The initiative is stated to include: (1) development of toolkits; (2) leveraging known tools; (3) developing capacity; and (4) disseminating best practices. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Ormond, Wallin, and Goldenson report in the work entitled: "Supporting the Rural Health Care Safety Net" (2000) state: "The policy - and market-driven changes in the health care sector taking place across country are not confined to metropolitan areas. Rural communities are experiencing changes impelled by many of the same forces that are affecting urban areas." However, due to the demographical differences and other facts existent only in rural life the health care system can be differentiated from those in urban areas in various ways. According to Ormond, Wallin, and Goldenson, it is that difference that highlights the importance of giving consideration "explicitly" to the "impact of competitive forces and public policy developments on rural health care systems and the patients and communities they serve." (2000) the changes that are occurring in the health care sectors are resulting in many providers being threatened in both rural and urban areas however, health care provider failures in a rural area is likely to a much greater impact as compared to health care provider failure in urban areas. "Because alternative sources of care in the community or within reasonable proximity are scarce, each provider likely plays a critical part in maintaining access to health care in the community. For this reason, in most rural communities all providers should be considered part of the health care safety net - if not directly through their care for vulnerable populations, then indirectly through their contribution to the stability of the community's health care infrastructure." (Ormond, Wallin, and Goldenson, 2000) the study reported by Ormond, Wallin and Goldenson is based on case studies in rural communities in the states of Alabama, Minnesota, Mississippi, Texas, and Washington selected in representation of "...a broad range of pressures facing rural providers." (2000) a debate is stated to exist in terms of 'limited services' models for hospitals who fear that more insured patients or those who are wealthier will be reluctant to use this facilities. Challenges to full-service facilities in rural areas include "recruitment and retention of health care professionals and of ensuring the financial viability of local hospitals." (Ormond, Wallin, and Goldenson, 2000) Also related is the fact that health care providers are very reluctant "to locate in communities without a hospital..." while simultaneously when there is not a strong physician practice in an area, hospitals "find it difficult to attract patients." (Ormond, Wallin, and Goldenson, 2000) Constraints upon a rural hospital of either a full or limited service hospital include its rural location. "The population required to support given service, such as a hospital or particular physician practice is spread over a much greater area. Low volume can mean high average costs, a factor that rural health officials feel is not always taken into account in reimbursement." (Ormond, Wallin, and Goldenson, 2000) Demographical and socioeconomic differences in rural areas places demands upon health care system providers in terms of the need for treatment for more elderly people which are those "more likely to have chronic health care needs." (Ormond, Wallin, and Goldenson, 2000) Furthermore, due to the lack of access to mass and major media in rural areas, the individuals residing in these areas are much less likely than those in urban areas to be aware of the availability of health care and public programs. Insurance coverage in rural areas is also a factor because rural areas have higher self-employment than urban areas, and specifically relating to farming operations making it very likely the employer-sponsored insurance in minimal. Of those who are insured in rural areas, it is likely that many of these are underinsured with high premiums and low benefits as compared to those insured in urban areas. "The social structure of rural communities may make the stigma attached to participation in public programs greater, particularly in the case of Medicaid." (Ormond, Wallin, and Goldenson, 2000)

The range of services offered in rural hospitals is limited by the size of the area it serves as compared to the population within that area. Many of the hospitals in the study reported by Ormond, Wallin and Goldenson "relied on a local primary care physician for core services...but augmented his or her capabilities by making arrangements with other, nonlocal providers. The core services each hospital offers depend primarily on the capabilities of their physicians." (2000) in order that a hospital be able to support a visiting specialist program it is a requirement that the hospital have the staff that is appropriate and qualified to assist "in the various specialties and public transportation. Internal strategies reported to be used by rural health care providers are inclusive of: "...increasing the stock of physicians and other health professionals, tailoring facilities and services to the needs of the community, and expanding, downsizing, or diversifying as needed." (Ormond, Wallin, and Goldenson, 2000) Other stated strategies are inclusive of "cooperation among rural providers and developing links with urban providers through mergers, management contracts, and joint projects." (Ormond, Wallin, and Goldenson, 2000) Initiatives have been developed for recruitment of physicians and other health professionals who are "familiar with life and medical practice in rural areas." (Ormond, Wallin, and Goldenson, 2000) Those who are recruited for practice in rural areas are likely to remain after recruitment. All five states in this study report that they provide support: "...for the development of rural health professionals by requiring, facilitating, or funding training opportunities in rural areas so that students become familiar with the particular demands and satisfactions of rural medical practice, or by funding education either through scholarships for aspiring providers from rural areas or through loan forgiveness for providers agreeing to locate in rural areas." (Ormond, Wallin, and Goldenson, 2000) Only the state of Washing is stated by this report to have a formal residency program. Service expansion is reported to be utilized by rural hospitals and clinics for enabling them in meeting a "broader range of health care needs in their communities." (Ormond, Wallin, and Goldenson, 2000) Areas of expansion included: (1) the construction or renovation of a physician plant; (2) the addition of new medical services; and (3) diversification beyond traditional acute services." (Ormond, Wallin, and Goldenson, 2000) in fact, "growth and expansion" as compared to downsizing "appeared to be the more common, and seemingly more successful, route." (Ormond, Wallin, and Goldenson, 2000) Expansion is also noted in outpatient services offered by hospitals and clinics. Cooperative efforts among rural providers as these health care providers collaborate in order to ensure the capability of serving their communities will continue is noted in this report stating that "cooperation with other rural providers is also a mainstay of rural hospitals' strategy to ward off encroachment by urban health care systems." (Ormond, Wallin, and Goldenson, 2000)
The work of Rygh and Hjortdahl entitled: "Continuous and Integrated Health Care Services in Rural Areas: A Literature Study" makes a review of literature that examines possible methods of improving healthcare services in rural areas. Stated by these authors is the fact that: "Healthcare providers in rural areas face challenges in providing coherent and integrated services." (Rygh and Hjortdahl, 2007) This study proposes a need for "greatly flexibility in traditional professional roles and responsibilities, such as nurse practitioners of community pharmacists managing common conditions." (Rygh and Hjortdahl, 2007) Further stated is that the "substitution of health personnel with lay health workers or paraprofessionals often in combination with interdisciplinary teams, is among measures proposed to alleviate staff shortage and overcome cultural barriers." (Rygh and Hjortdahl, 2007) Other findings of this study include that for those working in rural areas called for is "flexibility of roles and responsibilities, delegation of tasks, and cultural adjustments by the healthcare practitioners." (Rygh and Hjortdahl, 2007) This study states that rural case management is greatly dependent upon a locally-based case manager and that the highest ranked skills for rural case managers are: "the ability to be creative in the coordination of resources, multidimensional nursing skills, excellent communication skills, high-caliber computer skills and excellent driving skills." (Rygh and Hjortdahl, 2007) Stated is that: "Case management in a rural environment requires a much…