By Amy Oliver, Founder, Azul Heart
LinkedIn: Amy Oliver
LinkedIn: Azul Heart
A rural hospital leader told me recently that she had finally upgraded her whole hospital’s internet from 200 Mbps to 1 Gbps, and she was genuinely excited about it, because in rural health, those are the wins. I think about that every time someone talks about rolling out AI, telehealth, and cybersecurity in rural communities like it’s a simple switch to flip.
If only it were that simple. In reality, every one of those rollouts lands on top of the same tough math every rural leader is working through: fewer people, higher costs, lower reimbursement, and a growing list of things they’re expected to do just as well as a system 10 times their size.
At Upstream in Columbus earlier this month, which I co-hosted with the incredible Erica Olenski, we put policymakers, hospital leaders, technology leaders, and patient advocates in one room to work through those challenges, some math included, out loud. And since October is Cybersecurity Awareness Month, I wanted to look at what we heard through a cyber lens, because every pressure we talked about that day shows up again when a rural hospital tries to protect itself.
The math, straight from the panel
Our policy panel got right to the numbers. Rep. Anita Somani, an OB/GYN, did the math on Ohio’s roughly $202 million first-year Rural Health Transformation Program award and landed on about $71 per rural resident, then wondered out loud whether you could even see a doctor for $70. Ironically enough, my husband and I will no longer have employer-sponsored health insurance as of Jan. 1, so I’ve actually looked into the cash price for our family NP, and it’s $75. Even this non-numbers person can see that math doesn’t work, and that’s from a suburb outside Cleveland where my provider is a short drive away, which isn’t the reality for many rural Ohio families.
When the dollars stretch that thin, waiting to care for people until they’re already sick just doesn’t add up. Dr. Kaitlan Baston, a rural Ohio native and former New Jersey Health Commissioner, brought us back to the idea the whole day was named for: going upstream to help people stay healthy before the emergency. As CEO of Vinyl Health, an AI patient scribe and care companion for you and your loved ones built on the CMS Health Tech Ecosystem, she’s helping patients and families understand their care and follow through on it, which is a big part of staying healthy. As one of Vinyl’s advisors (and biggest cheerleaders!!), I can tell you Kait is building something special.
Fewer people, higher costs
Linda Stevenson, COO and CIO at Fisher-Titus in Norwalk and one of our Upstream speakers, made the workforce gap real in one sentence: her hospital is licensed for 99 beds and can staff 55, because there aren’t enough nurses. Cost works against rural hospitals too. Another leader told me they pay more for the exact same software as a big system, simply because they can’t bring the volume to negotiate, and another shared that because hers is a sole community hospital, she misses out on the discounts critical access hospitals get. She pays more for just about everything, and with the next level of care two hours away, her community is counting on her hospital to keep its doors open no matter what. I know large IDNs and academic medical centers aren’t flush with cash either, but I can’t help pointing out the obvious: how are these small shops supposed to have a fighting chance when the system itself is this flawed?
Money that’s hard to reach
Rural hospitals need every dollar they can get. The Rural Health Transformation Program was created to soften the blow of H.R. 1’s Medicaid cuts, but for a lot of these hospitals it’s a drop in the bucket. Ohio’s share, a little over $1 billion across five years, won’t come close to replacing the $5.6 billion in rural health funding the state is expected to lose over the next 10 years, according to KFF estimates cited by the Health Policy Institute of Ohio. And getting even that money into the hands of the hospitals who need it most takes capacity many of them don’t have. This is where Carahsoft, one of the Upstream partners, deserves a big shout out. Rob Courtney and the Carahsoft team started an initiative to help close that gap, bringing in Eric Stockmeyer and the team at Live Oak Solutions to help rural hospitals find the right grant and write it at no cost (!!). That’s how Linda got through a roughly 80-page application in about a month while running operations and IT. Eric also made a point I loved, and it matters even more when every dollar counts: the only thing worse than no grant money is grant money for something you don’t need.
The cyber lens
Rob also named cyber as one of the next big areas he expects rural funding to go, and it can’t come soon enough. When Linda testified before the Senate HELP Committee in 2025, she shared that small and rural hospitals put closer to 4% of their IT budgets toward cybersecurity, compared with 6 to 10% at mid-to-large hospitals, and that most can’t afford a full-time security leader at all (at Fisher-Titus, she wears the CISO hat, too, in addition to CIO and COO!).
Much like I’ll readily admit math is hard, I’ll also gladly call on the experts when it comes to cyber, and Carter Groome is one of the best. Carter is the Founder and CEO of First Health Advisory, received the Baldrige Foundation’s 2024 Award for Leadership Excellence in Cybersecurity, serves on the CHIME Board of Trustees, and is the reason I know Linda in the first place. He put it in a way every rural leader will recognize: “The economic pressures rural health face every day force executives to make gut wrenching risk acceptance decisions throughout the enterprise, with cyber security being no exception.”
When I asked Carter where he’d tell a rural hospital CEO to spend their very first cyber dollar, he started with the threats, and he didn’t sugarcoat them. “You’ve got to get your arms around 3rd party risk, you better be well positioned for ever more sophisticated social engineering, and you need to close down public facing cloud applications, servers, and API’s that have reachability via the internet.” He also called asset inventory the bedrock of every cyber program, because “in order to secure what you have, you must know it exists.”
But his answer for that first dollar was refreshingly simple: “I still hear stories of health entities that somehow did not deploy multi-factor authentication on everything they possibly could and that’s where I would spend that first dollar.” It lines up perfectly with this year’s Cybersecurity Awareness Month theme from the National Cybersecurity Alliance, “Don’t Make It Easy for Them.”
It all comes back to trust
At the end of the day, cybersecurity protects patients’ data and a hospital’s ability to keep caring for them, and when either one breaks, trust goes with it, which is why it’s no surprise trust came up at nearly every table that afternoon. The workforce and AI group talked about how patients don’t always know when they’re interacting with AI, and how clinicians worry it could replace them instead of help them. The maternal and child health table added that we’re moving into a misinformation age, and offered an idea I loved: giving patients their own AI tools may earn more trust than the big systems do. They paired it with policy fixes that could open real doors in rural Ohio, like removing licensing barriers so a mom can see a telehealth specialist across state lines.
Those are the wins
That 1 Gbps upgrade really is the perfect picture of rural health. The leaders in that room aren’t waiting for one big shiny fix, and the ideas we heard were wonderfully practical, from no-cost grant help to MFA on everything to putting tools right in patients’ hands. Every one of them starts with the right people talking to each other, which is exactly what Upstream was built for, and I’m so proud of what that room put on the table in one afternoon
If you lead IT at a rural or community hospital, I would love to hear where your first cyber dollar went. And if you want an Upstream in your community, let’s build it together!