS

&IECS  ARE ENHANCINGRURAL PRACITIIONERSACCESS10 HEALTH CARE 
INFORMATIONBY LINKINGTHEM WITHMEDICALLIBRARYRESOURCES. 
.  xlIZEGprovided  fibraty resources incliuk professional stafi  com~er  equipment 
(both hardware and software) for data base seadws  and documem  diwributioq 
practitioner  training  and books, joumdr,  and audw-til  tapex 
AHECS  make  available  a sophisticated  array  of library  services  to rural  practitioners, 
including  books,  journals,  and videotapes.  In our  review  of applications  for Federal 
AHEC  program  funding,  interviews  with AHEC  program  directors,  and  site visits to 
AHEC  programs  we found  that  AHECS  have  put  substantial  commitment  into 
facilitating  practitioner  access  to medical  library  resources.  These  efforts  have 
expanded  the  range  of materials  and  information  available  to isolated  practitioners. 
By virtue  of their  relationship  with academic  health  sciences  centers,  AHECS  have 
access  to the  full range  of medical  collections  that  are  available  in these  teaching 
settings.  In addition,  AHECS  have  undertaken  major  commitments  to link 
practitioners  with other  resources,  such  as computerized  literature  and  data  bases.  In 
late  1994, HRSAS  National  AHEC  Program  Office  surveyed  the  32 AHEC  programs 
that  receive  Federal  funds.  The  survey found  that  all the  programs  are  utilizing 
Internet  and  National  Library  of Medicine  (NLM)  telecommunications  resources. 
Each  AHEC  utilizes  the  NLMs Grateful  Med  program  (for  medical  literature 
searching)  and  Loansome  Doc  program  (for document  distribution).  Most  AHECS 
also access  other  data  bases  such as CINAHL  (Cumulative  Index  on Nursing  and 
Allied  Health  Literature),  either  via computer  modem-based  searches  or periodic 
updates  on CD-ROM  disks.  Eighteen  AHECS  are  linked  with AHECNet,  a system 
established  by the  Montana  AHEC.  Some  AHECS  also use methods  that  are  less 
high-tech  in nature,  such as distributing  journal  tables  of contents  to practitioners,  and 
photocopying  articles  in response  to requests. 
In addition  to searching  for and  distributing  literature  to practitioners,  AHECS  put 
substantial  effort  into  training  practitioners  about  how to use the  library  resources  that 
are  available.  This training  takes  place  through  on-site  instruction,  for example,  in a 
local  hospital.  Some  AHECS  use a circuit riding  librarian,  who visits physicians 
offices,  clinics, hospitals,  and  other  practice  sites, actively marketing  the  AHECS 
library  services.  The  circuit  rider  trains  practitioners  on how to use  services  such  as 
Grateful  Meal, but  also performs  searches  on site for the  practitioners. 
5
 	 As special incentives to attract cornmunity-based faculiy for their studknts, AHEC3 
providk  additional  training on using dhta bases, Pee  use of medical  libra~ 
resoumeq  and computer hurdware and software to access these resources. 
AHECS  use  library  training  strategies  to help  strengthen  their  ties with preceptors.

AHEC  students  and  residents  take  equipment--computers,  modems,  and  software-

with them  on their  rotations  in the  field where  they  use them  as part  of their  ongoing

work  with practitioners.  One  AHEC  director  summarized  this approach  by noting  that

Our students  at a rural  rotation  dial in, do a work  up, and  search  on-line  for

information,  so that  they  can illustrate  for themselves  and  for their  preceptors  how

these  systems work.  We  structure  this to make  it part  of the  learning  process.

In addition  to providing  free  data  base  searches  and  access  to documents,  some

AHECS  purchase  and  donate  equipment  to practitioners  who serve  as preceptors.

AHEC  staff we interviewed  told  us that  providing  this equipment  is important  for

rural  practitioners.  They  noted  that  most  rural  practitioners  have  computers  and

modems  in their  offices, but  that  they use  them  almost  exclusively for billing.

Consequently,  placing  computer  systems  in these  preceptors  offices meets  both  an

educational  need  for students  and  provides  access  to library  services  for the

practitioners.

Library  services  can  also be valuable  resources  for AHECS  in enhancing  their

relationships  with their  parent  institution.  One  AHEC  directors  comments

summarized  how these  services  constitute  a win-win relationship.  Making  library

services  available  is part  of the  marketing  strategy  of any health  sciences  center.  They

use it to build  up  the  referral  network  for the  hospital.  AHEC  enhances  this

approach  for the  medical  center,  because  we get out  into  the  rural  community  more.

AHECS  marketing  goal is to have  practitioners  take  students,  and  we use library

services  to help  reach  that  goal.

&IECS  ARE RESPONDINGTO THE NEEDSOF MANYTYPESOF PRACITIIONERSFOR

CONTINUINGEDUCATIONON CLINICALTOPICS.

	 AIECk  conthuu!ngeducation courses cover a wide range of topics in the health 
care field 
Drawing  primarily  on our  review  of funding  applications,  but  also on our  site visits, it 
is clear  that  the  preponderance  of courses  are  clinical  in nature.7  Examples  of topics 
that  appear  frequently  in the  lists include:  issues related  to HIV  infection;  emergency 
care,  cardio-pulmonary  resuscitation,  and  cardiac  life support;  identification  and 
treatment  of substance  abuse;  identification  of domestic  abuse;  prenatal  and  perinatal 
care;  and  management  of chronic  diseases  such as diabetes  and  asthma.  Some 
AHECS  also provide  continuing  education  courses  on social issues  (e.g., cultural 
sensitivity,  language  training),  management  (e.g., quality  assurance  and  risk 
management),  and  human  resources  (e.g., avoiding  burnout). 
6

  The  AHECS  generally  view their  role  in continuing  education  as meeting  specific 
needs  and  filling a void left by other  sources  of continuing  education.  Most  continuing 
education  programming  is provided  through  formal  courses.  Courses  may be  provided 
in large  scale  settings  (e.g., cosponsorship  of a statewide  conference  on rural  health), 
in a particular  geographic  area,  or for a small group  of eight  to ten  staff members  at 
one  rural  health  clinic.  In addition  to courses,  several  AHECS  sponsor  mini-
residencies  or fellowships  at the  health  sciences  center  in response  to  an individual 
physicians  need  for special  training  on a particular  subject.  Some  AHECS  also 
conduct  specialty  clinics in rural  communities;  at these  clinics, a specialist  from  the 
health  sciences  center  sees  patients,  while  also providing  training  for local 
practitioners. 
.	 In developing their continuing education  agend2q xlIZECk hy to be particular+ 
responsive to community-based  practitioners  in order to encourage their 
involvement  ~th AHEC-a~iated  students and resklenfi. 
Our  interviews  and  site visits showed  that  AHECS  use several  basic  strategies  to

identify  practitioners  continuing  education  needs.  Some  AHECS  convene  advisory

boards  comprised  of local  practitioners  and  staff from  health  care  facilities;  other

AHECS  conduct  written  needs  assessments  of local practitioners.  Less  structured

methods  of seeking  provider  input  include  ongoing  contacts  with practitioners,  and

course  evaluations  from  practitioners  who have  attended  continuing  education  classes.

AHECS  reported  making  special  efforts  to solicit ideas  for continuing  education

programs  from  faculty  and  staff in those  settings  in which students  and  residents  are

placed.  These  efforts  can meet  practitioners  needs  for continuing  education,  while

also providing  basic  education  for the  students.

We  identified  six strategies  that  AHECS  have  adopted  toward  this end.  First,  AHECS

take  programs  to the  practice  setting,  so that  all the  staff can  participate.  Second,  an

AHEC  may use its preceptors  as the  sampling  frame  for needs  assessments  surveys.

Third,  some  AHECS  have  developed  special  courses  to train  their  preceptors  on

clinical  issues, but  also, importantly,  on how to be  effective  teachers  and  mentors.g

Fourth,  AHECS  offer  noon  courses  as part  of their  primary  care  residency  training.

On  a regular  schedule--daily  in some  programs,  weekly  or biweekly  in others-

practicing  physicians  from  the  clinic or local  area  provide  lectures  for residents  and

other  staff.  Although  these  programs  are  targeted  at the  residents,  other  local

practitioners  are  invited,  as a way of facilitating  professional  interaction  and  learning.

Fifth,  some  AHECS  provide  dividends or credit  to preceptors.  These  preceptors  may

exchange  these  dividends  for free  registration  at AHEC  programs.  Finally,  AHECS

encourage  practitioners  to view teaching  as an important  means  of receiving

continuing  education.  One  physician  at a community  health  center  explains  how this

works:  It is stimulating  at all levels of the  profession.  Students  force  you to push

yourself,  because  they  are  up on the  latest  literature  and  research.  It also gives

7  providers  in an underserved  community  a sense  of credentialing  and  their  own worth, 
as they  can  think,  If Im a teacher  I must  be good. 
.	 On average  more than two-thin&of  parhcipantsin AHEC-sponsored  continuing 
education pmgrarns in 1993 were nonphysician practitioners,  including muse 
practitkmag  physician  assktan~,  numes, and allkd  health prcfewionalr. 
Even  though  AHECS  are  based  in medical  schools,  nonphysician  practitioners  make 
particular  use  of their  continuing  education  programs.  We  reviewed  data  submitted  by 
19 AHECS  to BHPr  for fiscal year  1993.  In 14 of these  19 AHECS,  physicians 
comprised  less than  25 percent  of participants,  and  in 9 of these  AHECS  they 
comprised  10 percent  or less.  In 14 of those  19 AHECS,  nurses,  nurse  practitioners, 
and  physician  assistants--who  often  are  direct  providers  of primary  care  services  in 
rural  areas--comprised  more  than  25 percent  of participants.  Other  participants  in 
these  programs  include  dentists,  pharmacists,  and  allied  health  professionals  such  as 
medical  technologists,  x-ray technicians,  and  medical  records  administrators. 
AHECS  fill a niche  in providing  continuing  education  programming  for nonphysician 
health  care  professionals.  Of particular  benefit,  this programming  can focus  on the 
specific  needs  of staff in an individual  clinic or practice  site in a rural  area.  Because 
of the  AHECS  flexibility, it can  design  continuing  education  that  may not  be  readily 
available  elsewhere  for these  practitioners. 
We  heard  four  additional  explanations  for this level of participation  by nonphysician 
practitioners,  First,  rural  practice  sites tend  to be multidisciplinary,  with  a team 
orientation  that  includes  nurses,  physicians,  and  allied  health  professionals.  As a 
consequence,  rural  practitioners  continuing  education  needs  also are  multidisciplinary. 
Second,  rural  sites need  continuing  education  that  is locally provided.  One  physician 
summarized  this need  when  she told  us, Clinic staff are  place-bound.  A nurse  may be 
the  only one  in the  rural  clinic, and  she cant get  away. You  simply cant  shut  down  a 
small  county  health  unit  for a day to go to a meeting. 
Third,  an obvious  reason  for this level of participation  is that  nurses  and  allied  health 
professionals  comprise  the  largest  proportion  of health  professionals.  Consequently, 
they would  be  expected  to  consume  a greater  share  of continuing  education.  Fourth, 
although  continuing  education  is widely provided  elsewhere  for physicians,  it often  is 
unavailable  for many  rural  nonphysician  practitioners. 
8
 FOR THE MOSTPART,AHECSARE MISSINGOPPORTUNITIESTO EDUCATE 
PRACTTIIONERSABOUT INNOVATIONSIN HEALTH CARE DELIVERY, SUCH AS 
CLINICALPRACIICEGUIDELINESOR MANAGEDCARE. 
.	 AMough  clinical practice guidelines are intended to help practklmtm  make 
cEnical &&ns  about patient  car% most AHEC3  have not included these topics 
in their continuing ed4cation  courses. 
In our  review  of applications,  interviews,  and  site visits, we sought  specific  information 
on whether  AHECS  have  provided  continuing  education  on the  use  of clinical  practice 
guidelines  developed  by the  Agency  for Health  Care  Policy and  Research  (AHCPR).9 
No AHEC  mentioned  in its application  that  it had  been  involved  in dissemination  of 
guidelines.  Of our  19 interviews,  2 AHEC  directors  told  us that  they  had  disseminated 
practice  guidelines.  One  director  told  us that  the  AHEC  had  sent  HIV  guidelines  to 
hundreds  of people  through  their  AIDS  Clinical  Newsletter,  saying that  AHECS  are 
a natural  entity  to do this.  The  director  of another  AHEC  told  us that  practice 
guidelines  are  frequently  presented  as part  of their  continuing  education  programs, 
and  he  expects  that  these  will be  even  more  commonly  used  in future  programs. 
Several  other  AHEC  directors  told  us that  the  guidelines  are  available  in their  medical 
library  collections.  As one  AHEC  director  summarized,  however,  We get  the 
information  from  AHCPR,  but  havent  done  much  with it.  Im not  sure why. 
On  our  site visits, staff from  the  South  Texas  AHEC  told  us that  although  continuing 
education  courses  for physicians  have  not  explicitly  addressed  AHCPR  guidelines,  the 
school  of nursing  had  used  pain  management  guidelines  in their  continuing  education 
program.  The  Arkansas  AHEC  conducted  a study to examine  different  methods  of 
disseminating  asthma  practice  guidelines  through  AHECS.  The  project  report 
concludes  that  AHECS are  in a position  to play an important  dissemination  role. 
Continuing  education  has  always been  a priority.  .,  . and  as such  [AHECS]  can  serve 
as an effective  dissemination  vehicle.lo 
During  our  site visits, rural  practitioners  raised  a number  of questions  about  practice 
guidelines  and  the  constraints  that  rural  practice  imposes  on their  applicability.  One 
difficulty  they  identified  was a perceived  need  for sophisticated  diagnostic  equipment 
that  might  not  be  available  in rural  areas.  Other  practitioners  identified  lengthy  travel 
time  in rural  areas  as a barrier  to following what  they  see  as rigid guidelines.  They 
also expressed  frustration  that  practice  guidelines  are  developed  by academic  experts 
who  do not  understand  the  constraints  on the  practice  of medicine  in rural  areas. 
Yet  practitioners  we spoke  with thought  that  there  was a need  for this information, 
perhaps  best  expressed  by the  medical  director  of a community  health  center  in 
Florida.  Traditional  performance  is based  on quality  assurance.  Insurers  now have 
measurement  criteria--numbers  of immunizations  or pregnant  teenagers  seen  in first 
trimester.  We  need  to be  able  to move  to statistically  sound  outcome  based  practice. 
9
 AHEC  can help  provide  the  expertise,  software,  education  on how to do this, and  on 
how we can  hook  in with CQI, 
.	 Despite  the potential  impact  of managed  care on mral practice,  most xlHEC3 have 
not included couzws on thh topic in their continuing education programs. 
In our  interviews  and  site visits, we asked  AHEC  directors  specifically  about  whether 
they  had  sponsored  programs  to educate  practitioners  about  managed  care.  Four  of 
the  19 AHEC  directors  we interviewed  told  us that  their  AHEC  had  provided  some 
typeofeducational  programming  on managed  care.  During  our  site visits, we were 
told  that  the  Florida  AHEC  programs  sponsored  a 2-day statewide  program  on 
contracting  with  Medicaid  managed  care  providers. 
Only one  AHEC  director  told  us that  managed  care  comprised  an important  part  of 
continuing  education  programs.  The  AHEC  responded  to physician  requests  for 
information  on how to practice  as a gatekeeper  and  how to form  managed  care 
organizations.  A second  AHEC  director  noted  that  a few of their  offerings  had  begun 
to address  managed  care.  Two AHEC  directors  stated  that  they  had  been  involved 
with  setting  up  public  hearings  as part  of State  efforts  to educate  providers  about 
Medicaid  initiatives  that  were  encouraging  managed  care  organizations.11 
Even  though  they  have  not  provided  continuing  education  on managed  care,  several 
AHEC  directors  cited  concerns  about  the  impact  that  managed  care  could  have  on 
their  own operations.  Foremost  among  their  concerns  was whether  managed  care, 
with greater  demands  for physician  productivity,  would  leave  community-based 
physicians  with  less time  for teaching  students, 
Rural  practitioners  we interviewed  during  our  site visits also indicated  the  need  for 
information  on how managed  care  will affect  their  practice.  They  cited,  for  example, 
AHECS  experience  in negotiating  with physicians,  which  could be  helpful  as rural 
practitioners  consider  and  review  provider  agreements.  One  director  of a county 
health  department  summarized  these  views when  he  said, Rural  health  providers 
know nothing  about  contracting  with providers  and  physicians.  We need  courses  on 
how to work  with HMOS  as government  providers,  and  how to work with them  as 
private  practitioners. 
AHECS ARE BEGINNINGTO USE TELECOMMUNCIATIONSTO PROVIDE SUPPORT TO 
ISOLATEDPRACITIIONERS,BUT THEY ARE NOT YET TAKINGADVANTAGEOF THE 
FULL POTENTIALOF THIS TECHNOLOGY. 
	 AHEC#  nwst  common  use of tekcommunications  k to provide  additional 
education forprof&nal  advancement  of local numes.  Ercept for this purpose, 
howeve~ few AHECs  utilize regularly scheduled  telecommun ications programming. 
In our  review  of funding  applications,  interviews  with AHEC  program  directors,  and 
site visits,  10 AHECS  reported  that  they have  a career  ladder  program  to enable 
10  nurses  to advance  professionally. 12 The  classroom  portion  of their  training  is 
provided  through  a long distance  interactive  format  by faculty  from  the  school  of 
nursing  at the  health  sciences  center.  The  classroom  expands  beyond  the  immediate 
four  walls, as lectures  are  transmitted  live to students  in a classroom  at a remote  site, 
such  as a community  college  or local AHEC  center.  Using video-audio  systems, 
students  in the  remote  site are  able  to interact  with the  instructor  in virtually  the  same 
way as those  in the  immediate  classroom.  The  hands-on  clinical  training  that  the 
students  require  takes  place  in a local  setting,  such as a rural  hospital  or clinic.  This 
approach  helps  the  distant  students  by letting  them  remain  in their  communities  while 
advancing  professionally.  It also can be  an important  retention  tool.  Several  AHEC 
directors  with whom  we spoke  noted  that  hospitals  spent  a great  deal  of money 
recruiting  nurses  from  more  urban  areas  to rural  areas,  only to find that  they  tend  to 
leave  after  a relatively  short  time.  By providing  training  for local  nurses,  AHECS 
expect  that  they will upgrade  their  skill level  and  ability to take  on more  responsibility, 
and  will remain  in the  local  area  after  completing  their  training. 
Other  than  these  career  ladder  courses,  AHECS use  of telecommunications  is in the 
early  stages.  Few AHECS  use telecommunications  to deliver  regularly  scheduled 
routine  continuing  education  courses.  A more  common  use of this technology  is local 
coordination  for special  national  or State  programs  on major  topics,  such  as AIDS 
awareness  and  treatment. 
For  the  most  part,  AHECS use  of long distance  telemedicine--clinical  diagnosis  and 
treatment  through  telecommunications--is  still in the  demonstration  phase.  Some 
AHECS  reported  that  they were  facilitating  the  use of teleradiology.  This technology 
permits  practitioners  at rural  hospitals  to send  digitized  x-rays via telecommunications 
to a contracted  radiologist  at a central  location,  such as the  health  sciences  center. 
The  radiologist  interprets  the  x-rays and  provides  a diagnosis  for the  rural  practitioner. 
A few AHECS  reported  that  they use telemedicine  for dermatology.  A local 
practitioner  (such  as a physician,  physician  assistant,  or nurse  practitioner)  sees  the 
patient  at a remote  site, while  a dermatologist  at the  health  sciences  center  examines 
the  patient  via specially  transmitted  televised  pictures.  The  specialist  is able  to 
diagnose  the  condition  and  prescribe  appropriate  treatment.  If hands-on  contact  is 
needed,  the  local  practitioner  can provide  that  contact  in conjunction  with the 
specialists  instructions. 
Because  it can be brought  on site, telecommunications  obviates  the  need  for 
practitioner  travel  to distant  sites for continuing  education  and  other  training.  This 
technology  can  address  the  time  constraints  facing busy professionals,  and  can  be 
provided  at a relatively  affordable  cost in many  areas.  By linking  practitioners  with 
resources  available  from  great  distances,  telecommunications  can  readily  expand  the 
range  of course  offerings  beyond  what  is available  locally. 
It is not  clear  how rapidly  telemedicine  will expand,  or indeed  whether  it will expand 
at all without  additional  funding.  AHEC  directors  in a number  of States  reported  to 
us about  plans  to implement  limited  demonstrations  that  utilize  telemedicine.  In most 
11
 cases, these  plans  were  developed  as part  of funding  applications  to obtain  necessary 
equipment  or external  support. 
	 Constrain  on greater AHEC  use of telecommunications  include AHEC#  kzck of 
ownership of the technology, its capital and oprating  costs, and lack of 
practitioner familimity  or comfort. 
Every  AHEC  we spoke  with and  reviewed  has had  some  involvement  with long 
distance  learning,  telemedicine,  and  telecommunications.  The  logic of using these 
technologies  for rural  medicine  seems  self-apparent.  In our  interviews  and  site visits, 
we found  that  a number  of constraints  are  inhibiting  its growth  and  use by AHECS. 
Lack  of ownership  of the  technology  means  that  AHECS  are  not  able  to control  access 
to it or to have  primary  use  of it.  In only a few instances  did we find that  the  health 
care  community  was a major  partner  in controlling  the  technology  needed  to provide 
telecommunications  and  long distance  learning.  Even  in those  instances,  the  AHECs-
and  especially  their  continuing  education  and  support  services--take  second  place.  In 
many  States,  telecommunications  is the  property  of the  higher  education  system, 
particularly  junior  colleges  or community  colleges.  In at least  one  State,  it is 
controlled  by the  criminal  justice  system.  As a consequence,  AHECS  must  take  their 
turn  along  with  all the  other  interested  parties  to use  the  technology. 
Telecommunciations  equipment  can be  costly.  A relatively  inexpensive  satellite  dish 
can be  used  for receiving  programming  in a one-way  transmission.  For  two-way, 
interactive  audio  and  video,  however,  we heard  prices  ranging  from  $38,000 to 
$100,000 for the  necessary  equipment,  money  that  the  AHECS  claim  is not  a priority 
in their  spending  plans. 
There  also is resistance  to these  technologies  among  some  practitioners.  AHEC 
directors  told  us that  practitioners  think  that  telemedicine  could  be  a good  idea,  but 
only in very rural  areas  where  there  are  no physicians  or hospitals.  Older  physicians 
appear  to be  uncomfortable  with these  new technologies,  probably  because  of 
unfamiliarity.  This  concern  implies  that  one AHEC  role  is training  practitioners  on 
how to use these  technologies. 
Despite  these  constraints,  AHEC  directors  foresee  greater  use  of and  reliance  on long 
distance  telecommunications  as a means  of delivering  continuing  education,  gathering 
research  and  data,  and  providing  consultation  and  diagnostic  services  for isolated  rural 
practitioners.  They  anticipate  that  entry  into  practice  of a younger  generation  of 
practitioners,  who are  familiar  with computers  and  electronic  transmission  as standard 
ways of doing  business,  will lead  to wider  acceptance  and  more  frequent  use  of these 
technologies.  At  the  same  time,  the AHEC  directors  stress  that  face-to-face  contact 
and  interaction  with  colleagues  will continue  to be important. 
12
 OPPORTUNITIES:

LOOKING  TO  THE  FUTURE

Clearly  AHECS  will continue  to emphasize  basic  medical  education  as their  primary

mission.  Indeed,  AHECS  appear  to be well-positioned  to play a leadership  role  in

supporting  the  increasing  national  emphasis  on primary  care.  AHEC  directors  we

interviewed  believe  that  emerging  medical  education  policy supports  the  basic  AHEC

approach:  linking  medical  schools  and  community-based  practitioners  to train  students

in primary  care.

How  do AHECS  support  services  fit into  this future?  AHECS  not  only help

practitioners  maintain  their  skill levels by providing  medical  library  resources  and

continuing  education,  but  these  services  can also reduce  a sense  of professional

isolation.  These  support  services  complement  the AHECS role  as a provider  of basic

education,  and,  indeed,  offer ways through  which AHECS  can strengthen  their

performance  in that  role.

On a strategic  level, providing  support  services  can play an important  role  in

enhancing  AHECS relationships  with State  officials.  AHECS  recognize  that  their  long

term  viability  depends  on support  from  their  State  governments,  predicated  on their

acceptance  within  the  broader  medical  community.  The  success  of AHECS  will be

measured  by the  number  of primary  care  students,  residents,  and  other  practitioners

that  they  produce.  At the  same  time,  an AHECS support  services  provide  ongoing

interaction  with  local  practitioners  that  can help  to secure  its place  within  the  local

medical  community.  By meeting  the  needs  of local practitioners  for the  services  they

provide,  AHECS  are  able  to build  a constituency  for their  services,  particularly  among

legislators  representing  rural  and  underserved  areas.

WE RECOMMENDTHATTHE PUBLICHEALTHSERVICESTRENGTHENTHE ROLE OF

~CS  BYFACILITATINGTHEiR ABILITYTO FOCUSSUPPORTSERVICESON THREE

AREAS:  CLJNICALPRACrICE GUIDELINES,MANAGED C- AND

TELEco MMUNICATIONS.

Our  recommendation  identifies  opportunities  to take  advantage  of AHECS potential

for assisting  practitioners  in the  emerging  health  care  environment.  We  also provide

some  options  for how PHS  can facilitate  AHECS ability to take  advantage  of these

opportunities.  We  encourage  and welcome  other  approaches  that  PHS  staff  and  the

various  AHEC  programs  may develop  on their  own to reach  this goal.

  CLINICALPRACTEE  GVLDELINES 
Variations  in clinical  practice  among  different  physicians  and  hospitals,  and  in different 
geographic  areas  have  long been  observed. 13 With  the  growing  awareness  of these 
variations,  concern  has  developed  about  adverse  patient  outcomes  and  financial  costs 
13
 associated  with inappropriate  medical  care.  Clinical  practice  guidelines  have  been 
developed  as part  of a larger  effort  to reduce  unwarranted  variations  in care  and  the 
costs associated  with them.  As part  of this effort,  PHS  has invested  in the 
development  of guidelines  and  their  use by practitioners  through  the  Agency  for 
Health  Care  Policy and  Research  (AHCPR). 
  ~EC3  could facilitate  adoption  of clbtical practice guidelbux  ik nualpractice  by: 
- I.hcluding guidelines as part of continuing education  courses 
In their  continuing  education  courses,  AHECS  could  disseminate  guidelines,  explain 
how they  can be  applied,  and  identi&  issues of particular  concern  in rural  practice. 
- Ensuring guidelines are available in their medical liiraries 
AHECS  could  ensure  that  the  guidelines  are  available  in their  medical  library  resource 
collections.  AHECS  could  see that  practitioners  are  made  aware  of the  guidelines  and 
how to access  them. 
. Helping  adapt guidelines to rural conditions 
AHECS  could  identi~  how and  under  what  conditions  clinical  practice  guidelines  need 
to be  adapted  to the  specific  needs  of rural  communities. 
w  %  PHS, wotig  through AHCP&  coukl encourage the guidklina  acihptiim by: 
- Involving AHECS in the development  of guidelines 
The  AHCPR  could  ensure  that  rural  viewpoints  are  reflected  in practice  guidelines  by 
including  representation  from  AHECS  in a consultative  role  as the  guidelines  are 
formulated. 
- Encouraging  AHECS to disseminate guidelines 
The  AHCPR  now includes  AHECS  on its routine  distribution  list for the  guidelines. 
As part  of its marketing  strategy,  AHCPR  could  utilize  AHECS expertise  in providing 
continuing  education  to see that  rural  practitioners  are  made  aware  of the  guidelines. 
For  example,  AHCPR  might  wish to consider  using some  of its dissemination  funding 
to assist AHECS  in developing  continuing  education  courses  on practice  guidelines. 
- Assessing rural practitioners  concerns 
The  AHCPR  could  determine  whether  those  concerns  noted  in this report,  and  any 
other  concerns,  need  to be  addressed  in the  guidelines.  If its assessment  identifies 
problem  areas  for rural  practice,  AHCPR  could  draw  on AHECS  expertise  to identify 
ways of addressing  these  concerns. 
.  E&mining  the use of guidelines in rural areas 
The  AHCPR  could  determine  where  and  how extensively  guidelines  have  been  applied 
in rural  communities,  and what  problems  practitioners  have  encountered  with  them  in 
practice.  The  AHCPR  might wish to identify  lessons  learned  from  these  experiences 
and  consider  how guidelines  can be  applied  elsewhere. 
14    MANAGED  CARE 
Even  without  enactment  of national  health  reform  legislation,  numerous  changes  are 
taking  place  in the  health  care  system.  Foremost  among  these  is the  development  of 
managed  care  systems, which  could  pose  particular  difficulties  in rural  communities. 
Analysts  have  projected  that  managed  care  could well exacerbate  existing  problems  in 
the  availability  of primary  care  practitioners  in rural  areas,  as urban  managed  care 
networks  recruit  additional  primary  care  physicians  from  the  limited  number  that  are 
available .14 Others  have  cited  the  difficulties  that  a system  relying  on managed 
competition  would  hold  for rural  communities  where  there  are  few practitioners, 
limiting  the  competition  that  could  take  place.ls  In addition,  managed  care  may 
develop  more  slowly in rural  areas  than  in urban  ones,  and  it is likely to encounter 
more  resistance  in those  areas.lG 
  xiIlEC3  could inform mral practitkmem  about managed  care by: 
- Sponsoring  informational  symposia for rural practitioners 
AHECS  could  develop  and  provide  information  for rural  practitioners  on multiple 
topics,  such  as the  role  of the  gatekeeper,  clinical  patient  management  in a system 
with  different  economic  incentives,  or standards  for practitioner  participation  in 
different  managed  care  plans. 
- Assisting practitioners in negotiating contracts 
AHECS  could  assist rural  practitioners  in negotiating  contracts  with existing  managed 
care  organizations,  or they  could  even  help  practitioners  develop  and  organize  their 
own managed  care  plans. 
- Participating in State-level planning 
In those  States  that  are  undertaking  their  own health  care  reform  initiatives,  AHECS 
could  play  an active  role  to ensure  that  the  needs  of rural  areas  are  addressed  in that 
debate. 
  %  PHS  AHECS in this  by: 
CO1.dii  assist  @Olt 
 Disseminating information  on managed  care 
The  PHS  role  in helping  AHECS  address  managed  care  is likely to be  primarily  an 
educational  one.  The  PHS,  through  the  Federal  AHEC  Program  or some  other  entity, 
could  disseminate  materials  on managed  care  for rural  practitioners.  These  materials 
could  address  how AHECS  have  been  involved  in the  development  of managed  care. 
Taking advantage of its ongoing  communications  with AHECS 
 
The  Federal  AHEC  Program  could  encourage  the  inclusion  and  discussion  of these 
issues  at annual  meetings  of AHEC  program  directors,  or as part  of routine 
newsletters  (e.g., the AHEC  Bulletin)  that  the  AHEC  community  publishes. 
15
   TELISCOiWUUVIC42T0hTS 
Telecommunications  has the  potential  to become  a central  focus  of efforts  to reduce 
the  professional  isolation  of practitioners.  This technology  holds  multiple  benefits  for 
rural  practitioners,  such  as overcoming  travel  distance  and  reducing  time  away from 
the  practice  setting.  By taking  a leading  role  in efforts  to expand  the  use  of 
telecommunications  technology,  AHECS  can help  assure  that  the  needs  of rural 
practitioners  are  met.  Significant  changes  in telecommunications  and  its applicability 
for health  care  are  on the  horizon.17  These  changes  include  emergence  of the 
information  superhighway,  the  evolution  of a new generation  of practitioners  who 
have  used  computers  and  other  technologies  as a routine  way of doing  business  for 
some  time,  and  likely improvements  in the  technology  in both  its capabilities  and  its 
user-friendliness. 
	 AHEC3  could lead flo~  to take greater advantage of telecommunications 
potential  to facilitate  rurdpractitioner  access to information by: 
 Actively participating in State telecommunications  initiatives, such as those 
involving State offices  of rural health 
Efforts  to expand  telecommunications  are  under  way in some  States  (e.g., efforts  led 
by State  offices  of rural  health  or departments  of education).  An AHECS  role  could 
be  to see  that  the  needs  of practitioners  in isolated  rural  areas  are  met.  Where  such 
efforts  are  not  yet under  way, AHECS  could  take  the  lead  in convening  consortia  of 
telecommunciations  users  to encourage  broader  application  of this technology. 
 Training practitioners, students, and primary care residents 
This  education  could  take  place  in the  basic  training  that  AHECS  provide  to health 
professions  students.  For  current  practitioners,  AHECS  could  include  training  on 
telecommunications  in their  continuing  education  programming. 
  The PHS could facilitate  these efJorts by: 
- Encouraging  the Federal AHEC  Program and the Federal  Office  of Rural 
Health Policy to work closely together to overcome  barriers 
Within  PHS,  the  Federal  AHEC  Program  within  BHPr  could  facilitate  this effort  by 
working  closely with the  Federal  ORHP  and with State  offices  of rural  health  to 
develop  strategies  for overcoming  the  barriers  to broader  utilization  of telecommu
nications.  The  Federal  AHEC  Program  and  ORHP  could  distribute  available 
information  and  training  materials  on expanding  utilization  of telecommunications.lg 
 Considering  the extent of AHEC  collaboration  with telecommunications 
networks in its review of funding applications 
The  Federal  AHEC  program  could  consider  the  extent  to which AHECS  are  involved 
in linking with State  efforts  to develop  telecommunications  in its rating  of applicants 
for AHEC  funding.  Current  guidelines  address  linkages  to State  initiatives,  such  as a 
State  office  of rural  health  and  statewide  training  consortia.  These  guidelines, 
however,  do not  specifically  address  an applicants  participation  in efforts  to expand 
the  utilization  of telecommunications. 
16
 COMMENTS  ON  THE  DRAFT  REPORT

We  received  comments  on the  draft  report  from  the  Public  Health  Service  (PHS)  and 
the  Assistant  Secretary  for Planning  and  Evaluation  (ASPE)  within  the  Department. 
We  also received  comments  from  the  National  Organization  of AHEC  Program 
Directors  (NOAPD).  We  include  the  full text  of all comments  in Appendix  A.  Below 
we summarize  the  comments  of the  respondents  and,  in italics,  offer  our  responses. 
PHS COMM13NTS 
The  PHS  concurs  with  our recommendations.  The  agency  identifies  a plan  of action 
that  it will undertake  to implement  those  recommendations.  We are pleased  that  PHS 
concurs  with  our recommendations,  and  we welcome  its implementatton  plan.  In 
particular,  we look forward  to achievement  of those  goals  that  the  agency  indicates  can  be 
accomplished  within  existing staff  and  resource  constraints. 
The  PHS  plans  to convene  a work  group  with staff from  HRSA  and  AHCPR  to 
address  our  recommendation  on the  use  of clinical  practice  guidelines.  The  objective 
of this effort  is to develop  a process  for increasing  the  involvement  of AHECS  in the 
dissemination  of existing  guidelines  and  in the  development  of new guidelines  as a way 
of providing  input  from  rural  providers.  We believe  that  this  work group,  plus  the 
agency k planned  involvement  of AHEC  program  directors  and MEC  center  directors, 
should  be able  to address  the issues  raked  in our report. 
The  PHS  acknowledges  that  a more  formal  process  could be  used  to incorporate 
current  information  on managed  care.  The  PHS  has already  established  a task  force 
within  HRSA  to identify  steps  that  could  be taken  to  assist its customers  and 
constituents  in responding  to the  growth  of managed  care.  The HRSA  !s establishment 
of a task force  to identify  steps  that  could  be taken  in this  area  is recognition  of its 
importance.  We would  welcome  receiving  a copy  of the report  and  action  plan  that  this 
task force  produces. 
The  PHS  notes  the  recent  increase  in the  awareness  and  use  of telecommunciations 
among  rural  practitioners.  The  HRSA  will undertake  efforts  to increase  interaction 
between  the  AHEC  program  and  the  Office  of Rural  Health  Policy as one  approach 
to further  strengthen  development  of telecommunications  systems.  The  agency  raises 
caution  about  costs associated  with initial  linkage  and  maintenance  of telecommuni
cations  systems. 
We appreciate  the  information  that  HRSA  has provided  on  the  use of the Internet  and  the 
Montana  MLEC5  AHECNet,  and  we have  incorporated  this  information  into  the  text of 
our report.  We believe  that  increased  interaction  between  the AHEC  program  and  the 
Office  of Rural  Health  Policy  will strengthen  development  of telecommunications  systems. 
We are aware  of the  expense  involved  in developing  and  maintaining  telecommunications 
systems.  We utge HRSA  to continue  to monitor  developments  in this  rapidly  evolving 
field.  We encourage  HRSA  to continue  to  work  with  other  Federal  agencies,  State 
17
 governments,  and private  organizations  involved  in telecommunications  to help  develop 
thti  technolo~h  potential  for  delive~  of health  care services  in underserved  rural  areas. 
ASPE  COMMENTS 
The  ASPE  generally  agrees  with our recommendations,  particularly  those  that  address 
clinical  practice  guidelines  and  managed  care.  The  ASPE  suggests  that  we might  wish 
to emphasize  grantee  involvement  in efforts  to explore  the  use  of telecommunications 
as a criterion  in scoring  grant  applications.  We are pleased  that ASPE  concurs  with  our 
recommendations.  We believe  that  an  indication  that AHECS  are exploring  telecommuni
cations  would not  be sufficient  for  assessing  their  actual  involvement  in that field.  But  we 
have  revised  the  language  suppomng that  recommendation  to emphasize  that  the Federal 
AHEC  program  could  consider  the extent  to which AHECS  are involved  in linking  with 
State  ejforts  to develop  telecommunications  in its rating  of applicants  for MEC  funding. 
NOAPD  COMMENTS 
The  NOAPD  made  a number  of technical  and  editorial  comments.  The  organization 
notes,  and  we indicate  in the introduchon,  that  this report  examines  only one  segment 
of the  total  AHEC  mission.  We have  included  in the  text language  suggested  by the 
organization  that AHECS  view  their role in continuing  education  as filling  a void  not  met 
by other  sources  of continuing  education.  We have  also  made  some  editorial  changes  in 
the  case  descriptions  in Appendix  B. 
The  NOAPD  questions  whether  the AHCPR  guidelines  may be  pertinent  topics  for 
continuing  education  in some  communities  served  by AHECS  because  they  have  not 
been  requested  by local  practitioners.  We u~e  MECS  to not  on~  take  advantage  of

existing  opportunities  to educate  prachtioners about  the information  contained  in these

guidelines,  but  to also play  a proactive  role in making  practitioners  aware  of their

potential  use.  In addition,  we note  that  an  important  thmst  of our recommendation  is to

involve  the  expertise  residing  in AHECS  to make  these guidelines  more  relevant  and  useful

to rural practitioners.

The  NOAPD  recognizes  the  role  that  AHECS  could  play in providing  information  on 
changes  in the  health  care  system.  The  organization  questions  whether  one  such role 
is negotiating  contracts  with managed  care  organizations.  We believe  that  this  is a 
potential  role for  some  AHECS.  We offer it as one  example  of ways  in which  AHECS  can 
help  keep  rural practitioners  informed  about  managed  care.  We agree that AHECS  also 
have  an  important  role  in sponsoring  informational  symposia  on managed  care  topics. 
The  NOAPD  supports  efforts  to encourage  AHECS  to take  an active  role  in the 
advancement  of telecommunications  technology,  but  cautions  that  AHECS  role  in this 
development  will vary among  States.  The  NOAPD  also notes  that  developing 
telecommunications  requires  substantial  financial  effort.  We recognize  the  variation 
among  States  in how  thk  development  is proceeding,  and  we are aware  of the  expense 
involved.  We are not  suggesting  that funds  be subtracted  @om  the AHEC  program  for 
this purpose,  but  rather  that fimding  applications  pay  explicit  attention  to how AHECS  are 
involved  in linking  with  State  eflorts  to develop  telecommunications. 
18  APPENDIX  A 
DETAILED  COMMENTS  ON THE DRAFI  REPORT 
A-1  4  ,*  *,**,, %,
.  (  DEPARTMENTOF HEALTH& HUW  SERVICES  PublicHealth%rvice 
/ 
[  Ad 
-4
%
%> ,m Memorandum 
APRII  1995

Date 
From  Assistant  Secretary for  Health 
Office of Inspector General  (OIG) Draft Report  mea  Health 
Subject 
Education  centers:  A Role in Enhancing the Rural Practice 
Environment,  0EI-01-93-O0570 
To 
Inspector General, OS

Attached are the Public Health Service comments on the subject

OIG report.  We concur with the reports recommendations.  Our

comments delineate  the actions taken or planned to implement

these recommendations.

ItLip(cL

1

Philip R. Lee, M.D.

Attachment

A-2
 PUBLIC HEALTH SERVICE  (PHSI COMMENTS ON THE OFFICE OF 
INSPECTOR GENEm  ~OIG\ DIUU?T REPORT AREA HE~TH  EDUCATION 
CENTERS: A ROLE IN ENHANCING THE RURAL PFL%CTICE ENVIRONMENT, 

OEI-01-93-00570

General Comments

We believe  that achievement of the goals and tasks outlined in

the subsequent  PHS comments is possible over a three-year

Some of the

Deriod if sufficient resources are available. 
tasks described  can be accomplished through existing staff and  .

resources .  However, other tasks will require additional

resources .

OIG Recommendation

We recommend  that the PHS strengthen the role of Area Health

Education Centers  (AHEC) by facilitating their ability tO

focus support services on three areas:

A.  Clinical  Practice Guidelines

The AHECS could facilitate the adoption of clinical

practice  guidelines  by including guidelines as part of

continuing  education courses, ensuring that guidelines

are available  in their medical libraries, and helping

adapt guidelines  to rural conditions.

In  addition,  the PHS, working through the Agency for 
Health Care Policy and Research  (AHCPR), could encoura9e 
guidelines  development  by:  involving A.HECS in the 
development  of guidelines, encouraging JLHECS to 
disseminate  guidelines,  assessing rural practitioners 
concerns,  and examining  the use of guidelines  in rural 
areas .

PHS Comment

We concur with this recommendation.  Routinely, AHCPRS Center

for Research  Dissemination  and Liaison  (CRDL) sends clinical

practice guidelines  to AHEC directors urging guideline

dissemination .  As the guidelines on various clinical issues

have been developed,  AHEC programs have distributed  some of

these guidelines  to health care practitioners participating  in

continuing  education  programs.  AHEC staff received  feedback

that some of the guidelines  could be made more rele~antto

rural practice  settings.

In October  1990,  PHS Health Resources and Services 
Administration  (HRSA) awarded a contract to the Arkansas A.HEC 
to compare  three dissemination  modalities.  The AHCPR 
contributed  the funding for this contract.  The project 
examined the use of different  educational interventions  to

A-3  2 
achieve cognitive and behavioral changes in physicians in

primarily rural settings.  Three areas in Arkansas received

tailored interventions,  while a fourth control area received

routine notification  of the 1991  asthma treatment guidelines 
issued by the National Heart, Lung, and Blood Institute.  The 
three tailored  strategies used a standard continuing medical

education conference with peer academic detailing; COmputer

conferencing and computer teaching modules to highlight key

aspects of the guidelines;  and multiple  facsimile

transmissions  of executive  summaries, along with posters and

audio and video tapes.

A review of the projects  results  did  not  reveal great 
differences  in the performance and cognitive knowledge of

physicians; although  the multimedia,  repetitive exPosure

strategy showed some clinical and cognitive impact.  It was

also found that the success of various strategies was

correlated with phys~clan  and  practice  characteristics.  This 
suggests the importance of designing disseminations  that are

appropriate  for the target audience.

We believe that worthwhile  the development of 
objectives  are 
(1) a process  for the dissemination  of existing guidelines to

AHEC programs,  centers, and trainees; and (2) a strategY to

increase the involvement  of local AHEC staff and trainees, and

a range of rural health care providers, in the development of

new guidelines.  Staff from both HRSA and AHCPR will form a

work group to develop a plan to achieve these objectives.  The

work group will  consult with AHEC program directors and Center

directors  in the development  of this plan.

The goals of this effort are to:

o	 ensure existing guidelines are available in hard copy 
in the libraries of the schools associated with 
ongoing AHEC programs, and also in local community-
based AHECS and affiliated  learning resource training 
sites , 
0	 ensure  that a representative number of local AHEC 
staff and rural health care providers are added to 
existing AHCPR advisory groups charged with the 
development  of guidelines, and 
o	 explore  the use of INTERNET and/or AHECNET to enhance 
the dissemination  of AHCPR guidelines. 
In z related effort, AHCPR is testing a prototype of AHCPR

Clinical Practice  Guidelines  on CD-ROM.  This prototype

version of the 15 current .ZLHCPRguidelines is expected to be

available at the May 1995 annual meeting of the Medical

A-4  3

Library Association.  If this proves successful,  this version 
of the guidelines can be made available to the AHEC libraries. 
OIG Recommendation

!3.  Managed Care

The AHECS could inform practitioners about managed care 
by:  sponsoring informational  symposia for rural 
practitioners,  assisting practitioners  in negotiating 
contracts , and participating  in State-1evel  planning. 
The PHS  could  assist AHECS in this effort by 
disseminating  information on managed  care, and taking 
advantage of ongoing communications with AHECS  to 
encourage  the inclusion and discussion  of this issue at 
annual meetings of AHEC program directors. 
PHS Comment

We concur.  In the past, managed care has been a focal point

of several ~EC  programs and a part of a continuing education

program.  These efforts were often in response  to requests by

provider groups, many of whom are being asked to join managed

care organizations.

We acknowledge, however, that a more formal process could be 
developed  to incorporate current information on managed care 
issues into  ongoing  AHEC dissemination  efforts.  In January 
1995, the HRSA established  a task force to explore the steps

zhat could be taken to assist customers and constituents of

HRSA to respond to the dynamic grow-thof managed care

organizations  throughout the nation.  One task of this task

force on managed care will be to analyze the dissemination

role of the AHEC and other HRSA programs.  Once this task

forces assignment is completed, HRSA will determine whether 
efforts like those envisioned by  the  OIG  will  be undertaken  tO 
assist AHECS in disseminating  info~ation  on managed  care.

31G Recommendation

<.  Telecommunications

The AHECS could lead efforts to take greater advantage of

telecommunications  potential to facilitate rural

practitioner  access to information by actively

participating  in State telecommunications  initiatives,

such as those involving State offices of rural health;

and training practitioners,  students, and primary care

residents .

A-.5
 4

The PHS could facilitate these efforts by encouraging  the

Federal AHEC program and Office of Rural Health Policy

(ORHP) to work closely together, and considering  the

extent of A.HECcollaboration with telecommunications

networks  in its review of funding applications.

PHS  Comment 
We concur.  In the past few years there has  been a significant 
increase in the awareness and use of telecommunications 
technology  and electronic media among rural practitioners.  A 
recent survey of 32 AHEC programs that currently  receive 
Federal funds indicates that all 32 are utilizing  INTERNET and 
National Library of Medicine  telemedicine resources.  The 
AHECNET  (established  by  the  Montana  AHEC)  is  used  to  a  lesser 
extent, with  18 of the AHEC programs surveyed reporting  a

linkage to AHECNET,  Also, six AHEC programs report a linkage

with a teleco~unications  awardee of the ORHP.

The HRSA will undertake efforts to increase interaction 
between staff from the AHEC and ORHP programs.  A goal is 
enhanced  staff communication  and familiarity with the 
respective  programs by sharing info~ation  regarding  current 
awardees,  participating  in merit review sessions of the 
respective  programs, and following  up  with  awardees  of  each 
program  to  encourage  the  Use  of  ORHP supported 
telecommunications  systems.

A  second goal is to explore the feasibility of linking each of 
the 124 community-based  AHECS to AHECNET,  INTERNET, or an ORHp 
supported  telecommunications  system.  It would be possible to 
accomplish  this goal over a three-year period if sufficient 
resources were available.  To aate, AHEC program resources 
have been used to support the establishment  of community-based

training programs,  and to enhance learning resources and the

development  of preceptors  in local areas.  Funds have not been

sufficient  to support the cost of the initial linkage to

telecommunications  systems in many States, or the costs of

maintenance.

A-6
 . 
.* 
:
.,*JM  ,,  ,,, 
+*
Jg

DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  Office  of  the  Secretary
;
-0 
%,+ 
/>.,, w  Washington,  D.C.  20201
M  I 3  1995

TO:
 June Gibbs Brown

Inspector General

FROM:
 Assistant Secretary for

Planning and Evaluation

SUBJECT :
 Review of OIG Draft Report:  Area Health Ed~t@n

Centers:  A Role in Enhancing the Rural Practie

Environment,  0EI-01-93-O0570

Thank you
 for giving me the opportunity to review your dtaft 
report on
 area health education centers  (AHECS) .  We are pleased 
to see that your inspection shows that AHECS are enhancing rural

practitioners  access to health care information and providing

needed continuing education.

We generally agree with your recommendations, particularly  those

focused on strengthening AHEC activities in the areas of clinical

practice guidelines  and managed care.  While we also agree that

AHECS should become increasingly involved in efforts to develop

the use of telecommunications  in health care, it may be premature

for PHS to consider the extent of AHEC collaboration  with

telecommunications  networks in its review of funding applications

(as recommended at the bottom of page 16).  Telemedicine  is a

rapidly evolving field, and many complex technical, medical, and

financing issues need to be resolved before there will be any

consensus on the appropriateness of its use in rural health care.

While A.HECScertainly could  (and should be encouraged  to) PlaY a

key role in exploring and resolving these issues, it may not be

advisable at this point to include the extent to which

telecommunications  are utilized as a criterion on which grant

applicants are scored.  Perhaps this recommendation  could be

reworded to emphasize  the level of the grantees  involvement in

efforts to exulore the use of telecommunications  in health care,

rather than the level of its utilization of telemedicine.

,, 
,
/~ 
7X=
David T. Ellwood  ,;  -

L 
Y 
// 
PREPARED BY: ASPE/HP:THertz:245-7779 :3-13-95

A-7  Mmch 21, 1995 
AreaHealthEducation 
June GibbsBrown
Centers Pfogram 
Inspector General 
Department of HeaIth and Human Services 
O!fkosfthe  Washington,DC 20201 
ExeedvDeirectof 
Dear Ms. Brown: 
University  of Arkansas 
for MediealSciences  Thank you for the opportunity to comment on the dratl inspection report 
4301  W. Markham, Slot 599  entitled, Area Health Education Centers: A Role in Enhancing the Rural
LittJe Rock,  Arkansas  72205 
Practice Environment. The National Organization of AHEC Program 
(501)  SSS-5200 
Directors believesthat the repoti accurately reflects the need for expansion of 
Fax: (S01) M&Moe	
support setvices provided through Area Health Education Centers,  The 
National OrganizationofAHECProgramDirectors is especiaUyconcerned 
MEG FORTSMITH  that the report clearly specifi that it addresses only one segment of the total 
612 Eaub121hs8e4 
FOIISmith,AR72sot  mission of Area Health Education Centers. The repofi was not a 
FhorI&(501)7S$242! 
comprehensivereviewofthe AHECProgram,but rather, was an assessment 
AHECPM! BLUFF 
aloh4uromy  of the role that the Program is currentlyperforming or could pefiorm in 
PineBIJR,AR71603  providingsupport servicesto enhancethe practice environmentfor health care 
mma  [501)54I.SO1O 
wcsourn  ARKANSAS  1practitionersin rural areas. 
490 WaI FwIkner 
HM,  AR717W 
mma  (501)es7-24a3  In the Executive Summaryof the report at the top of page ii, we suggesthtat 
AHECNORTNWEST  a statementbeaddedwhichsays,.4HECSgenerallyviewtheir role in 
2s07 Emi Joym Slfeef 
Fee,  AR Z??&l  continuing education as one of meetingspecific needsa ndfillinvgo idtshat 
R&w  (541)S21~69 
maybelefbty othesro urceosf continuiendgu catiwoint houdtu plicattihnegs e
AHECNORTNEAST 
222 EA,UJackmM  othesro urcesTh.is  same missionof AHECs should be included on page 6,
&M6bf0,  AR?2401 
paragraph 4 or 5. Afso, the same theme should be carried fon.vard to the 
Pllmeu(al)  mm 
AHECSOUl14WE6T  recommendations on page 13 and 14 considercilnign ipcraalc tigcueidelines.
603 Wdlvl Slma 
TBIakm& AR755%? 
FtIOneWt JI] 774-7236  The developmentofcontinuingeducationprogramsbased on specific 
identified needs in the communitsye wedbytheAHEC maynotincludtehe 
topiccso verebdy theclinigcuaild elidneevseloped by AAHCPR, AHECS.
should not be required to provide continuing education courses simply 
because guidelineshave been developbeydA AHCPIL Continuiendgu
 cation
courseasr
enot well received by the audience unless topics are covered that 
have been specificallyrequested or seem to be extremely relevant at the time 
of presentation. 
An important role for AHEC is to make providers aware of the practice 
guidelines and to make them availableto constituents located within their 
respective areas. AHECSshouldbe encouraged to include the guidelines as 
resource materialanytimeapro~ramisconductedthat would encompassthe 
I 
h  Equal  C@ortunky  Emdoyer 
A-8
 Ms, June GibbsBrown 
March 21, 1995 
Page 2 
scope ofa publishedguideline.Theadoption ofpractice guidelines ofien 
requires significantcultural change by practitioners, Continuing education 
courses may not done accomplishthese changes, but they are art important 
way of providinginformationto practitioners. 
An appropriate role for AHECSis to provide informationregarding the 
numerouschangesthat aretakingplaceinthehealthcare system.However, 
the statementonpage 15,paragraph3, which saysthat AIIECScould assist 
mral practitionersinnegotiatingcontracts suggestsa role forAKECSthat 
wot.ddnotbewidelyadopted, Specialskillsareneededinthese areas that do 
not occur frequentlyintheAHECstaff Theappropriaterole forA.HECSin 
this area shouldbe more preciselystated byrecommendingthat AHECS 
shouldprovidesponsorshipandcoordinationofworkshops and conferences 
to inform and teach practitioners and administrators how to work within 
managed care systems. 
Itis an appropriate role for AKECSto actively pursue the development of 
telecommunicationslinkages,andto be the communityfacilitatorfor groups 
that wishto pursuedevelopmentoftelecommunications.Every effort should 
be made to encourage AHECSto take an active role in the advancement of 
this technology. Although AHECSare aware of the usefi.dnessand potential 
for telecommunicatiol~sin bridgingthe informationgap from academic health 
centers to remote and mral practitioners, these efforts require substantial 
financialbackinggenerallybystate governments,and cefiairdysignificant 
commitment of large medical centers, The role of the AF3ECProgram will 
vary from state to state. In some, the AI-EC will be only a facilitator; in others 
the AHECSwillplaya leadroleindevelopingtelemedicine.The specific 
activityshouldbecarefilly reviewedbecauseofthe great variabilityin 
regional needs and resources. Because telemedicineis an extremely expensive 
operation, specialfi.mdingwouldberequiredto assistinthe development of 
these networks, finding that would not subtract from the finding that is 
needed to develop the general infrastructure of a balanced AHEC Program. 
Somespecificeditorialcommentsare suggested.(Note: strikethrough = 
delete, underline= add.) 
Page A-7, last paragraph, first sentence 
TheNova SoutheasternUniversityM-EC Program hasprovided 
computers to 12 CHCSand County Public Health Units where ... 
&3!l@!m .,.studenttrainingtakes piace.Mmgm&k 
A-9
 Ms. June GibbsBrown

March 21, 1995

Page 3

~=hL  order to utilize these comuuters to conduct 
literature searches. the AKEC Program .,. 
Page A-8 
CONTINUINGEDUCATION COURSES 
2nd paragraph add a bullet:  Tuberculosis and Other Infectious Diseases 
 
Page A-8, last paragraph, first sentence: 
... courses were provided ... for health care professionals 
emoioved.,. in CHCs ... 
Page A-9 
TELECOhlNfUNICATIONS 
2nd paragraph, add second sentence: 
N  ofthe AI-EC Centers in Florida took an active role in conducting th~ 
cotierence. 
Page A-10, last paragraph, last sentence; 
... 
Page B-3, last paragraph: 
... FUUT,,~.   of the 19 counties in the Nova Southeastern 
~  ...UniversityAHECprogram area,., -M,,. ~  have 
partial county ... 
SOUTH TEXAS AREA HEALTH EDUCATION CENTER. 
RECOMMENDEDCHANGES/ADDITIONS 
Note: changes/addedtext is underlined. 
A-10
 Ms. June Gibbs Brown

March 21, 1995

Page 4

OVERVIEW 
1stsentence: 
.. basedat~he UniversityofTexas,.. 
MEDICAL LIBRARY RESOURCES 
1stparagraph: 
Based atthe AHECprogramofficeinSanAntonio... area 
consortiumof host)ita]sandhealthcareproviders... 
3rd paragraph: 
.,. and Valley Baptist Medical Center, hosts of mimatv care 
residencvrotatiom and student meceutor momms  which the 
AI-EC sponsors. 
Continuing  EDUCATION COURSES 
1stparagraph: 
EachUTHSCS~ professionalschool--medicine,nursing, 
dentistry, and allied heaith --M well as UT-Austinse~ension 
pharrnacvurowam, hasitsownofficeofcontinuingeducation. 
Zndparagraph: 
Addsentenceat end:Instructionaldevelopmenturomuns  are also . 
gnlt inely conducted for new receptors  or communitv-base~ 
clinicalfacultv$ 
CONCLUSIONS(TELECO~CATIONS) 
Addendum: 
The SouthTexas AHECutilizedtheknowledgegainedbythe 
demonstrationactivityto developaplan,financethe acquisitionof 
equipment,andimplementthe SouthTexasDistanceLea~n$  and 
A-n  Ms. JuneGibbsBrown 
March 21, 1995 
Page 5 
TeleHeaithNetwork whichcumentlylinksten communityclinical 
trainingsiteswiththeUTHSCSAcampus,(NOTE: Thisactivity 
wasinprocessatthetimeoftheinitialw-sitinJune, 1994. 
Installation of the equipmentbegan in Januruy, 1995.) 
Thank you for the opportunity to provide comments on the drafi of the report. 
We believethat the report containsverypositiverecommendationsfor the 
A.HECProgramas it addressesnewtechnologyandnew opportunitiesthat 
are now beingpresented. 
Yours most sincereiy, 
Ch$arles O. Cr~ord,  DDS
Vice Chancellorfor RegionalPrograms 
Executive Director, AHEC Program 
COC:he 
cc: Ocic Hanis, M.D. 
Lou Coccodrilli 
Cherry  Tsutsumida 
A-12
 APPENDIX  B

AHEC  SUPPORT SERVICES IN THREE  STATES: 
CASE DESCRIPTIONS 
TABLE OF CONTENTS 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  B-2

CASE  DESCRIPTIONS

  Arkansas  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-3

  Florida  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-7

  South  Texas  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-11

B-1
 INTRODUCTION

This  appendix  reports  on support  services  provided  by four  Area  Health  Education

Centers  (AHECS)  in three  States:  Arkansas  AHEC,  a statewide  program  based  at the

University  of Arkansas  for Medical  Sciences,  Little  Rock  Nova  Southeastern

University  AHEC  Program,  based  in Miami  Beach,  which  serves  southern  and  central

Florida  and  the  University  of Floridas  North  Florida  AHEC  Program,  which  serves

northern  Florida;  and  South  Texas  AHEC  Program,  based  at the  University  of Texas

Health  Science  Center  at San Antonio,  one  of three  AHEC  programs  in that  State.

Our  intent  in selecting  these  sites was to provide  information  on a range  of activities

that  AHECS  might  undertake  to make  the  rural  practice  environment  more  attractive

for health  care  professionals  and  to help  them  keep  their  clinical  skills up  to date.

We visited  each  of these  AHECS  for two-to-three  days in June  1994.  During  our

visits, we interviewed  administrative  personnel  from  the  central  AHEC  program  office

and  from  individual  AHEC  centers  affiliated  with each  program,  Our  visits included  a

review  of documents  and  records  kept  by the  AHEC.  We  also interviewed

practitioners--physicians,  nurse  practitioners,  nurses,  and  allied  health  personnel--who

use these  services,  in an effort  to get  an assessment  of their  views.

In this appendix,  we describe  how individual  AHECS  provide  support  services,  which

we recognize  are  only one  facet  of an AHECS operations.  Each  AHEC  also provides

clinical  clerkships  and  training  opportunities  for medical  and  other  health  sciences

students,  such  as nurses,  nurse  practitioners,  pharmacists,  and  allied  health

professionals.  Each  AHEC  either  maintains  or is affiliated  with a primary  care

residency  program  for physicians.  Each  of these  AHECS  also has in place  programs

to recruit  high school  students  to health  careers,  for example  through  summer  health

career  opportunities  camps.

To  select  the  AHECS  for our  case  studies,  we relied  on our  review  of Federal  AHEC

Program  Office  files and  discussions  with officials in that  office  to identify  sites that

might  be  instructive  to us.  To make  our  final selection,  we relied  on our  own

judgments  about  programs  that  would  provide  information  to benefit  our  study  and

provide  illustrative  examples  of how AHECS  can help  to meet  the  needs  of rural

practitioners.

We  report  on each  AHEC  using the  same  format.  Following  a background  section,

we describe  what  each  AHEC  is doing in medical  library  resources,  continuing

education  courses,  and  telecommunications.  We  then  draw  some  conclusions  about

the  role  that  support  services  play for the  AHEC  and  assess their  responsiveness  to

practitioner  needs.

B-2
 ARKANSAS

AREA  HEALTH  EDUCATION  CENTER

OVERVIEW 
Arkansas  AHEC  is a statewide  program  that  has  operated  since  1973.  Initially  funded 
by State  appropriations,  Arkansas  AHEC  received  its first federal  AHEC  support  in 
1985.  Arkansas  AHECnow  operates  onanannual  budget  of about  $14 million  with 
325employees  (including  clinical facul~,  residents,  and  administration).  The  AHEC 
program  is coordinated  through  the  University  of Arkansas  for Medical  Sciences 
(UAMS)in  Little  Rock,  the  States  onlymedical  school.  Six AHECcenters  operate  in 
Arkansas.  This  case  study is based  onsitetisits  tothe  WECprogram  office  in Little 
Rock,  and  to two AHEC  centers  in Pine  Bluff and  Fayetteville.19 
Each  Akansas  MECcenter  operates  asagroup  practice  in family medicine.  Each 
center  provides  a residency  program  for graduate  medical  students  and  preceptorships 
for undergraduate  medical  students,  in addition  to other  services.  The  AHEC  group 
practices  are  mainstream  health  care  providers  that  compete  with  other  private 
practitioners  in their  communities,  while  providing  training  opportunities  for medical 
students  and  residents  in a real world  practice  environment. 
MEDICAL  LIBRARY  RESOURCES 
Each  AHEC  center  maintains  its own library  that  is linked  to the  UAMS  medical 
library,  the  States  primary  source  of medical  research  literature.  The  UAMS  library 
enables  the  centers  to link with a five state  regional  library  network  and  the  National 
Library  of Medicine  (NLM).  Four  libraries  have  CD-Rem  technology  for accessing 
documents,  and  two have  been  designated  as NLM  access  libraries.  The  six AHEC 
libraries  served  65,000 patrons  and  conducted  24,000 searches.n 
Fayetteville  AHEC  library  served  over  6,000 users  in 1992-93, 80 percent  of whom 
were  health  professionals.  According  to data  provided  by the  AHEC,  60 percent  of 
these  health  professionals  were  physicians;  about  16 percent  of that  subset  were  rural 
practitioners  from  Northwest  Arkansas.  Pine  Bluff AHECS data  show that  the  library 
had  more  than  30,000 users  in 1992-93.  Health  professionals  accounted  for 42 percent 
of the  users;  48 percent  were  students  and  residents,  and  10 percent  were  members  of 
the  general  public,  The  AHEC  librarian  told  us that  34 percent  of the  practicing 
professionals  were  from  rural  communities. 
Pine  Bluff AHEC  has  established  the  Southeast  Arkansas  Medical  Information  Center 
(SEAMIC),  a consortium  of 11 rural  hospitals.  The  SEAMIC  makes  audio-visual 
materials  available  to staff at these  member  hospitals.  These  materials  are  available 
to a wide  range  of users--including  x-ray technicians,  medical  records  administrators, 
B-3
 hospital  managers,  dietitians,  and housekeepers;  in practice,  nurses  and  nursing 
students  account  for about  three-fourths  of the  3,400 users. 
CONTINUING  EDUCATION 
Each  AHEC  center  in Arkansas  determines  the  amount  of continuing  education  that  it 
will provide.  The  AHEC  centers  we visited  offer  only limited  continuing  education  for 
physicians  other  than  noon conferences  for AHEC  family practice  residents.  These 
noon  conferences  are  daily training  sessions  at the  affiliated  hospital  that  feature 
lectures  and  discussions,  led by local physicians  and  AHEC  staff.  Although  the  noon 
conferences  are  open  to all local practitioners,  in most  cases  only those  leading  the 
session  are  in attendance.  In addition  to these  noon  conferences,  Pine  Bluff AHEC 
hosts  a monthly  continuing  medical  education  lecture  series  for local physicians, 
combined  with a dinner  meeting,  and  Fayetteville  AHEC  sponsors  18 to 20 courses  for 
physicians  from  the  AHEC  service  area,  often  in conjunction  with a cosponsor  such as 
a hospital  or pharmaceutical  company. 
Arkansas  AHECS  fill the  need  for local  nonphysician  continuing  education  to a 
limited  extent.  During  the  1992-93 fiscal year,  SEAMIC  offered  29 courses  on  13 
different  topics  to member  hospitals.  These  courses  were  attended  by 620 individuals. 
These  courses  are  directed  primarily  at nurses,  but  also are  open  to hospital  managers 
and  other  staff.  Pine  Bluff AHEC  also sponsored  19 emergency  medical  service 
training  courses  for cardiac  life support. 
Fayetteville  AHEC  sponsored  45 nonphysician  practitioner  continuing  education 
courses,  attended  by 338 people  in 1992-93.  Nurses  accounted  for  74 percent  of these 
participants.  Nursing  staff at the  Fayetteville  AHEC  also took  the  lead  in conducting 
a statewide  survey  and  needs  assessment  that  provides  some  instructive  views on the 
types  of continuing  education  that  nurses  are  interested  in.  Staff  nurses  and  hospital 
directors  of nursing  differed  in their  priorities.  The  directors  ranked  most  highly the 
need  for nurse  training  on: 
  documentation  and  record  keeping; 
  motivating  others; 
  communication  skills; and 
.  basic  assessment. 
Staff  nurses,  on the  other  hand,  expressed  the  most  interest  in topics  such  as: 
  care  of patients  with HIV; 
  legal  aspects  of practice; 
  ethical  concerns;  and 
  clinical  topics. 
The  two AHEC  centers  we visited  focus their  continuing  education  within  disciplines, 
rather  than  on multidisciplinary  education.21  The  views of one  of the  AHEC  center 
directors  we spoke  with provides  an explanation.  He  told  that  doctors  teach 
US 
B-4
 doctors  andnurses  teach  nurses.  Recourses  offered  bynursing  areopen  to  other 
disciplines,  but  doctors  rarely  go to them. 
TELECOMMUNI  CATIONS 
Arkansas  AHEC  utilizes  interactive  video  at two centers  (Fayetteville  and  El Dorado) 
to give registered  nurses  an opportunity  to advance  educationally  to a bachelors  or 
masters  degree.  The  UAMS  School  of Nursing  purchased  the  video  equipment  with 
grant  funds  from  the  State  Department  of Higher  Education.  22 This  program 
electronically  links nursing  students  in the  two centers  with other  students  and 
instructors  at the  UAMS  School  of Nursing  in Little  Rock.  Students  receive  theory 
and  research  courses  directly  from  Little  Rock  through  interactive  video.  The  local 
AHEC  center  director  of nursing  education  supervises  the  students  clinical  education. 
The  BSN completion  course  enrolls  30 students,  and  the  MSN course  enrolls  15. 
This  system  is used  for continuing  education  on a very limited  basis.  The  nursing 
school  staff  cite three  primary  obstacles  to its broader  application.  First,  the  grant 
used  to purchase  equipment  was provided  for nursing  education,  so that  education 
naturally  takes  precedence  over  other  activities.  Second,  the  equipment  requires  a 
dedicated  classroom;  to use it for activities  such as continuing  education  means  that 
substantial  advance  planning  and  scheduling  is needed  to avoid  conflicts.  Third,  at this 
time  the  equipment  is available  in only two AHEC  centers,  so it would  not  be 
accessible  to practitioners  elsewhere  in the  State. 
CONCLUSIONS:  The Role  of Support Services in Arkansas 
AHEC  centers  in Arkansas  operate  physician  group  practices,  so support  services  play 
a limited  role  (with the  notable  exception  of medical  library  resources  which  are  seen 
as important  for  all local practitioners).  Because  the  AHEC  centers  employ  physicians 
directly,  they  already  have  preceptors  on staf~  the  centers  do not  need  to use  support 
services  to  attract  physicians  to teach  students. 
  Medical  Library  Resources 
Medical  library  resources  clearly  are  the  most  important  support  services  provided 
through  Arkansass  AHECS.  The  AHEC  libraries  are  an important  source  of overall 
medical  information  for practitioners  throughout  Arkansas,  both  those  in the  AHEC 
practice  and  those  not  affiliated  with it. 
The  Arkansas  AHEC  programs  medical  library  system provides  widespread  access  to 
practitioners  throughout  the  State  to medical  research  literature.  One  practitioner  we 
interviewed  explained  the  significance  of this system  for practicing  physicians,  when  he 
told  us, Sometimes  it is good  to get  away [for continuing  education],  but what  you 
really  need  is answers  to questions  that  come  up on a day-to-day  basis.  The  AHEC 
center  directors  we spoke  with cited  the  availability  of medical  library  resources  as an 
important  attraction  recruiting  new physicians. 
B-5    Continuing  Education  Courses 
Providing  continuing  education  courses  for physicians  is not  a major  focus  of these

AHEC  centers.  Physicians  indicated  that  continuing  education  courses  are  readily

available  elsewhere,  either  through  local  meetings  (e.g., the  local  medical  society)  or at

major  conferences  out  of state. 23 In addition,  as a staff model  group  practice,  each

AHEC  center  can reduce  the  isolation  of the  centers  physicians.

There  does  appear  to be  a need  for continuing  education  for  allied  health

professionals.  Arkansas  AHECS,  however,  are  primarily  physician-focused

organizations,  Consequently,  continuing  education  for allied  health  professionals  is not

strongly  institutionalized  as part  of the  basic  mission  for this AHEC,  meaning  that  it

could  be vulnerable  in times  of budgetary  constraints.

  Telecommunications 
The  Arkansas  AHEC  program  has taken  initial  steps  toward  expanding  telecommu
nications  through  long distance  interactive  video  education  for nurses.  This  initiative 
appears  to be well supported  and  liked  by those  who use it.  It holds  promise  for use 
in continuing  education  programs,  particularly  for allied  health  practitioners  and 
nurses.  We were  informed  by allied  health  faculty we spoke  with,  and  by nursing 
faculty  in the  AHEC  center  without  interactive  video,  that  they wished  it were 
available  for them.  The  AHEC  should  be well positioned  to help  advance 
telecommunications  because  it has direct  access  to and  involvement  with the  system 
used  in nursing  education. 
Nurses  enrolled  in the  interactive  video  course  in Fayetteville  (roughly  200 miles  from 
Little  Rock)  told  us about  two major  advantages.  First,  they  are  able  to continue 
living at home,  rather  than  having  to move  to Little  Rock.  Second,  they  are  able  to 
continue  their  current  nursing  practice  while pursuing  a degree,  rather  than  becoming 
full-time  students. 
We  discussed  this approach  with faculty  for allied  health  programs  in both  Pine  Bluff 
and  Fayetteville.  Those  at Fayetteville  told  us that  the  technology  greatly  facilitated 
education  when  they  had  been  able  to use it.  Those  at Pine  Bluff thought  that  it 
would  be very useful  to have  interactive  video,  both  for initial  training  of allied  health 
professionals  and  for continuing  education. 
The  AHEC  physicians,  however,  were  skeptical  about  its potential  for continuing 
education.  Long  distance  technology  is not  used  in the  Arkansas  AHECS  for 
consultative  or diagnostic  purposes  at this time.  However,  they  are  making  plans  to 
establish  a telemedicine  program  in the  future.  One  physician  told  us that  compressed 
video  would  be  a waste  of time  for physicians  education.  He  agreed  that  it might  be 
useful  for  consultation--but  he, personally,  would rather  just  pick up  the  phone  and 
call someone  he knew. 
B-6
 FLORIDA

AREA  HEALTH  EDUCATION  CENTERS

OVERVIEW 
Four  AHECprograms  operate  in Florida.  Revisited  twoofthese  programs,24 
where  we met  with staff from  two centers  within  each  program,  as well as providers 
affiliated  with  community  and  migrant  health  centers  (CHCS),  county  public  health 
departments,  and  practitioners  in private  practice.  It is in these  clinical  sites  that 
AHECS  provide  the  bulk  of their  student  training  and  the  substantial  share  of their 
support  services.  Although  there  are  four  different  AHEC  programs  in Florida,  from 
a statewide  basis  they may be viewed  as a single network.  The  State  of Florida 
appropriated  $6.5 million  for AHEC  programs  in fiscal year  1994. 
Nova  Southeastern  University  AHEC  Program,  based  in North  Miami,  received  its 
initial  Federal  AHEC  funding  in 1985.  This program  includes  two AHEC  centers. 
Everglades  AHEC  Center,  based  in West  Palm  Beach,  serves  ten  counties  in Southern 
Florida.  Central  Florida  AHEC  Center,  based  in Apopka,  covers  nine  counties.25 
The  University  of Floridas  North  Florida  AHEC  Program,  based  in Gainesville, 
received  its first Federal  AHEC  award  in 1992.  Two North  Florida  AHEC  centers  are 
fully operational:  Suwannee  River  AHEC  Center,  based  in Alachua,  covers  a 
12 county  area  in north  central  Florida,  and  Big Bend  AHEC  Center,  based  in 
Tallahassee,  covers  14 counties  in the  Florida  Panhandle.  Two  additional  centers  are 
in the  early  stages  of operation,  and  one  more  is in the  planning  stage.~ 
MEDICAL  LIBRARY  RESOURCES 
Medical  Library  Resources  at Nova  Southeastern  University  AHEC  Program 
F 
The  focal  point  of this AHECS library without  walls is a dissemination  service  for 
learning  resource  materials.  The  AHEC  distributes  the  tables  of contents  from  about 
40 journals  to 80 practice  sites in which it places  students  and  residents.27  In 
addition,  it distributes  texts  and  other  materials  from  the  AHECS  clearinghouses  on 
HIV/AIDS,  child abuse,  and  ethnocultural  issues in health  care.  Nova  Southeastern 
data  show that  the  library  delivered  3,152 information  requests  in the  July  1992-June 
1993 fiscal year,  and  4,291 from  July  1993 to June  1994. 
The  Nova  Southeastern  University  AHEC  Program  has provided  computers  to 
12 CHCS and  county  public  health  departments  where  significant  student  training 
takes  place.  In order  to utilize  these  computers  to conduct  literature  searches,  the 
AHEC  program  provides  Grateful  Med  software  and  on-site  training  in its use to 
preceptors  and  other  staff in those  sites. 
B-7
 Medical  Library  Resources  at the  North  Florida  AHEC  Program 
F 
North  Florida  AHEC  emphasizes  a computerized  reference  service  using CD-ROM 
technology  through  the  Florida  Health  Information  Network  (FHIN),  in the  University 
of Florida  School  of Medicine.  The  FHIN  is available  to any physician  or health 
services  provider  in Northern  Florida  on a subscription  basis  at $200 per  year.  As an 
incentive  to work with its students,  AHEC  gives its preceptors  a free  subscription. 
The  AHEC  provides  computer  terminals  for its permanent  teaching  sites--those  in 
which  students  are  regularly  placed--so  that  practitioners  can  access  this service 
directly.x  In the  15-month  period  ending  in June  1994, the  AHEC  had  interactions 
with  173 individuals,  55 percent  of whom  were  medical  students. 
CONTINUING  EDUCATION  COURSES 
These  AHECS  target  their  continuing  education  courses  at CHCS and  county  public

health  departments,  the  settings  on which they focus for clinical  placements.  The

AHECS  have  used  formal  needs  assessments  to identify  continuing  education  needs,

but  the  staff believe  that  more  useful  insight  comes  from  less formal  methods,  such  as

recommendations  made  in written  evaluations  of other  continuing  education

programs. 29 In addition,  the  statewide  association  representing  community  health

centers  works with the  AHECS  to identify  multidisciplinary  training  needs  of staff in

those  centers.

AHEC  staff we spoke  with indicated  that  topics  related  to ~DS  and  HIV  are  of

paramount  interest  to practitioners.  Other  topics  of interest  frequently  mentioned

included:

.  pesticide  exposure;

  early  breast  cancer  detection;

  tuberculosis  and  other  infections  diseases;

.  procedural  skills (e.g., joinitn
jection  and  aspiration,  or colposcopy  training); 
  identification  of domestic  abuse; 
  cultural  sensitivity  in providing  care  to members  of immigrant  and  minority 
groups; 
  training  in a second  language  (primarily  Spanish  and  Creole);  and 
  avoiding  staff burn  out. 
AHEC-sponsored  continuing  education  is important  for nurses  and  allied  health 
professionals.  From  1991 through  1993, almost  11,000 participants  attended 
continuing  education  programs  sponsored  by these  2 AHEC  programs.  Nine  percent 
of participants  were  physicians,  37 percent  were  nurses  and  nurse  practitioners, 
40 percent  were  allied  health  professionals,  and  15 percent  were  other  health 
professionals~ 
Data  from  Nova  Southeastern  show that  58 percent  of continuing  education  courses 
were  provided  for health  care  professionals  employed  in CHCS or county  public  health 
departments  in 1992-93.  The  North  Florida  AHEC  does  not  maintain  data  in this 
B-8  format;  qualitatively,  though,  during  our  site visit we met  with a number  of CHC  and 
health  department  physicians  and  staff in North  Florida  who noted  that  the  AHEC 
had  sponsored  continuing  education  courses  in their  practice  sites. 
TELECOMMUNI  CATIONS 
AHECS  use  of telecommunications  in Florida  is still in an early  stage,  with  little 
telemedicine  or long distance  education  provided.  The  Florida  AHECS joined  with 
the  State  Department  of Health  and  Rehabilitative  Services  (DHRS)  in the  Spring  of 
1994 to  coordinate  a teleconference  on current  treatment  for tuberculosis. 
Because  of its proximity  to the  DHRS  central  office in Tallahassee,  Big Bend  AHEC 
Center  took  on a prominent  role  in coordinating  conference  details.  All of the  AHEC 
centers  in Florida  took  an active  role  in conducting  the  conference.  The  program 
utilized  a case  presentation  method,  with  a pre-conference  instructional  guide.  Prior 
to the  actual  televised  program,  staff solicited  questions  from  conference  registrants  by 
fax.  The  speaker  reviewed  these  questions  and  attempted  to address  them  in his 
presentation.  The  teleconference  ran  for one  and  one-half  hours.  Teleconference 
sites included  CHCS, county  public  health  departments,  nursing  homes,  and  community 
colleges.  Requirements  were  a satellite  dish ($5,000-$7,000),  TV monitor  with  a 
special  unit,  and  a hand  held  telephone  set.  The  result  was a conference  that  reached 
1,080 participants  at  77 sites at a delivery  cost of about  $2 per  person. 
CONCLUSIONS:  The Role  of Support Services in Florida 
Support  services  play an important  role  in these  AHECS overall  operations.  The 
AHECS  use  support  services  to develop  and  solidify relationships  with the  community-
based  practitioners  who  serve  as preceptors  for AHEC  students.  These  clinicians-
practicing  in community  health  centers,  county  health  departments,  and  private 
practice--are  an important  educational  resource  for the  AHECS,  because  they  practice 
in the  sites in which AHEC  students  are  trained. 
The  AHECS  target  their  preceptor  and  training  sites for special  attention  with  library 
resources  and  continuing  education.  By providing  support  services  in these  sites, 
AHECS  are  able  to help  these  practitioners  maintain  their  skills.  In addition,  these 
support  services  provide  a way through  which AHECS  can provide  tangible  assistance 
to those  practitioners  who form  their  educational  base  in the  community. 
  Medical  Library  Resources 
In both  AHECS  we visited,  practitioners  told  us about  the  usefulness  of these  types  of 
services.  One  county  health  officer  rated  medical  library  resources  as the  most  useful 
service  that  AHEC  provides.  The  medical  director  of a community  health  center  told 
us that  having  access  to a medical  library  was critical  in her  practice.  Another 
physician  said that  access  to medical  library  resources  is important  to her  because  she 
often  feels  cut off from  academic  medicine.  The  medical  director  of a county  public 
B-9  health  unit  challenged  all the  practitioners  associated  with the  department  to use the 
tables  of contents  services,  because  they  would really be  stupid  not  to use  these 
resources.  The  staff took  him up on this challenge,  and  that  one  unit  now accounts 
for 20 percent  of the  total  information  requests  received  by the  AHEC. 
F  Continuing  Education  Courses 
We  did not  formally  evaluate  continuing  educations  impact  on practitioner  retention; 
however,  physicians  we met  with told  us of its importance.  An AHEC  preceptor  in 
private  practice  typified  the views shared  by others  when  he  said that  Once youre  out 
in the  community,  youre  it.  This is not  the  kind  of training  that  you get  on grand 
rounds  at a teaching  hospital,  but  giving the  local hospital  staff something  to keep 
current  is critical.  Another  physician  we spoke  with went  so far  as to credit  the 
availability  of AHEC-sponsored  continuing  education  in his rural  CHC  as a key factor 
in attracting  two new physicians  to the  area.  From  the  point  of view of the  CHCS, the 
AHECS  fill an important  need.  The  director  of a group  of CHCS told  us that  AHEC 
is our  training  arm.  Without  AHEC  we couldnt  put  this training  on. 
  Telecommunications 
Practitioner  reactions  to telecommunications  are  not  clear  cut.  According  to those 
involved  with  coordinating  the  TB program,  evaluations  showed  that  participants  liked 
it as a learning  mode.  As one  physician  told  us, this was a good example  of how to 
use technologies  at the  site.  Everyone  got to watch  it; the  course  came  to us, and  we 
were  too  busy to go out  of town for it.  But for other  practitioners,  this technology 
has not  been  completely  accepted.  Despite  the  apparent  success  of the  TB televideo 
conference,  one  physician  expressed  concern  about  potential  problems  with  the 
equipment.  She  also complained  that  even if it all works  fine, it still requires  a time 
commitment  and  it wont be  as personal  as more  traditional  programming. 
State  officials  told  us that  Florida  is the  only State  to have  a dedicated  network  for 
public  health  professions.  The  DHRS  owns this network  and  plans  to utilize  it for 
additional  state-activated  Clinical Hot  Topics  series.  The  four  Florida  AHECS  have 
formed  a Statewide  educational  programming  committee  to address  the  need  for 
additional  teleconferences.  Three  additional  teleconferences  are  planned  for the 
1994-95 fiscal year  on topics  of domestic  violence,  and  ethnocukural  sensitivity. 
B-10
 SOUTH  TEXAS

AREA  HEALTH  EDUCATION  CENTER

OVERVIEW 
The  South  Texas  AHEC  Program  (STAHEC),  based  at The  University  of Texas

Health  Science  Center  at San Antonio  (UTHSCSA),  began  operation  in October  1990.

South  Texas  is one  of three  AHEC  programs  in the  State.31  This  AHEC  program

serves  a 48,000 square  mile  area  from  San Antonio  to the  Texas-Mexico  border.

During  our  visit, we met  with staff from  the  STAHEC  program  office  and  the  Lower

Rio  Grande  Valley  AHEC  Center  in Weslaco,  and  with practitioners  served  by that

AHEC  center.  This  center  was the  first established  in this program  and  has been  in

operation  since  January  1991.32 Its service  area  contains  a population  of about

800,000 people  in the  4 southernmost  counties  of Texas.  Three  community/  migrant

health  centers  and  one  State-designated  rural  health  clinic are  located  in this  area.

MEDICAL  LIBRARY  RESOURCES 
In addition  to facilitating  access  to the  medical  library  at UTHSCS~  South  Texas 
AHEC  Program  uses  a circuit  rider  librarian  to take  medical  library  resources  to 
practitioners.  Based  at the  AHEC  program  office in San Antonio,  the  circuit  riders 
primary  clients  are  a consortium  of hospitals  and  health  care  providers  in the  Lower 
Rio  Grande  Valley  area  served  by the  AHEC  center.  Consortium  members  pay a 
membership  fee  that  covers  a portion  of the  cost of the  service.33 
The  librarian  spends  one week  each  month  visiting the  consortium  members  and  other 
providers  in the  Rio  Grande  Valley.  During  her  circuit,  she provides  training  on how 
to access  various  data  bases.w  The  librarian  conducts  searches  for practitioners, 
using a lap  tap  computer  with fax-modem  capability.  When  not  riding  circuit  in the 
Valley,  she  is accessible  through  a 1-800 telephone  number.  She gives out  her  home 
telephone  number  to all of her  clients  and  takes  the  lap  top  computer  home  at night 
and  on the  weekends  so that  she can conduct  emergency  literature  searches,  if needed. 
In addition  to the  circuit  rider,  AHEC  has placed  a permanent  computer  with  Grateful 
Med  software  in Brownsville  Community  Health  Center  and  Valley  Baptist  Medical 
Center.  These  facilities  host  primary  care  residency  rotations  and  student  preceptor 
programs  which  the  AHEC  sponsors. 
South  Texas  AHEC  focuses  on the  circuit  rider  librarian  approach  for two primary 
reasons.  First,  it meets  the  need  for information  required  by practitioners  in the 
community.  Between  October  1990 and  August  1993, AHEC  data  show that  the 
circuit  rider  system  completed  3,425 searches  and  delivered  12,671 documents.  The 
AHEC  calculates  that  the  value  of this on-line  searching  and  document  delivery  totals 
more  than  $100,000 in direct  costs. 
B-n  Second,  the  circuit  librarian  is a strong  marketing  tool  for the  AHEC.  Although  labor 
intensive,  this service  continually  demonstrates  AHECS presence  and  services  to 
practitioners.  The  circuit  riding  librarian  model  reinforces  the  availability  of medical 
library  resources,  as well as the  role  that  AHEC  can play in helping  practitioners. 
CONTINUING  EDUCATION  COURSES 
South  Texas  AHEC  provides  little  continuing  education  directly.  Fiscal year  1992-93 
data  show that  the  AHEC  provided  continuing  education  for 225 professionals.  Allied 
health  professionals  comprised  51 percent  of participants,  nurses  29 percent,  and 
physicians  19 percent.  Instead  of developing  a separate  continuing  education  capacity, 
the  STAHEC  program  office  and  the  centers  support  continuing  education  offered  by 
the  individual  health  professions  schools.  Each  UTHSCSA  professional  school-
medicine,  nursing,  dentistry,  and  allied  health--as  well as UT-Austins  extension 
pharmacy  program  has its own office of continuing  education. 
The  AHEC  centers  support  the  continuing  education  provided  by these  schools  by 
giving information  on the  needs  of community  practitioners  to these  continuing 
education  offices, based  on input  from  community  advisory  committees,  with  support 
and  assistance  from  the  STAHEC  program  office.  The  AHEC  centers  also  coordinate 
and  publicize  continuing  education  that  is available  locally, and  provide  some  financial 
support  for program  offerings  requested  for a local  area.  The  AHEC  routinely 
conducts  instructional  development  programs  for new preceptors  or community-based 
clinical  faculty. 
TELECO MMUNICATIONS 
In  1993, the  AHEC  sponsored  a month-long  telemedicine  demonstration  project.  The 
goals  of this project  were  to demonstrate  the  use of telemedicine  and  telecommuni
cations  between  the  UTHSCSA  and  the  AHEC-affiliated  Family  Practice  Residency 
Program  in McAllen,  over  200 miles  away.  The  demonstration  included: 
.	 A  series  of lectures,  seminars,  and  grand  rounds  on topics  such  as orthopedics, 
dermatology,  and  neonatal  resuscitation; 
.	 Consultations  and  case  presentations  in obstetrics,  pediatric  cardiology  and 
pediatric  neurology;  and 
.	 Hands-on  demonstration  and  use  of electronic  imaging  equipment,  microscopes, 
and  stethoscopes. 
All equipment  was donated  by private  vendors.  Educational  programs  were  based  at 
the  Health  Science  Center.  In McAllen,  family practice  residents  and  staff physicians, 
community  physicians,  medical  students,  nurses,  and  allied  health  staff participated. 
Most  lectures  were  delivered  from  UTHSCSA,  some  sessions  were  interactive,  with 
presentations  from  both  settings.  In addition  to the  practitioners  who  attended  the 
B-12  San Antonio  sessionpsa,r ticipanitnsM cAlleninclude8d8 people  for the  lectures,  29 in 
the  consultation  sessions,  and  14  for the  equipment  testing. 
South  Texas  AHEC  also uses two-way interactive  video  between  the  Health  Science 
centeratSanAntonioandtheUniversitoyf TexascampusinBrownsvillteo
provide

nursingc oursesf ora BSN-MSN degreeprogram.The programenroll2s9
 students

andprovide2s5 0classroohmo
 urspersemester.

The TelecommunicatioNnest workofTexas,anexistinnegt
 workhousedintheTexas

DepartmentofEducationa,ls
o has  some  experience  with providing  live audio  (via 
telephone  lines)  continuing  education  for credit  for health  care  providers,  along  with 
visual  materials  (such  as slides)  to accompany  the  audio  broadcast. 
CONCLUSIONS  The  Role  of Support Services in South Texas 
FortheSouthTexasAHEC, supportseficesisoneimportanwta
 y ofproviding

outreacha ndtangiblsee rvicetso ruralp ractitioneprasr,t iculatrhloys einvolveidn
 

trainintgh eirs tudentsT.h e directoorf acommunityhealthcenters
ummarizedthis

importancweh en shenoted, AHEC isimportantto ouroveralwlo
 rk.Itprovides

residentsst,u dentfso rtraininagn,d helpstosupportt heCHCS effortsO.ne
  rural

practitionweer i nterviewehde resummarizedtheneedforsupportservicewsh
en he

toldus,Thehardestt hingaboutpracticiinnga rurala
realikeoursisthatyoudont

haveanacademiccommunitytoprovidea liflei
 netonew ideas.

  Medical  Library  Resources 
The  medical  library  resources  meet  an important  need.  The  AHEC  staff and  local 
practitioners  told  us that  medical  library  facilities  in this area  are  minimal,  even  at the 
local  university  campus  with a school  of nursing.  They  cited  a lack  of available  books 
and journals,  as Wdi as difficulty in providing  t~ose  m~terials  to professionals  located 
at a distance  from  the  library.  For  many  physicians,  the  librarian  offers  the  only 
access  to professional  journals  outside  of their  own personal  libraries. 
The  AHEC  program  also faces  opportunity  to expand  the  circuit  riding  library 
program  as it develops  AHEC  centers  in new geographic  areas.  This  opportunity, 
however,  presents  a challenge  to AHEC:  How to expand  the  service  to other  areas, 
given the  staffing  requirements  and  cost of meeting  the  increased  demand,  and  how to 
ensure  that  it this resource  is accessible  to all practitioners  in the  area,  not just 
members  of the  consortium. 
  Continuing  Education  Courses 
Additional  opportunities  exist for continuing  education  provided  by this AHEC.  As 
we note,  AHEC  provides  little  continuing  education  itself, relying  instead  on the 
programs  provided  by the  individual  health  professions  schools  a~ UTHSCSA.  In our 
interviews  in the  Lower  Rio  Grande  Valley, practitioners  expressed  a need  for 
B-13 
  additional  continuing  education  focusing  on three  areas.  First, we heard  of the  need 
for multi-disciplinary  continuing  education,  While  the  continuing  education  provided 
through  the  health  professions  schools  meets  the  needs  of the  professions,  it tends  to 
be  isolated  within  individual  disciplines,  rather  than  cutting  across  them. 
Second,  practitioners  expressed  a need  for locally-provided  continuing  education.  This 
is a particular  need  for nonphysician  and  allied  health  personnel,  for whom  traveling 
to San Antonio  or Houston  for continuing  education  may be  prohibitively  expensive 
for them  or their  employers. 
Finally,  we heard  about  a need  for continuing  education  that  addresses  specific  local 
problems  unique  to this area,  rather  than  having  to pick from  a broader  agenda  of 
health  care  issues.  One  nurse  expressed  this as, We dont need  any more  training 
about  home  health  visits, but  we do need  education  on asthma,  diabetes,  psycho-social 
skills, and  cultural  sensitivity. 
  Telecommunications 
The  South  Texas  AHEC  Program  has been  actively  involved  in examining  telecommu
nications  potential,  both  for providing  nursing  education  and  for continuing  education 
and  telemedicine  demonstrations.  AHEC  staff note  that  they  are  committed  to 
increasing  the  use  of telecommunications  for all types  of medical  providers.35  The 
AHEC  views telecommunications  as a means  to circumvent  cost- and  travel-
restrictions  on provider  learning.  Community  practitioners  and  administrators  believe 
that  telecommunications  can fill an important  need.  The  administrator  of a 
community  health  center  summarized  these  views when  she told  us that  her  local 
continuing  education  committee  is very excited  about  telemedicine  as a way of 
delivering  information  to local  practitioners. 
The  telecommunications  demonstration  provided  information  to practitioners,  The 
practitioners  also identified  some  problems  that  need  to be  overcome  if telecommu
nications  are  to be  an effective  method  for providing  long distance  education.  On  the 
positive  side, the  demonstration  evaluators  found  that  practitioners  agreed  about  the 
potential  for the  technology.  However,  participants  in the  workshops  raised  questions 
about  its current  design.  They  expressed  reservations  about  diagnostic  telemedicine, 
primarilbye
causeofproblemswiththeequipment?6Inthetelecommunications

demonstratioint,a ppearsthattechnicaplr oblemswiththeequipment--nporta
 ctitioner

interest--tloetdh enegativvei ews.To addresst heseproblemsS,T AHEC  stafafr
 e

attendinwgo rkshopsandaretalkindgi rectwliyt
 hequipmentvendors.Accordingto

AHEC  stafft,h equalitoyf thediagnosteiqcu ipmentisimprovinga,n
 dtherangeof

availableeq
uipmentisexpanding.3

South  Texas  AHEC  utilized  the  knowledge  gained  by the  demonstration  to develop  a 
plan,  finance  the  acquisition  of equipment,  and  implement  the  South  Texas  Distance 
Learning  and  TeleHealth  Network.  Equipment  installation  began  in January  1995, 
and  the  network  links ten  community  clinical  training  sites with the  UTHSCSA 
campus. 
B-14
 APPENDIX  C

ENDNOTES 
1.  Other  Federal  efforts  include: 
	 Support  for educational  institutions  that  train  practitioners.  This  approach 
includes,  the  Health  Education  and  Training  Centers  Program,  Rural 
Interdisciplinary  Training  Grants,  and  Nursing  Special  Project  Grants; 
	 Direct  personnel  placement  strategies,  such as the  National  Health  Service 
Corps  (NHSC); 
.	 Reimbursement  approaches,  such as the  Health  Professional  Shortage  Area 
bonus  payment  program;  and 
.	 Direct  delivery  programs,  such as Rural  Health  Centers  and  Community/ 
Migrant  Health  Centers  programs. 
2.  P.L.  102-408 established  a model  State  supported  program.  This  program  requires 
a 50 percent  hard  dollar  match  from  State  funds  in order  to obtain  Federal  funding. 
3.	 U.S.  General  Accounting  Office, Health  Professions  Education:  Role  of  Title 
VII/VIII  Rrograms  in Improving  Access  to  Care  is Unclear,  .luly 1994, p. 4. 
4.  U.S.  Congress,  Office  of Technology  Assessment,  Health  Care  in Rural  America, 
OTA-H-434  (Washington,  DC:  U.S. Government  Printing  Office,  September  1990), 
p. 318. 
5.  Ibid. 
6.  Charles  O. Cranford,  Continuing  Professional  Educational  Support  Systems, The 
National  MIEC  Bulletin,  IX (Summer  1991)  1:1-2.  Emphasis  in original. 
7.  The  offerings  cover  dozens  of different  subject  areas,  and  it is not  possible  to 
identify  the  exact  number  of courses  given on different  clinical  topics.  Some 
applications  do not  contain  course  specific  information.  Other  applications  list course 
titles  differently  or aggregate  courses  according  to different  criteria. 
8.  One  AHEC  we visited  sponsored  a weekend-long  retreat  for rural  preceptors,  and 
plans  to repeat  it annually  or more  often.  Another  AHEC  brings  its preceptors 
together  three  times  each  year  at the  health  sciences  center.  These  sessions,  taught 
for the  most  part  by other  preceptors,  include  courses  on teaching,  evaluating  students, 
and  handling  problem  situations. 
c-1
 9.  The  AHCPRguidelines  issued  to date  are:  Acute  Pain  Marzagement  (issuedin 
March,  1992); Urinaiy  Incontinence  in Adults  (March,  1992) ;Pressure  Ulcers in Adults 
(May,  1992); Cataracts  in Adults  (February,  1993); Depression  in Primary  Care  (April, 
1993);Sickle  CellDisease  (April,  1993) ;EarlylWVInfection(  January,  1994) ;Benign 
Prostatic  Hyperplasia  (February,  1994); Management  of Cancer  Pain  (March,  1994); 
Unstable  Angina  (March,  1994); Heart  Failure  (June,  1994); and  Otitis Media  with 
E~ion  (July,  1994). 
10.  University  of Arkansas  for Medical  Sciences  Area  Health  Education  Centers, 
Demonstration  of Dissemination  of Medical  Technolog  Using Area  Health  Education 
Centers,  Contract  No. RFP  HRSA  240-BHPr-24(0)MAD,  October  1990 to January 
1993, Executive  Summary,  p. 8.  These  guidelines  were  not  developed  by AHCPR,  but 
were  the  product  of another  PHS  effort,  a consensus  development  conference  of the 
National  Heart,  Lung  and  Blood  Institute. 
11.  In two other  States,  the  AHEC  directors  told  us that  they were  cooperating  with 
efforts  of the  State  medical  society to provide  information  to practitioners  about 
managed  care  and  health  care  reform. 
12.  These  programs  are  designed  for associate  degree  nurses  or diploma  nurses  to 
earn  bachelors  degrees  or, in some  cases for bachelors  level nurses  to receive 
masters  preparation. 
13.  See,  for  example,  John  E. Wennberg,  J.L. Freeman,  R.M.  Shelton,  and  T.A. 
Bubolz,  Hospital  Use  and  Mortality  among  Medicare  Beneficiaries  in Boston  and 
New Haven,  New England  Journal  of Medicine  321  (October  26, 1989)17:  1168-1173. 
14.  The  Office  of Technology  Assessment  has noted,  for  example,  that  rural  areas 
are  increasingly  competing  with urban  practices  (such  as those  associated  with health 
maintenance  organizations)  for primary  care  physicians.  OTA,  p.  18. 
15.  See,  for  example,  Washington  Statewide  Office  of Rural  Health,  Implementing 
Health  Care  Reform:  Setting  a Course for  Rural  Washington,  Workshop  Summary, 
November  9-10, 1993, Seattle. 
16.  One  AHEC  director  in a rural  State  summarized  this view when  he noted  that, 
Our physicians  dont  even  know how to spell HMO. 
17.  See,  for  example,  Peering  into  2010:  A Sulvey  of the  Future  of Medicine,  Z7ze 
Economist,  March  19, 1994. 
18.  The  ORHP  sponsored  a Rural  Telemedicine  Workshop  in November  1993 that 
brought  together  Federal  and  State  officials, researchers,  and  members  of the  business 
community  to address  issues related  to telemedicine.  See,  Reaching  Rural:  Rural 
Health  Travels  the  Telecommunications  Highway, Office  of Rural  Health,  1994, for a 
summary  of conference  proceedings.  A report  prepared  for ORHP  also addresses  the 
potential  of telecommunications  in detail;  see John  P. Witherspoon,  Sally M. 
c-2
 Johnstone,  and  Cathy  J. Wasem,  Rural  TeleHealth:  Telemedicine,  Distance  Education 
and  Informatic,s  for  Rural  Health,  Western  Cooperative  for Educational 
Telecommunications,  Boulder,  CO, September  1993. 
19.  Other  centers  operate  at Jonesboro,  Fort  Smith,  El Dorado,  and  Texarkana.  Only 
Pulaski  County  (Little  Rock)  is not  covered  by an AHEC  center. 
Pine  Bluff AHEC  is located  on the  grounds  of the  Jefferson  County  Regional  Medical 
Center.  Professional  fees provide  58 percent  of their  $4.9 million  budget,  36 percent 
comes  from  State  appropriations,  and  the  balance  from  community  support,  such  as 
the  local  hospital.  These  funds  support  the  AHEC,  one  community  health  center,  and 
a library/learning  resource  center. 
Northwest  AHEC,  based  in Fayetteville,  is located  about  two miles from  the 
Wilmington  Regional  Medical  Center,  where  hospital-based  training  of residents  takes 
place.  Northwest  AHEC  operates  on an annual  budget  of $3.2 million--about 
38 percent  from  professional  fees,  38 percent  from  million  in state  money,  10 percent 
from  grants  for special  projects,  and  15 percent  from  local hospital  support. 
20.The  access  libraries  are  located  in Fayetteville  and  Jonesboro.  Being  an NLM-
access  library  means  that  they provide  information,  training,  and  demonstrations  on 
Grateful  Med  to users  who  are  not  affiliated  with AHEC,  as well as to those  who  are. 
The  data  on users  is a duplicated  count. 
21.  AHEC  staff told  us, however,  that  at the  El Dorado  AHEC  center,  there  is a 
much  greater  focus  on multidisciplinary  continuing  education. 
22.The  equipment  costs about  $100,000 per  unit. 
23.One  physician  told  us that  More  CE  goes on in the  hallways  of the  hospitals  than 
in all the  local  courses  combined. 
24.The  other  programs  are  located  at the  University  of Miami  Medical  School  (which 
has two AHEC  centers)  and  the  University  of South  Florida  School  of Medicine  in 
Tampa,  a new program  with two AHEC  centers  in the  planning  stage. 
25.Southeastern  College  of Osteopathic  Medicine,  the  original  home  of this AHEC, 
merged  with  Nova  University  in January,  1994 to form  Nova  Southeastern  University. 
The  university  includes  several  off-site  campuses  that  utilize  electronic  learning 
facilities  and  already  operates  a technology  center  that  includes  broadcast  studios  with 
interactive  compressed  two-way video. 
Five  of the  19 counties  in the  Nova  Southeastern  University  AHEC  Program  area 
have  been  designated  as county-wide  Health  Professionals  Shortage  Areas  (HPSAS), 
and  the  remaining  14 have  partial-county  HPSA  status.  Twenty-one  CHCS operate  in 
15  of the  19  counties. 
c-3
 26.In the  North  Florida  AHEC,  33 of the  37 counties  are  either  wholly or partially 
designated  HPSAs.  Four  counties  have  nohospital,  andsixcounties  have  only 
one  hospital  with  60 bedsorfewer.FourCHC organizatioonpserateinthisarea,

many ofthemwithmultiplsea tellictlei niicnsr uralc
ommunities.

27.The AHEC  programofficaet Nova Southeastermna intaintsh ejournalasn
 d

photocopieisn dividuaarlt iclfeosr distributiwohni,l ethecentralF loridAaH
 EC  center

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 wouldlikea copyofan

articlfer omanyofthesejournalwsr itehsi sorhername andaddresso
n the

photocopiecdo ntentpsa geandreturnist tothelibrarcyo ordinatorA. 
Nova 
Southeastern  student  photocopies  the  article  and  mails it to the  requestor. 
28.While  the  practitioners  have  the  option  of contacting  the  university  library 
directly,  according  to AHEC  staff few do so.  The localAHEC  centerk viewedasa

friendliyn termediarAyc.c ordingt oAHEC  staffm,o stpractitiongearisn accesst
o

FHIN througha phonecallt othelocaAlH EC  centerw,h erea stafmfe
 mber is

trainetdo narrowthesearchtoidenti~r eferencetsh
atwouldbe ofmostusetothe

practitioneTrh.e  AHEC  centers taftfh enphonestheAHEC  medicallibrariawnh,o


performstheactuasle archandfaxesthereferencaen dabstracttso
thepractitioner.

29.One  of the  early  activities  of North  Florida  AHEC  was contracting  with  a local 
entity  (e.g., the  board  of commissioners  orcountyhospitailn) each  county  to conduct  a 
large  scale  survey  on how AHEC  could  meet  local needs,  including  continuing 
education.  The  staff reported  to us that  while  this was an interesting  exercise,  they 
found  it most  helpful  to meet  with locally developed  groups  of professionals  to define 
needs. 
30.This  distribution  also holds  true  for the  other  AHECS  in the  state.  On  a 
statewide  basis,  8 percent  on participants  in AHEC-sponsored  CE were  physicians, 
25 percent  were  nurses  and  nurse  practitioners,  and  67percent  attended 
multidisciplinary  courses  (1993).  Virginia  Fowkes,  The Florida  Area  Health 
Education  Center  Program,  July 1992 through  June  1993: Report  to the  Legislature. 
31.The  other  Texas  AHEC  programs  are  based  at Texas  Tech  School  of Medicine  in 
Lubbock  and  the  University  of Texas  Medical  Branch  in Galveston. 
32.Four  other  centers  have  opened  more  recently  in Eagle  Pass, Laredo,  Del  Rio, 
and  Corpus  Christi. 
33.  The  consortium  consists  of 10 hospitals,  2 State  mental  health/mental  retardation 
clinics, an  affiliated  family practice  residency  clinic, and  a CHC.  The  South  Texas 
AHEC  Program  is extending  the  circuit  riding  library  concept  to other  areas  of South 
Texas  as new  centers  come  on line. 
The  current  subscription  rate  for a hospital  is $1,000 per  100 beds.  In  1993 the 
circuit-rider  librarian  program  cost about  $58,000 for staff, travel,  subscriptions,  and 
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 fax services.  South  Texas  AHEC  covered  about  two-thirds  of the  cost, and  consortium 
fees  about  one-third. 
34.The  librarian  provides  one-on-one  instruction  for anyone  who wants  to learn  how 
to conduct  his or her  own searches,  but  she feels,  at this time,  that  physicians  have 
neither  the  time  nor  the  inclination  to conduct  their  own searches,  they  expect 
someone  else  to do so.  She told  us, You cant just  throw  equipment  at them.  You 
need  to establish  a human  connection  for it to work. 
35.For  example,  STAHEC  program  staff noted  that  they have  written  and  submitted 
various  proposals  to State  and  Federal  funding  sources  to further  the  use  of 
telecommunications. 
36.The  demonstration  evaluators  note,  The most  anticipated  equipment  turned  out 
to be,  perhaps  the  biggest  disappointment.  They  cited  problems  with  static  and 
interference  in using electronic  stethoscopes,  and  insufficient  light for the  electronic 
otoscope.  See,  The  University  of Texas  Health  Science  Center  at San Antonio, 
Telemedicine  Demonstration  Evaluation,  pp.  6-7. 
37.  One  vendor  told  the  AHEC  staff that  it had  made  changes  to equipment  based  on 
the  evaluation  from  this demonstration. 
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