Department of Health and Human Services 

OFFICE OF


INSPECTOR GENERAL


AREA HEALTH EDUCATION CENTERS


A Role in Enhancing


the Rural Practice Environment


#J SERWCE3 

& “0$ 

-+ 4 

$V JUNE GIBBS BROWN 

:	

z Inspector General 

% 

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%@ MAY 1995

> 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


u


a Inspector General


73 

%++ $ 

%d~~ MAY 1995

>

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 telecommunications. We agree that thk is an emeW”ng 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 

suppom”ng 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 addih”on, 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 

INTRODUCI’ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 program’s 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 HRSA’S 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 communitybased 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 President’s Council on Integrity and Efficiency. 

4

FINDINGS


&IECS ARE ENHANCINGRURAL PRACITI’IONERS’ACCESS’10 HEALTH CARE 

INFORMATIONBY LINKINGTHEM WITH MEDICALLIBRARYRESOURCES. 

. 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 NLM’s 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 AHEC’S 

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 director’s 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.


AHEC’S marketing goal is to have practitioners take students, and we use library


services to help reach that goal.”


&IECS ARE RESPONDINGTO THE NEEDS OF MANYTYPES OF PRACITI’IONERSFOR


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 miniresidencies or fellowships at the health sciences center in response to an individual 

physician’s 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 I’m a teacher I must be good.’” 

.	 On average more than two-thin&of parh”cipantsin 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 AHEC’S 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 can’t get away. You simply can’t 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 

PRACTTI’IONERSABOUT INNOVATIONSIN HEALTH CARE DELIVERY, SUCH AS 

CLINICALPRACI’ICEGUIDELINESOR 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 haven’t done much with it. I’m 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 TELECOMMUNICATIONSTO PROVIDE SUPPORT TO 

ISOLATEDPRACITI’IONERS,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 

specialist’s 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 AHEC’S 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 RECOMMENDTHAT THE PUBLICHEALTH SERVICESTRENGTHENTHE ROLE OF


~CS BY FACILITATINGTHEiR 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 CO1.dii assist AHECS in this @Olt by: 

“ 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 AHEC’S 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 telecommunications. 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 applicant’s 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 implementatt”on 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 telecommunications 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 telecommunications would not be sufficient for assessing their actual involvement in that field. But we 

have revised the language suppom”ng 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 introduch”on, 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 prach”tioners 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 

Subject Office of Inspector General (OIG) Draft Report “mea Health 

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 report’s recommendations. Our


comments delineate the actions taken or planned to implement


these recommendations.


ItLip(c‘L­
 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


Deriod if sufficient resources are available. Some of the


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, AHCPR’S 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~’ant to


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 project’s 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 objectives are the development of 

(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 communitybased 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


force’s 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.HEC collaboration 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 ,, ,,, 

+*’ :.* . 

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of the Secretary

“;

-0 

%,+ Jg/.,, > w Washington, D.C. 20201

M I 3 1995


TO:


FROM :


SUBJECT :


Thank you


report on


June Gibbs Brown


Inspector General


Assistant Secretary for


Planning and Evaluation


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


Centers: A Role in Enhancing the Rural Practie


Environment, “ 0EI-01-93-O0570


for giving me the opportunity to review your dtaft 

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.HECS certainly 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 grantee’s 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 

Area HealthEducation 

June GibbsBrown Centers Pfogram Inspector General 

Department of HeaIth and Human Services 

O!fksofthe Washington,DC 20201 

ExeedveDirectof 

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 

(501) SSS-5200 Practice Environment”. The National Organization of AHEC Program 

Fax: (S01) M&Moe	 Directors believesthat the repoti accurately reflects the need for expansion of 

support setvices provided through Area Health Education Centers, The 

National Organizationof AHECProgram Directors is especiaUyconcerned 

MEG FORTSMITH 

612 Eaub121hs8e4 that the report clearly specifi that it addresses only one segment of the total 

FOIISmith,AR 72sot mission of Area Health Education Centers. The repofi was not a 

FhorI&(501) 7S$242! 

AHECPM! BLUFF comprehensivereview of the AHECProgram, but rather, was an assessment 

aloh4uromy of the role that the Program is currentlyperforming or could pefiorm in 

PineBIJR,AR 71603 

mma [501)54I.SO1O providingsupport servicesto enhancethe practice environment for health care 

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 suggestthat 

AHECNORTNWEST 

2s07 Emi Joym Slfeef a statement be added which says, “.4HECSgenerallyview their role in 

Fee, AR Z??&l continuing education as one of meetingspecific needs voids R&w (541)S21~69 andfilling that 

AHECNORTNEAST maybeleft byother sources ofcontinuing education without duplicating these 222 EA,UJackmM other sources”. This same missionof AHECs should be included on page 6, &M6bf0, AR?2401 

Pllmeu(al) mm paragraph 4 or 5. Afso, the same theme should be carried fon.vard to the 

AHECSOUl14WE6T recommendations on page 13 and 14 considering clinical practice guidelines. 603 Wdlvl Slma 

TBIakm& AR755%? 

FtIOnetWJI] 774-7236 The development of continuingeducation programs based on specific 

identified needs in the community sewedbytheAHEC may notincludethe 

topics covered bytheclinical guidelines developed by AAHCPR, AHECS.­

should not be required to provide continuing education courses simply 

because guidelineshave been developed byAAHCPIL Continuing
 education

courses
 arenot 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 material anytimea pro~ram is conducted that would encompass the 

h Equal C@ortunky Emdoyer I 

A-8

Ms, June GibbsBrown 

March 21, 1995 

Page 2 

scope of a publishedguideline.The adoption of practice 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 

numerous changesthat are taking place in the health care system. However, 

the statement on page 15,paragraph 3, which saysthat “AIIECScould assist 

mral practitionersin negotiatingcontracts” suggests a role for AKECSthat 

wot.ddnot be widelyadopted, Specialskillsare needed in these areas that do 

not occur frequentlyin the AHEC staff The appropriate role for A.HECSin 

this area shouldbe more preciselystated by recommendingthat AHECS 

should provide sponsorshipand coordination of workshops 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, and to be the communityfacilitator for groups 

that wish to pursue developmentof telecommunications.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 

financialbackinggenerallyby state governments, and cefiairdy significant 

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 AHECSwillplay a lead role in developingtelemedicine.The specific 

activity shouldbe carefilly reviewedbecause of the great variabilityin 

regional needs and resources. Because telemedicineis an extremely expensive 

operation, specialfi.mdingwould be required to assist in the 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. 

Some specific editorial commentsare suggested.(Note: strikethrough = 

delete, underline= add.) 

Page A-7, last paragraph, first sentence’ 

The Nova Southeastern UniversityM-EC Program has provided 

computers to 12 CHCSand County Public Health Units where ... 

&3!l@!m .,. student trainingtakes piace. Mmg—m&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 

~ ... UniversityAHEC program area,., -M,,. ~ have 

partial county ... 

SOUTH TEXAS AREA HEALTH EDUCATION CENTER. 

RECOMMENDED CHANGES/ADDITIONS 

Note: changes/addedtext is underlined. 

A-10

Ms. June Gibbs Brown


March 21, 1995


Page 4


OVERVIEW 

1stsentence: 

.. based at ~he Universityof Texas ,.. 

MEDICAL LIBRARY RESOURCES 

1st paragraph: 

Based at the AHEC program officein San Antonio ... area 

consortium of host)ita]sand health care providers ... 

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: 

Each UTHSCS~ professionalschool-- medicine,nursing, 

dentistry, and allied heaith --M well as UT-Austin’se~ension 

pharrnacvurowam, hasits own officeof continuingeducation. 

Zndparagraph: 

Add sentence at end: Instructional developmenturomuns are also . 

gnlt inely conducted for new receptors or communitv-base~ 

clinicalfacultv$ 

CONCLUSIONS (TELECO~CATIONS) 

Addendum: 

The South Texas AHECutilizedthe knowledgegained by the 

demonstration activityto developa plan,financethe acquisition of 

equipment, and implementthe South TexasDistance Lea~n$ and 

A-n 
Ms. JuneGibbsBrown 

March 21, 1995 

Page 5 

TeleHeaithNetwork whichcumentlylinksten community clinical 

training sites with the UTHSCSAcampus,(NOTE: This activity 

was in process at the time of the initialw-sitin June, 1994. 

Installation of the equipmentbegan in Januruy, 1995.) 

Thank you for the opportunity to provide comments on the drafi of the report. 

We believe that the report containsvery positive recommendationsfor the 

A.HECProgram as it addressesnew technology and new opportunities that 

are now beingpresented. 

Yours most sincereiy, 

Charles ‘$” 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 Florida’s 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 AHEC’S 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 State’s 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 State’s 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 AHEC’S 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 US that “doctors teach 

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 Arkansas’s 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 program’s 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 center’s 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 telecommunications 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 Florida’s 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 

F Medical Library Resources at Nova Southeastern University AHEC Program 

The focal point of this AHEC’S “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 AHEC’S 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

F Medical Library Resources at the North Florida AHEC Program 

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., joint
injection 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 communitybased 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 education’s 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 you’re out 

in the community, you’re 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 couldn’t 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 won’t 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 rider’s 

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-Austin’s 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 telecommunications 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 

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San Antonio sessions, participants inMcAllenincluded88 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 

centeratSan Antonioand theUniversity ofTexascampusinBrownsville
 toprovide


nursing courses fora BSN-MSN degreeprogram.The programenrolls
 29 students


and provides 250classroom
hourspersemester.


The Telecommunications NetworkofTexas,an existing
etworkhousedintheTexas


DepartmentofEducation,
 also 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, supportseficesisone important
way ofproviding


outreach and tangible services torural practitioners, particularly thoseinvolved
in


training their students. The director ofa communityhealthcenter
summarizedthis


importance when shenoted, “AHEC isimportant toouroverall
 work. Itprovides


residents, students fortraining, and helpstosupport theCHC’S efforts.”
 One rural


practitioner we interviewed heresummarizedtheneedforsupportservices
 when he


toldus,“Thehardesthingaboutpracticing ina rural
arealikeoursisthatyou don’t


havean academiccommunitytoprovide a life
linetonew 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 don’t 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 telecommunications’ 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 travelrestrictions 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 telecommunications 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, 

primarily
 becauseofproblemswiththeequipment?6Inthetelecommunications


demonstration, itappearsthattechnical problemswiththeequipment--not
 practitioner


interest--led tothenegative views.To address theseproblems, STAHEC staff
are


attending workshopsand aretalking directly
 withequipmentvendors.Accordingto


AHEC staff, thequality ofthediagnostic equipmentisimproving,
 and therangeof


available
 equipmentisexpanding.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 C’ellDisease (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 don’t 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 NLMaccess 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 organizations operateinthisarea,


many ofthem withmultiple satellite clinics inrural
communities.


27.The AHEC programoffice atNova Southeastern maintains thejournals
 and


photocopies individual articles fordistribution, whilethecentral Florida
AHEC center


librarian coordinates thedistribution. A practitioner
 who wouldlikea copyofan


article fromanyofthesejournals writes hisorhername and address
on the


photocopied contents pageandreturns ittothelibrary coordinator.
 A 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


friendly intermediary. According toAHEC staff, mostpractitioners gainaccess
to


FHIN througha phonecall tothelocal AHEC center, wherea staff
 member is


trained tonarrowthesearchtoidenti~ references
 thatwouldbe ofmostusetothe


practitioner. The AHEC center staff thenphonestheAHEC medicallibrarian,
 who


performstheactual searchand faxesthereference and abstracts
othepractitioner.


29.One of the early activities of North Florida AHEC was contracting with a local 

entity (e.g., the board of commissioners orcountyhospital)in 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 

c-4

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 can’t 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. 

c-5