An Interview with Kip Smith
Kip Smith was hired as the first Executive Director for the Health Information Exchange of Montana in November 2008. HIEM is a network of rural hospitals and clinics in northwest Montana working collaboratively on development of electronic health records, health information exchange and shared telehealth/telemedicine services. Prior to joining HIEM, Smith was Director of the Montana Health Research and Education Foundation, a division of the Montana Hospital Association, for nine years. In this capacity, he established the Montana Rural Healthcare Performance Improvement Network and oversaw the provision of support services to Montana’s 47 Critical Access Hospitals.
Smith has nearly 25 years of experience in rural health care and network development and has served on several national boards and federal advisory committees, including the National Rural Health Resource Center based in Duluth, Minnesota. He holds a Bachelor of Science degree in Finance from Iowa State University.
Smith’s volunteer activities have included coaching his daughter’s Little League softball team, working on a search and rescue team, and serving on a high school Booster Club. In his spare time, he enjoys fly fishing, hiking, carpentry, and going to his family’s mountain cabin. His favorite music includes DMB, the Eagles and Phil Collins. He and his wife, Sherrie, live in Kalispell, Montana. They have two grown, married daughters and are “someday” hoping for grandchildren.
You grew up in Iowa. How did you get to Montana?
I was working for Northwest Bancorporation (now Wells Fargo) in Minnesota and was offered a transfer to Helena. My wife and I saw it as an adventure and assumed we would only stay for a few years—now it’s nearly 29! In terms of climate change it was much milder than northern Minnesota (but don’t tell anyone!), but a long way from our Iowa families. Montana has been a great place to raise our daughters and a fabulous place for recreational activities. Our move from Helena to Kalispell this year is our “new adventure” with access to hiking, biking, fishing and Glacier National Park in our backyard.
You were a volunteer with a few search and rescue organizations after you moved to Montana. What was that like?
During my years with search and rescue (when I was much younger), I went on many missions, mostly looking for overdue hunters, snowmobilers and skiers—of course, always beginning at night and in a snowstorm. We also searched for a few “lost” individuals, some who did not survive. While that was never easy, at least there was some closure for the family. My most difficult search was for a young girl who went missing during a group picnic event in the mountains—a multi-day search with hundreds of volunteers and she was never found. Pretty hard on a father of two girls!
How did you make the jump from banking to health care?
Purely chance. I was working as a human resource director at a bank in Helena, Montana, and one of the bank’s Board members was the hospital CEO who approached me about becoming the HR Director for the hospital. The rest just happened.
Do you think you’d found your way to rural health without that chance encounter?
I thought I’d always be a banker or accountant. I don’t know if I would have found rural health on my own. My guess is that I might have wandered in some direction other than finance, but rural health turned out to be a good fit. We’re not big city people. I’m sure we’d be in rural somewhere, although by Montana standards, Helena is not as rural as other parts.
Did anything in your background give you a particular affinity for rural health?
I’m sure that being from Iowa had an impact and then living in Montana, which is very rural/frontier, influenced me to advocate for non-urban areas. My time with the Montana Primary Care Association (MCPA) working with community health centers and rural health clinics also had a major impact. Prior to that I was at the State Medicaid agency, where my responsibilities included rural health clinics and community health centers. I had a feel for some of their issues but it was still a big learning curve. I learned a lot at MPCA about the federal side of things.
Montana created the Medical Assistance Facility (MAF) model in the late 1980s. How did it start?
The MAF concept was initiated by a state legislator, Cecil Weeding, when his local hospital was on the verge of closing due to the loss of their only physician. The Montana Legislature passed legislation to develop an alternative hospital model and then, working with Senator Baucus, the Montana Hospital Association obtained authorization for a Medicare demonstration.
Does Montana take pride that MAF evolved in the Critical Access Hospital model we have today?
I think folks in Montana feel we were a major part of that model in terms of demoing the concept. There are still a handful of administrators around from the MAF demo who feel that the CAH model has gone well beyond MAF, but there’s no question it started here. It was a year-to-year demonstration model for 11 years and part of the effort was to make that model permanent.
What was your role in the creation or evolution of MAFs?
In the early years of the demonstration I was the hospital program officer at Montana Medicaid. My only real involvement was responding to a request from the Montana Hospital Association to consider cost-based reimbursement for MAFs—which we eventually did, and which continues to this day for CAHs.
You’re at the Health Information Exchange of Montana (HIEM) now. How did HIEM start, and what is its current focus?
HIEM was initiated as a RHIO (Regional Health Information Organization) and the focus has been on being able to exchange patient information in northwest Montana. We’re trying to connect disparate electronic information systems in six different hospitals and 15 clinics, but we’re a long ways from being done. We’re also developing fiber connectivity infrastructure in this area, including some areas where there is no fiber broadband currently. And we’re trying to expand telehealth and telemedicine services in this region.
What are the some of the challenges in accomplishing this?
First, there’s a lack of cash for major capital investment by small rural/frontier providers; second, the cost of broadband connectivity is very high; and finally, there’s no medical school and/or large tertiary hospitals to support regional telehealth services. We have a $13.6 million grant from the FCC to develop the infrastructure, but we must try to sort out the rules from the FCC in order to use it. Everything we do has to be competitively bid and go through several steps of review. Even after a contract has been awarded, each payment has a set of steps we must take. We have taken a very systematic, sequential approach to our network development.
Our other challenge is geographic. Our service area covers 17,000 square miles and broadband infrastructure development in western Montana is different than it would be in other parts of the state. Most fiber optics lines are buried in the ground, and that’s harder to do and more expensive in mountainous terrain. The eastern plains of Montana are way ahead of us in terms of connectivity because it’s flatter and less expensive to develop, plus the distance between communities is greater so the need was recognized sooner there. In western Montana you have areas with higher population density so the critical need wasn’t recognized as early.
How much does a project like this cost?
We’ve built 185 miles of 24-strand fiber optics between Whitefish and Conrad, across the Continental Divide, so far. It cost $5.2 million to do that. We also had to go through Glacier National Park and an Indian reservation—there were lots of hoops to jump through.
With an FCC award, we’re required to come up with a 15 percent match. That’s one of our other challenges, to come up with a $2.4 million cash match. There’s not that kind of money lying around in these facilities. A fair amount of my time is spent looking for funding.
Higher bandwidth provides more options and can be used for multiple purposes at the same cost. The price for it varies depending on where you are, and how much competition there is. Once these hospitals get connected, they’ll be thrilled with the possibility of connecting at higher and faster speeds and doing telehealth and telemedicine.
Where do you get the other funding?
We are partners with the University of Montana to expand connectivity in this area for medical and educational purposes. We are jointly pursuing all funding options at the state, federal and private levels, including recently released ARRA (Stimulus) broadband opportunities. It’s a never ending search.
What do you hope will happen in the next five years with health IT in Montana?
Our goals are to collaboratively address the challenges I’ve just discussed. We hope to have a functioning health information exchange that meets the federal “meaningful use” criteria being developed, and to have a robust telehealth/telemedicine program that ensures access to quality health care services for all residents in our remote service area.
