Community Health Center Information Systems Assessment: Issues and Opportunities

Appendix A:
Environmental Scan

DRAFT Revised Environmental Scan
Community Health Center Information System Assessment:
Issues and Opportunities

Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services

NORC at the University of Chicago

TABLE OF CONTENTS
Introduction
Environmental Scan Methods
Community Health Center Landscape
Overview
Federal Requirements
Funding
Priority Initiatives
Health Center Information Systems and Vendors
Background
Practice Management
Electronic Health Records and Electronic Medical Records
Vendor Landscape
CHC Information Systems
Support for CHC Information Systems
CHC Use of Information Systems
CHC Information Systems Needs and Challenges
CHC-Specific Vendor Overview
Themes for Additional Study

Introduction

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services (HHS) has contracted with NORC at the University of Chicago, a non-profit social science and policy research organization to assess the status of health information systems at the nation’s HHS-funded community health centers (CHCs). The assessment will identify information management issues and opportunities facing CHCs and inform federal initiatives aimed at supporting CHCs in their efforts to more effectively utilize information systems (IS) on a center, community and regional level. A major motivator for the project is the National Health Information Infrastructure (NHII) vision articulated by HHS to maximize availability of health data for improvements in public health, health care financing policies and quality of care. The main purpose of this project is to gather and analyze information from CHCs on the relevant characteristics of their current systems applications, technical infrastructure, data management and transfer practices, processes for systems selection and implementation and the prioritization of information systems related issues within the larger organization.  In summary the projects seeks to:

• Assess ongoing information systems related programs and practices employed by CHCs;
• Identify and describe models for successful systems implementation on a CHC and community level;
• Articulate major information systems challenges facing CHCs;
• Describe important barriers to realization of systems-related goals such seamless electronic data transmission to government and health care system partners; and
• Assess findings in relation to ongoing and potential policy initiatives at ASPE and HRSA and across HHS

This report presents results from the initial stage of this study, an environmental scan of the CHC and IS landscape.  This environmental scan is based on review and synthesis of existing published and unpublished literature and a small set of discussions with thought leaders in the area of health information technology.  The scan is designed to supply general context and background for the project and provide initial results and areas to be further explored during subsequent planned project activities.  These activities will include detailed telephone discussions with 25 CHCs, and in-depth site visits with seven of these CHCs. The remainder of this document is organized as follows:

Environmental scan methods.  We begin with a brief discussion of the overall approach and specific methods used to collect and analyze the information presented in the environmental scan.

Community health center landscape.  We provide a description of CHC characteristics and goals as they relate to health information management activities. In addition to describing basic features of CHC financing and operations, we describe CHC activities that drive health center information system needs and requirements as they relate to administrative, financial and clinical practices.

Health center information systems and vendors. We next describe current resources systems used by health centers for the electronic management and exchange of clinical and administrative information. This discussion provides a description of “state of the art” systems used in larger public and private health centers as well as findings on use of technology such as practice management software and electronic medical records (EMR) more broadly among primary health care providers. The section also includes an overview of major software vendors who typically work with outpatient primary care health centers.

CHC information systems. Following the discussion of the basic CHC environment and the state of current information system technology relating to health centers, we describe the specific experiences of CHCs with information systems. Because this topic represents the main focus of key stakeholder interviews and site visits, this section will provide a very preliminary discussion based on our review of published and unpublished materials and conversations with thought leaders. In particular, we will identify models of innovative management of information systems at CHCs and raise questions for further elaboration with the planned qualitative data collection with CHCs.

Themes for additional study. We conclude the environmental scan report with a summary of key findings and conclusions for the larger study.

Appendices. Appendices 1 and 2 contain supplementary materials on project methods, including a list of printed materials identified for review and the main discussion guide used in conducting thought leader discussions. Next steps, in the form of possible CHCs to include in the next phases of the project and a CHC interview protocol are provided as Appendix 3.  Appendix 4 contains a more detailed summary of the health information technology vendor marketplace to supplement the information presented in the main text and Appendix 5 includes an overview of our first planned set of stakeholders and case study involving community health care providers in Indianapolis, IN.

Environmental Scan Methods

As described in above, our environmental scan is based on two major information gathering activities: (1) review of published and unpublished documentation and (2) discussions with a small group of thought leaders and key informants knowledgeable about health information systems (HIS) and CHCs.  We note that these discussions (which expanded on the initial activities originally planned at the start of the study) are not intended as substitutes for the series of 25 telephone discussions and seven in-depth site visits that will be undertaken once the environmental scan is complete.  Rather, the discussions with key informants were conducted to supplement what was a relatively thin literature (both published and unpublished) on HIS issues confronting CHCs, and to identify relevant information that conventional literature search strategies might miss.  Although ASPE, HRSA and NORC anticipated this dearth of relevant literature at the outset, we later determined that it would be important to conduct these initial supplementary discussions in order to ensure that the discussion guides and site selection for the later stages of the project were on target.  Accordingly, we note that — as indicated in our original proposal — this environmental scan is more important as a vehicle to set up the subsequent project activities than it is as a mechanism for identifying conclusive results.

In conducting both activities, NORC worked closely with ASPE and representatives from HRSA in order to relate environmental scan process and findings as closely as possible to the goals of the main project sponsors and CHCs themselves. In particular, we were asked to assure complete coverage of the range of current programs related to improving health center information systems, including use of grants sponsored by HRSA and private foundations, the potential use of existing government systems, such as the VA Vista system in community health settings, an overview of private sector advances in health center information systems and promising models for advancement of information systems goals at CHCs.

Preliminary activities and coordination with ASPE. In the weeks following the project kickoff, NORC met with HRSA and ASPE to discuss key study questions and scope out environmental scan activities. At these meetings, ASPE and HRSA underscored the need to think broadly about the systems infrastructure, efficiency and regulatory compliance issues as they related to the mission of CHCs and the environment under which they operate. Furthermore, we were encouraged to look at CHC experiences working on systems projects funding through existing HHS or privately funded programs such as Shared Integrated Management Information Systems (SIMIS) and Community Access Program (CAP). We were also directed to a series of initial thought leader discussants including consultants who regularly work with CHCs on information systems issues. Following this initial meeting and initiation of environmental scan activities, NORC has produced two interim memos outlining progress on key tasks and next steps for completion of the environmental scan and subsequent project phases. Following delivery of each of these memos, NORC met with ASPE and HRSA in order to discuss findings and identify additional avenues for inquiry.

Review of existing documentation. The environmental scan includes review and synthesis of information from existing published and unpublished documents. We used two major approaches in identifying materials for review. First, we conducted a formal search of major social science and health services research databases such as PubMed, HSRProj and PsychInfo, as well as databases such as Lexis-Nexis that may include popular, non-peer reviewed publications. Finally, in order to assure comprehensive coverage of publicly available information, we conducted targeted searches of content available on the Internet using Google.com and other powerful search engines. Searches were conducted using a range of subject-level key words crossing  “community health centers” or “FQHC” and “information technology”; “HIPPA”; “practice management”; “electronic medical records”; etc. In addition, we conducted a general literature search on HIS related topics alone to uncover review articles or other publications that characterize the current state of health information management systems as they relate to both public policy and the goals of CHCs.

The second and more fruitful approach, to identifying appropriate information for review included directly contacting individuals at relevant organizations in order to gain access to unpublished information or publications that were not readily available through public sources. These organizations included government Agencies such as the Bureau of Primary Health Care, the Veteran’s Administration and the Indian Health Service; relevant associations such as the National Association for Community Health Centers, the Association of State and Territorial Health Officials (ASTHO), the National Association for City and County Health Officials (NACCHO), the Indiana and Oregon Primary Care Associations (PCAs) and the American Academy of Family Practice (AAFP); charitable foundations such as the Tides Foundation of California and the Robert Wood Johnson Foundation (RWJF); and academic institutions such as the Indiana University’s Regenstrief Center. In many cases, in addition to providing materials for review and synthesis, contacts from these organizations participated in thought leader discussions described in greater detail below. Upon identifying and obtaining these materials NORC reviewed relevant content and important findings were summarized for inclusion in the current report. A comprehensive list of materials identified as part of this scan is included as Appendix 1 to this report.

Thought leader discussions. Thought leaders identified for the environmental scan ranged from independent consultants working with HRSA, individual health centers and networks on systems issues to representatives from relevant associations and foundations such as PCA’s and NACHC, to HRSA and Bureau of Primary Health Care (BPHC) regional staff.   Discussions were initiated by telephone or email contact with the discussant or his/her staff. Prior to these discussions, thought leaders were forwarded a set of materials describing the overall project and its methods and providing a preliminary set of topics for discussion in the form of a discussion guide. This guide covered basic questions regarding the current state of CHC information systems including commonly observed challenges and issues as well as examples of how CHCs have leveraged existing sources of funding and expertise to enhance their systems capabilities and the specialized needs of CHCs relative to other providers in this area. Although the discussion guide, included as Appendix 2 to this document, provided an appropriate starting point for many of the thought leader discussions, we did not seek a detailed response to each topic across all respondents. Instead, we encouraged each discussant to provide detailed information on issues of which they had particular experience, knowledge, or interest. In some cases, where the discussants’ expertise focused on a particular area of interest rather than broader issues related to the study, we developed a specialized set of questions. Representatives from ASPE and HRSA were provided an opportunity to participate in each of these discussions. Table 1 below provides a comprehensive list of thought leader discussants, their affiliation and the type of information they were able to provide.

Table 1. Thought Leaders and Areas of Contribution

Thought Leader (s)	Organization	Areas of Contribution
Steve Dorage, Dennis McMahan, Steve Laslo	HRSA/BPHC	Background on HRSA regional office contributions to CHC systems monitoring Update on innovative health center systems activities in the Midwest
William Gaud	Independent Consultant	Ongoing CHC information systems activities Perceived successful models and challenges CHC-vendor information
Marc Wilcox	Independent Consultant	Ongoing CHC information systems activities Perceived successful models and challenges CHC-vendor information
Carter Crafford	Miterek Systems	Ongoing CHC information systems activities Perceived successful models and challenges CHC-vendor information
Alice Rae	Indiana Primary Care Association (PCA)	Role of PCA’s in health center information systems
John Ruiz	National Association of Community Health Centers (NACHC)	Overview of information systems from a center perspective Ongoing NACHC publications and activities
Mike Leahy	Oregon Community Health Information Network (OCHIN)	OCHIN activities to date, including relationship including fostering statewide collaboration and vendor relationships Use of OCHIN as a model for other community’s
Ellen Freedman	Tides Foundation	Role of private foundations and Tides in particular in the area of electronic medical records (EMR)
David Gans	Medical Group Management Association (MGMA)	Private health center experience with HIPAA compliance, practice management and EMR
Clem McDonald	The Regenstrief Institute	Regenstrief Medical Records system (RMRS)
Barbara Kelly	The Gartner Group	Private health center experience with practice management and EMR Overview of vendor types
Theresa Cullen	Indian Health Service (IHS)	IHS’ RPMS
David Kibbe	American Academy of Family Physicians (AAFP)	Physician experience with EMR AAFP’s open source EMR product
Gary Christopherson	Veterans Health Administration	Potential use of  Veterans Health Information Systems and Technology Architecture (VISTA) software in community health settings, ongoing activities in the D.C. area

In addition to the activities described above, NORC has participated in a number of HRSA-sponsored events related to CHC information systems. These include a CAP grantees conference, three sessions with Michael Leahy, Executive Director of the Oregon Community Health Information Network (OCHIN) and HIPPA-compliance related activities with CHCs. Attendance and participation in these meetings have enhanced our understanding of the issues at hand and inform the discussion of project findings provided below.

In the sections that follow, we present the results of all of these environmental scan activities and conclude with a section on how these results will be used to inform the subsequent project activities (telephone discussions with 25 CHCs and in-depth site visits with seven CHCs).  It is important to note that, due to the mixed methods used to gather this information, some of the results presented (e.g., those that represent syntheses of information from literature) are more generalizable than others (e.g., an impression or perception reported by one, or even several, of our key informants).  We clearly differentiate these different types of results throughout the following sections.  Still, it should be emphasized that all of the results presented here — other than basic descriptive information on CHCs and HIS vendors and products — are considered preliminary.  As described above, the purpose of this environmental scan is to provide basic context and background on the CHC and HIS landscape, and to use this information, plus initial findings from literature and a relatively few discussions with key informants to illuminate areas for further investigation through a systematic set of interviews and site visits.

Community Health Center Landscape

This section summarizes general information on CHCs as a means of providing context for the specific themes that are the focus of this study — the ways in which CHCs are using health information technology to accomplish their missions.  In effect, this document “drills down” to its specific focus by first describing the CHC environment, then describing the health information technology environment, and then describing (to the extent possible) the union of these two areas. 

Overview

Federally sponsored health centers are an integral part of the nation’s health care “safety net” (providers who service underserved and uninsured populations) in both rural and urban regions across the United States.  Since their inception as a pilot program by the Federal government in 1964, CHCs have been instrumental in delivering primary care medical services to vulnerable populations. They represent a critical public resource for individuals and families who face barriers to securing medical insurance or obtaining care from private providers.  Originally supported under the Economic Opportunity Act, the eight inaugural “neighborhood health centers” (NHCs) opened their doors in 1965 as a component of President Johnson’s Great Society plan.   With expansions requested in the FY 2004 budget, there will be well over 800 funded Community and Migrant Health Centers with close to 3,700 sites. HHS estimates that CHCs will serve approximately 12.55 million patients during FY 2003 and plans on increasing this number by 1.2 million for FY 2004.

The NHC program was expanded and transferred to the oversight of the Public Health Service in 1969, where it eventually became known as the Community/Migrant Health Center (C/MHC) program.  The C/MHC Federal grant program is currently authorized under Section 330 of the Health Centers Consolidation Act of 1996, under the guidance of the Division of Community and Migrant Health Division at the Health Resources and Services Administration’s Bureau of Primary Health Care (BPHC). In its current form, Section 330 governs grants to four types of health centers including community health centers (CHCs); migrant health centers; health care for the homeless clinics; and health care for residents in public housing. Collectively, these grantees are known as Federally Qualified Health Centers (FQHCs). Although the principal subject of the current study are community health centers or CHCs, issues covered will be of general relevance to the broader group of FQHCs and community-based providers.

Although Section 330 mandates certain common elements and requirements for CHCs (see below), they differ substantially in terms of their organization and size. While some operate as primary care physician group practices with a large professional staff scattered around several sites within a community and serving tens of thousands of patients, others operate as single clinician offices with a handful of full-time employees and serving a much smaller population. Furthermore, CHCs exist within a range of larger organizational settings. While all are non-profit organizations, some are church or Foundation sponsored charity clinics, while others have relationships with Universities, non-profit hospitals or other community stakeholders.  Given this diversity of organizational partners and size, CHCs differ substantially in terms of their internal management structure. For example, smaller clinics often have a single professional manager who serves as the primary clinician and administrator, whereas larger CHCs often have a Chief Executive Officer (CEO) or Executive Director, a Medical Director and a Chief Financial Officer, each with responsibilities over specific aspects of center administration, clinical services and finances.

Federal Requirements

The Health Centers Consolidation Act and associated regulations lay out minimum requirements for qualification as a FQHC. These qualifications include issues of governance, populations to be served, services provided and administrative reporting requirements. Each of these requirements is described in greater detail below.

Service and operational requirements. FQHCs must provide services to underserved populations or be located in a medically underserved area (MUA) as designated by HHS and provide services to all residents within that area without regard to income or insurance status. They are also required to provide comprehensive primary care and ancillary services including clinical care by physicians and nurses; diagnostic laboratory and radiology services; perinatal services; immunizations; well-child exams; pediatric eye, ear and dental screening; family planning; and, pharmacy services. Finally, FQHCs are required to maximize patient payments (using an income-based sliding fee schedule) and third party payments, using the Section 330 grant, only to cover deficits after other sources of funding have been exhausted.

Health center governance. In addition to the basic requirements described above, CHCs, like all FQHCs, are subject to federally defined governance requirements. Specifically, HRSA rules require full authority and oversight responsibility for the center to rest with a governing board of 9-25 members, the majority of whom must have actually used clinic services in the last two years or be the legal guardians of CHC clients. Non-client members must represent the area served by the center and have expertise in community affairs. Half of these non-client members cannot earn more than 20 percent of their income from the health care industry and, overall, board members must demographically reflect the group of individuals served by the center. Finally, center staff and their spouses are not eligible for the governing board. Board responsibilities include meeting at least once a month, selecting the services to be provided by the center, scheduling the hours during which services will be provided, approving the center’s budget and leadership and establishing general policies for the center.

Reporting requirements. CHCs are required to annually submit data to the national Uniform Data System (UDS).  Data for this annual submission includes basic information on the center finances, staffing and resources as well as encounter and patient based information. The list of items for submission includes:

• contact information for center grantee and service delivery sites;
• services offered and delivery methods;
• center staffing;
• encounter based information including frequency of selected diagnoses and utilization of selected services (e.g., pregnancy and prenatal care, mental health services, etc.);
• demographic information on health center users including age, gender, race/ethnicity, languages spoken, socioeconomic characteristics and insurance status; and
• center revenues broken out by patient related revenue (managed care and non-managed care) and other sources of revenue

Because centers are required to provide these data electronically, the ability to accurately and efficiently manage this information is an important feature of CHC information systems. In addition to federal reporting requirements related to the UDS, many CHCs fulfill requirements for accreditation by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO).

Funding

Since the 1996 passage of the Health Care Consolidation Act, the C/MHC program has grown steadily  both in terms of provision of services to target populations and funding. For FY 2003, the program was funded at over $1.45 billion dollars. This funding includes all center grants included under Section 330: CHCs, MHCs, public housing clinics and Health Care for the Homeless Sites. Growth in funding has resulted in the increase in health center access points: new health center grantees and new health care delivery sites that expand the reach of existing center grantees. The President’s budget FY 2004 increases requested appropriations for the Community and Migrant Health Centers to $1.627 billion, a figure that was recently approved by Congress. Table 2 below, provides a breakdown of estimated actual revenue accrued by C/MHCs in 2002 as well as planned revenue for 2003 and 2004.  In addition, the Exhibit 1 shows the share of total revenue by source of funding (roughly consistent across years).

Table 2. C/MHC Revenue by Source 2002 — 2004

	Estimated 2002 Revenues (in millions)	Planned 2003 Revenues (in millions)	Proposed 2004 Revenues (in millions)	%
Section 330	1,328	1,433	1,582	25%
Medicaid	1,660	1,800	1,950	31%
Medicare	300	325	350	6%
SCHIP	90	100	110	2%
Other Third Party	430	470	510	8%
Self Pay	305	330	360	6%
Other Federal Grants	150	160	175	3%
State/Local/Other	1,020	1,100	1,200	19%
Total	5,283	5,718	6,237	100%

Priority Initiatives

The BPHC’s 2004 budget justification emphasizes the importance of HIS to overall health center effectiveness. In particular, the budget justification describes systems efforts related to the Bureau’s Health Disparities Collaboratives program and promotion of systems issues through the Integrated Services Delivery Initiative (ISDI). Information on other HIS support initiatives is provided in Section 5 of this report.

Health Center Information Systems and Vendors

This section presents high level trends in the use of information systems across the range of primary health care providers in the United States. This information was obtained from a review of recent publications in the area of health information technology as well as detailed conversations with thought leaders on the major systems related issues facing primary health care providers. In particular, we queried industry thought leaders on aspects of information systems most relevant for CHCs including implementation of practice management and electronic medical records systems and HIPAA compliance. We also include information on selected vendors in this area. Because thought leaders estimate that there are over 1,000 current vendors of electronic health record or practice management applications, it was beyond the scope of this study to exhaustively list and describe these vendors.  In sections that follow we present information from our more detailed research using company websites, on vendors identified as particularly relevant to community-based providers such as CHCs.

Background

Over the past several years information systems (IS) and health care experts alike have reflected on the relatively slow pace of adoption of information technology in the health care industry compared to many other industries. Although specific sectors within health care, such as the hospital supply and pharmaceutical industry, have been using advanced electronic information management and data interchange for decades, other segments of the health care marketplace, physicians in particular, have been cautious about introducing even basic information management technologies such as email or networked computers.  Recent estimates indicate that the health care organizations make approximately one fifth of the investment in information technology (as a percentage of their overall operating budget) compared to industries with similar information needs. Another trend of note is the lack of commonly accepted and utilized standards for health information management and transfer. Such standards would facilitate the important goal of efficient and secure exchange of electronic health data among providers and between providers and other entities. This is a particular challenge in light of HIPAA data standards and privacy requirements.

There are, however, important exceptions to the overall trend of relative underutilization of information technology and systems by providers.  Key among these is the increasing prevalence of electronic submission of claims to Medicare and other large health care purchasers, although these submissions are largely mediated by third-party clearinghouses that take data produced through hospital and or physician office systems and convert it to meet purchaser standards. In addition, there are examples of larger public and private providers such as Kaiser Permanente, Partners Healthcare System and the U.S. Veterans Administration that have successfully used information system technology to implement electronic medical records, enhanced communication with patients, greater access to medical knowledge resources, electronic order entry and clinical decision support tools. Because the recent focus of health centers in this area has been to implement tools related to more efficient administrative management of center activities and, in some cases, employment of electronic systems for electronic capture of clinically relevant information, we focused our environmental scan around these two broad issues. In the sections that follow we discuss concepts and tools involved in enhanced practice management and use of EMR or electronic health records.

Practice Management

Practice management  systems generally deal with appointment scheduling, billing and accounting, enrollment and eligibility, coding and claims processing, patient demographics information management, master patient index, and, in some cases, recordkeeping functionality (i.e.: encounter documentation). According to industry sources the vast majority of large to medium sized physician group practices have implemented some form of practice management software to handle basic administrative and office management tasks such as scheduling, billing and resource management. Still, thought leaders indicated that the majority of clinics are running multiple systems for administrative record keeping and that these systems are not meaningfully integrated and are running at less than full efficiency. For example, many clinics combine use of dedicated practice management tools with generic tools such as the MS Office Suite (e.g., Outlook, Word, Access, etc.) to manage and track the wide range of administrative functions central to the operations of a clinic. Very few clinics under 10-15 physicians have dedicated IT staff or a conscious strategic plan to systematically integrate practice management tools into their operations.

Interviewees described a highly fragmented market for practice management software, both in terms of demand from clinics and the landscape of vendors. Customers are gradually developing sharper preferences regarding requirements and service providers are slowly adapting to these preferences and growing smaller through mergers, acquisitions and closings, making it difficult to get an accurate sense of the core differences between providers. Most providers offer the same basic functionalities: patient appointment scheduling, tracking of patient insurance plan status and terms, patient billing/claims submission and financial systems and inbound and outbound referrals. Many products also include advanced features such as capitated billing and financial management and allow for easy exchange of data with managed care and major insurer information systems to facilitate overnight verification of eligibility and automated electronic claims submission and payment.

Because practice management marketing efforts primarily target administrators rather than clinicians the most sophisticated products include tools to help identify and address opportunities to recover lost revenue including electronic submission of all insurance claims, claims editing and tools to facilitate analysis of revenue and claims by payment source and other relevant variables. Another relatively new, advanced functionality is combining resource management (both plan and labor) with scheduling. Finally, looking forward, thought leaders indicated that the major distinguishing feature among practice management vendors is their ability to offer products that easily integrate all administrative, financial and resource management aspects of clinic operations and that effectively sync data from those functions with patient-level electronic medical records or electronic health records. Relatively sophisticated vendors that currently offer combined practice management and electronic health record products include Medic computer systems and Mysis LTD of the UK.

Electronic Health Records and Electronic Medical Records

Electronic Medical Records (EMR) systems are multi-functional.  EMRs typically document patients’ past clinical history and family history; capture encounter information; create prescriptions and track current/past medications, allergies; act as a repository for laboratory and other diagnostic data and, in some cases, varying degrees of clinical decision support tools, such as checking for medication interactions or some practice management functionality, such as appointment scheduling and master patient index. In recent years, a broader model for implementing these systems has been referred to as electronic health record (EHR) systems. According to one of our thought leaders, David Kibbe of the AAFP, EHR refers to an integrated system that makes an appropriate level of medical or clinical data available to both providers and patients, facilitates reporting of medical events for public health purposes, includes a secure messaging system for placing pharmacy or laboratory orders and integrates with a health center’s practice management system.

In contrast to practice management, there are very few stand alone outpatient clinics that have any form of EMR.  A recent survey of 6,000 members by the AAFP revealed that only 3-5 percent of their members have any type of electronic health record while between 10 and 24 percent have some form of electronic medical record. As with practice management, the vendor landscape for electronic health records and electronic medical records is fragmented, with the substantial majority of regional vendors having fewer than fifty clinic clients.

Vendor Landscape 

On the vendor side, interviewees indicated that there are between 1,000-2,000 total practice management vendors on the market in the U.S. This estimate suggests substantial but unrefined demand and a maturing vendor landscape. Thought leaders also acknowledge that the market is consolidating and the total number of vendors will likely markedly decline over the next several years. The majority of these vendors are considered regional players, providing basic administrative software to a limited number of small or medium sized clinics in a defined geographic area. Many of these vendors are small companies that promise to custom design software and provide support services to meet the specific needs of their client clinics. Interviewees indicated that these vendors develop systems and services of inconsistent quality, with a common difficulty being the ability to create useful interfaces with other systems both existing and anticipated (e.g., an electronic health record system or community-wide eligibility tracking system for low income individuals), facilitate the use of data standards for reporting and exchange and build in the flexibility to accommodate compliance with regulatory provisions such as those imposed by HIPAA.

The AAFP survey showed approximately 256 different EMR or e-health record software vendors, the largest being Medicalogic with 148 clients out of the approximately 1,440 clinics who indicated having some type of software in this area. Thought leaders describe the vendor landscape for the this market as similar to that of practice management applications with the bulk of vendors being regional players and with a few of the larger HIT and health care companies packaging EMR tools or functionalities with a full suite of practice management and clinical decision support applications.

Thought leaders identified four general groups of IT vendors in terms of market orientation and product focus:

• Regional players. As described above, the bulk of organizations currently developing and marketing physician office practice management software are small to medium sized regional players with 10-20 clients. Interviewees indicated that they often caution physicians who are tempted by the customization and low cost offered by many of these companies because of their lack of stability (most will either go out of business or be purchased by larger vendors over time) and their tendency to oversell the virtues of their customizations relative to the need to install systems that are easily integrated and designed to accommodate relevant data standards and regulatory requirements. One advantage to these systems may be in the area of support services because they deal with a smaller number of clients and support is provided, in many cases, by individuals who were involved in design and initial software installation.
• Application service providers (ASP). There are a growing number of dot.net organizations selling rights and support services for practice management software that they make available for installation and operations via the Internet. These organizations also tend to be smaller and offer the advantage of, in many cases, being focused exclusively on designing, improving and supporting a single package of practice management (and increasingly electronic medical record) software.
• Enterprise vendors. Interviewees indicated that there is a growing group of health care and health information technology corporations that combine practice management and electronic medical records functions with comprehensive offerings for health care information applications across all types of providers and settings. Prominent among this group of vendors are Epic, Mckesson and Cerner. Larger IT companies such as IBM also fall into this category.
• Best of breed vendors. Interviewees identified a number of vendors considered best of breed. These vendors have developed and marketed products with high-end functionality and performance in one particular aspect of practice management or electronic health record application. Examples include: AthenaHealth a partner of Siemans; Amico, a three-way partnership between IBM, Microsoft and Pfizer; Nexgen, Microsyst, GE Medical and Vitalworks.

Some thought leaders felt that the ASP model is a particularly promising mechanism for developing electronic records capabilities in individual physician clinics because it offers a low cost option for accessing and implementing the software in a particular clinic and an easily accessed platform in the Internet for data exchange between network providers and other community and policy stakeholders. Other thought leaders expressed skepticism that these products can be successfully integrated with a clinic’s locally operated system(s) for practice management functions.

In addition to the general information on the scope of the overall vendor landscape for practice management and electronic health records our environmental scan activities revealed the following, more generic findings on the nature of product offerings in this market:

• Modular product formats. In general, in most cases vendors do not market a single system that claims full services practice management or electronic health records functionalities. Instead, practice management or electronic health records (or, more often EMR) is used by vendors to describe a package of their products (called “modules”) that perform specific functions.
• Product modality. Most of the companies researched offer access to their data using multiple modalities, e.g., clinical workstation, handheld computer and web site.
• Clinical data repositories. Every product must store its data somewhere, more than likely in a relational database management system. It is also likely that this data has some degree of structure that can be used for analysis or other types of intelligent processing (e.g., alerts). In this sense, every vendor has what could be called a “clinical data repository.”  However, only one or two products contain a sophisticated, fully integrated data repository by general IT industry standards

The cost of implementing and maintaining practice management systems vary widely depending on the nature of the application and services acquired and the particular clinic setting and requirements. Thought leaders indicated that, on average, physicians spend approximately 15 percent of revenues on health information management tools and applications and related applications over a fixed period of time that includes a major purchase or upgrade with approximately about one fifth of that amount being spent ongoing user support and technical assistance services. One interviewee indicated that this substantial investment in information technology has not reaped commensurate benefits in terms of efficiency or improved patient care. He attributed this to the lack of integration among different information management systems within the same clinic and the lack of attention to health information technology purchases as core strategic investments that will determine the success of the clinic in achieving clinical, operational and financial goals.

CHC Information Systems

Like other members of the provider community, CHCs face opportunities and challenges related to their approach to accessing, producing, reporting and storing information. As core safety net providers, serving, according to the BPHC, approximately 11.3 million Americans in 2002 and as publicly sponsored centers with ties to the public health infrastructure, CHCs represent critical consumers and producers of health data for patient care and public policy purposes. For these reasons, CHCs play an important role in achieving a National Health Information Infrastructure. As described above, CHCs vary substantially in terms of their size and organizational characteristics. Still, there are shared information systems needs across CHCs and other community-based primary health care centers and many CHCs have made substantial strides in this area.

Support for CHC Information Systems 

In recent years, the federal government have directed additional funding towards advancing CHC information management goals. In addition to programs focused exclusively on specific information management issues, CHCs have made use of more general grants to make important advances in IT. The main focus of these programs, described below, has been to encourage community-wide collaborations on systems issues. This type of collaboration helps pool costs to accommodate the substantial fixed costs of operating and maintaining systems and helps facilitate the important goal of seamless exchange of data across all relevant health care stakeholders.

Integrated Services Development Initiative (ISDI). The Integrated Services Development Initiative (ISDI) is a CHC focused grant that funds two major activities: (1) implementation joint practice management systems and EMR systems across centers in a single area and (2) to work with (or establish) managed care networks to maintain CHC share of clients eligible for Medicaid coverage. Since its initiation in 1994, the ISDI program has awarded approximately 70 grants (ranging from $250,000 to $400,000) for up to four years.

Shared Integrated Management Information Systems (SIMIS). The Shared Integrated Management Information Systems (SIMIS) grant administered by BPHC supports inter-center collaboration on systems issues. Funded grantees typically design and implement common platform and tools for centralized billing, utilization review and quality assurance. Another goal of the program is to encourage integration of administrative and clinical information management functions within and across centers. In addition to joint purchasing of HIS resources, the SIMIS program requires health centers to implement strategic model for community-wide systems decision-making including: fulfilling IT staffing needs, conducting employee trainings, optimizing use of software licenses and support contracts, planning for regulatory compliance and mapping out future systems-related investments.

Community Access Program (CAP). The Community Access Program (CAP) funds models for enhancing integration of safety net services provided in any community. Unlike the SIMIS program, CAP is not designed to exclusively support systems initiatives. Examples of activities funded under CAP include development of client eligibility tracking databases to be used by a range of community social service providers and establishment of a shared electronic medical records (EMR) system public health plans and safety net providers in a community. Although, not restricted to systems-specific initiatives, nearly all recent CAP grants include substantial allocation of funds for information systems issues. The Oregon Health Information Network’s (OCHIN) use of CAP to establish a common, state-wide system for practice management including safety-net health care providers and health plans represents a leading case of the use of a CAP grant for an information system enhancement and integration. CAP grants are currently found in 158 communities around the U.S. in urban, rural, and tribal areas.  

HIPAA-related support from HRSA.  A major regulatory compliance issue facing CHCs and other primary health care centers involved in electronic transfer of health care related information is adherence to Health Insurance Portability and Accountability Act (HIPAA) requirements for Standard Transactions and Code Sets, Privacy and Security. In an effort to assist CHCs in moving with the development and implementation of HIPAA compliant electronic data systems, HRSA has contracted with MGMA to conduct a series of technical assistance audio conferences. As an initial phase, MGMA conducted a focus group with CHC grantees to determine HIPAA implementation status and common problems. Focus group participants revealed that many vendors were not planning on developing HIPAA compliant software, instead directing clients to use data clearinghouses at extra cost. Based on this feedback, HRSA incorporated management and negotiation with vendors as an important aspect of the audio conference curriculum. To date, three audio conferences have been presented. The first audio conference on Standard Transactions and Code Sets drew 420 registrants and 1,500 listeners. Subsequent audio conferences focused on the privacy rule and drew over 1,000 listeners. Future audio conferences are being planned to cover the security rule as well as additional information on later stages of standard transactions and code set implementation, including testing systems with payers. Although thought leaders knowledgeable on CHC issues related to HIPAA compliance expressed support for the technical assistance effort, some expressed concern regarding CHC access to technical resources to implement recommendations provided as part of this effort.

Electronic Medical Records Resources Project. BPHC is currently working on an initiative to assist CHCs in developing effective Electronic Medical Records (EMR) and Disease Management (DM) systems to enhance the quality of care.  This effort hopes to identify the functional role that EMR and DM systems would ideally play for CHCs and help determine how CHCs can reach this ideal with their systems.  The project includes: in-depth research of EMRs history, goals, current status, and future direction; identifying current EMR vendors; interviewing health care providers as well as Health Information Management professionals to assess their Medical Record needs in addition to their opinion of currently available systems; and creating a set of functional specifications to establish a standard for ambulatory care EMR. BPHC is currently funding an EMR pilot program involving three California CHCs and provides extensive guidance on its website for CHCs interested in using EMR technology in their clinic. The project’s website also includes information on basic functional requirements for EMR vendors appropriate for community-based health centers, vendor assessments and guidance related to planning EMR projects.

Veterans Health Information Systems and Technology Architecture (VISTA). VISTA is a federally-run, publicly-owned health information software system administered by the Department of Veterans Affairs that has become available for use by some community-based providers.  First implemented in 1996, VISTA is a comprehensive system supporting all sizes of health care providers ranging from small community-based clinics to community hospitals to tertiary facilities, covering virtually all aspects of care.  Currently, VISTA is undergoing a number of modifications to enhance and improve its capabilities with the aim of forming both a next-generation VISTA system for the VA, Healthe-Vet VISTA, as well as a public version, Healthe- People VISTA, which will be made available to such entities as state departments of health, medical schools and physician group and solo practices and individual practices.  Currently VISTA automates patient records and provides VA clinicians with patient level information during encounters using a graphical user interface (GUI). The VISTA system has been incorporated by community health providers in Washington, DC, who received a grant from the Department of Commerce to fund the purchase and implementation of the software.  In addition, a new project will look at using VISTA in a number of community health settings in West Virginia, possibly hosted by one of the state’s universities or major hospitals in the area. We note that while many observers consider VISTA a strong model for health center information management, others note the challenge of adopting VISTA for non-VA use. Important requirements include development of clinical modules not relevant to the VA population such as pediatric care as well as recording and coding encounter data for billing purposes.  

Indian Health Service. Finally, the Indian Health Service also implements a computer-based health system known as Resource and Patient Management System (RPMS) to meet their health center management needs. Because IHS clinics are largely, rural and modestly staffed, the IHS currently does not use a GUI front end for data entry and clinical information dissemination (though IHS is in the process of developing a GUI). Instead, clinic staff enter data from a specifically designed encounter form into the RPMS system. This data entry includes comprehensive therapeutic and diagnostic information including CPT codes for billing. Specific information entered varies by diagnostic module. In addition to allowing for automated billing based on the encounter specific data entered into the system, for subsequent patient visits the encounter form can be printed out to include information on prior visits and serves as a clinical tool. Notably, a number of IHS tribal clinics, particularly those in Alaska and California are also designated as FQHCs eligible for Section 330 funding and so some FQHCs currently use the RPMS system.

Tides Foundation. In addition to public sector funders, some community providers receive support for technical infrastructure from charitable foundations. Most notably in partnership with the California Endowment, The Tides Foundation has granted approximately $30 million to help develop basic health infrastructure (i.e. automated accounting, practice management) for community-based safety net providers in California since 1999. Tides reports that 80% of funding has gone to individual primary care clinics with the remaining amount going to regional provider networks in California. The program targets funds towards centers that lack basic electronic resources such as Internet access or any form of automated information system. According to Tides much of the funding under this initiative goes toward planning and training health center staff. Specific grants have also gone toward implementation of practice management and EMR systems in community based health settings.

CHC Use of Information Systems

Generally speaking, the needs of CHCs are quite similar to mainstream, private practices: both have significant practice management and record-keeping needs. As a result, the most prevalent applications in use at CHCs are practice management and EMR systems. As expected, we also discovered that CHCs have some unique characteristics that complicate their needs when compared with private practices. These needs include special reporting needs (i.e. the uniform data set) and eligibility/coverage determination. In the paragraphs below we briefly describe the two prominent applications that are currently in use, or are being contemplated by CHCs, as well as CHC-specific data needs.

Practice Management Systems. From discussion with thought leaders and review of environmental scan materials, it appears that practice management systems are the most widely implemented recent infrastructure enhancement at many CHCs and networks and, as described above, are a focus of many grantees to the SIMIS or CAP programs. Furthermore, tailoring practice management systems for CHC-use has been a focus of some software vendors, most notably Medical Manager.

Electronic Medical Records. Like other providers, CHCs are cautious in adopting EMR software and integrating its use into every day practice.  Thought leaders cite multiple specific challenges.  These include the computer literacy of the providers and their overall comfort with using the technology; staff turnover that necessitates an ongoing training plan; the inefficiency of information transfer from existing medical records; and a hesitance on the part of some administrative staff and providers to invest in technologies that are still evolving and might quickly become obsolete or unsupported.   However, once the EMR has been implemented, doctors and administrative professionals tend to be highly satisfied with the system, and especially appreciate EMR for preventing lost medical records and making the effort associated with losing this information a thing of the past, as well as the constant availability of organized, current information. There some CHCs that are working with EMR software both through the grant programs described above and through an EMR pilot study involving three California CHCs.  A pilot study for EMR systems is currently being conducted by the Central Valley Health Network in Central San Joaquin, California.  Three of the Networks 12 health centers, are participating in the pilot study: the Darin M. Camarena Health Centers; the Family Healthcare Network; and the Golden Valley Health Centers.  
In addition to the pilot study in California, thought leader discussions revealed that other CHCs are also planning EMR system implementations. One example of this is planned implementation of an EMR program by the Oregon Community Health Information Network (OCHIN), a network of CHCs and other community provider stakeholders in Oregon, which they are attempting to fund, partially, through a SIMIS grant application.

CHC Information Systems Needs and Challenges

Environmental scan activities have revealed substantial activity in the implementation of health center information systems. Advances identified to date in locations such as Oregon, Miami-Dade County, Washington D.C. and other locations reflects both strong vision on the part of community leadership timely, well-focused support by key federal stakeholders such as HRSA and the VA. However, as with other health care providers, CHCs vary dramatically in terms of their approach to health information systems. Thought leaders indicated that many CHCs still rely on long outdated methods for basic administrative tasks and that most CHCs face an uphill struggle with respect to issues such as assuring HIPAA compliance without the use of clearinghouses. We note that this situation is not different from that of most small to medium size primary care health clinics and group practices. Some of the key challenges and barriers related to design and implementation of health information systems in CHCs are described below.

CHC-specific Needs. As community-based safety net providers, CHCs have a special set of data and administrative needs that may be addressed using health center and community based information systems. For example, CHCs are typically required to assess the eligibility of clients for Medicaid, Medicare or other insurance or health care subsidization programs to ensure maximum reimbursement from third party payers. This is particularly challenging when working with a population that frequently falls in and out of eligibility criteria and may seek care only at sporadic intervals and at different locations. Community-wide tracking eligibility systems have been offered as a solution to this need. In addition, CHC administrative systems must accommodate the need for double and triple bookings and sliding fee schedules for determining patient out of pocket costs. Finally, the requirement that CHCs submit data on UDS means that CHCs must have an efficient way to tabulate encounters by diagnosis and procedure and provide additional information such as birth weight and trimester of first prenatal visit for specific types of visits.

Procedural Challenges. Overall, thought leaders indicated that the majority of the IT challenges facing CHCs seem to fall into the area of CHC organization and administrative procedures used in decision-making, design, and implementation activities related to their systems. These challenges include those related to application/system implementation (i.e., project management, skills for proper configuration); vendor performance against contract requirements; user training and issues related to “homegrown” systems solutions. Of these, thought leaders emphasized the concept of poor vendor management and relationship building leading to the inefficiencies and failure to meet important project objectives. Some specific deficiencies cited included the vulnerability of CHCs to unfavorable contracts due to lack of appropriate technical knowledge and also varying levels of assertiveness from leadership. In addition to lacking the appropriate technical knowledge, thought leaders indicated that CHCs face difficulties related to negotiating major vendor contracts generally. Finally, CHCs entering into systems decisions are especially vulnerable, not only because they are more likely to lack appropriate contract and technical expertise, but also because they receive none of the benefits available from group price negotiation. We note that HRSA has acknowledged the importance of vendor relations and provides CHC with substantial guidance on procurement and contract management issues.

Other challenges stem from the lack of knowledge among vendors regarding CHC operations. While there are specific examples of CHCs working with vendors to familiarize themselves with their specific challenges, many of these relationships encounter difficulties because of a lack of understanding of CHCs among vendors. One common refrain is that vendors tend to underestimate the level of support CHC users will require relative to users with their traditional customers.

Organizational Challenges. Environmental scans and thought leader discussions in particular, have elucidated a number of organizational challenges related to issues and opportunities for CHCs in regard to information systems development and implementation. For example, our discussions suggested that strong leadership from a Chief Information Officer (or similar individual) with an accurate sense of organizational mission and culture is an important element to progress on systems issues both for individual CHCs and networks. CHCs and networks that lack strong systems expertise suffer from implementation of systems that are consistent with the expertise and biases of existing staff, rather than those representing the optimal solution given the organization’s mission and constraints. Perhaps most telling is the notion reported by thought leaders that primary care providers including CHCs generally invest too much of their information management resources on specific applications and systems, rather than developing and implementing a strategic plan for procuring and using information technology for their clinic. Again, this is a challenge that HRSA has addressed to some extent by emphasizing the importance of CHC-investments in HIS strategy and dedicated leadership to follow through on HIS objectives.

Finally, there exist challenges related to funding and resources.  These include a lack of knowledge or a failure on the part of CHCs to take advantage of all funding sources and other support mechanisms. Conversely, some have expressed concern that the multiple funding sources and programs are too small and seem uncoordinated. Additionally, thought leaders mentioned that individual CHCs that are not in States with strong networks are often ineligible for systems-specific grant funding and that the levels of funding available are not adequate to support necessary improvements even among network CHCs with good management practices. Finally, while CHCs are encouraged to form networks and consortiums to take advantage of funding opportunities or respond to changes in the reimbursement environment, some thought leaders indicated that CHCs are provided relatively little guidance on how to operate successfully as members of a consortium or network.

CHC-Specific Vendor Overview

As described in this earlier, there exist a number of serious barriers to implementation and maintenance of advanced information management applications in CHCs as well as the difficulties in CHC relationships with vendors and in compliance with regulatory requirements on health data exchange mandated via HIPAA.  We have found that most of the sophisticated practice management applications on the market can accommodate special CHC-requirements related to administrative and financial management applications (e.g., sliding fee schedules, robust patient scheduling capabilities, tracking of specific clinical outcomes and UDS reporting)   In the bullet list below we describe vendors identified by thought leaders as being of particular relevance to CHCs. We note that more detailed information on these vendors and others is provided as Appendix 2 to this document. Finally, we note that the descriptive information provided here is taken from both thought leader discussions and the vendors own websites. We plan to obtain independent confirmation in subsequent key stakeholder interviews or case studies involving CHCs currently using these systems.

• Epic. Epic is one of the largest and most respected enterprise applications vendors. Epic’s clients are typically very large healthcare provider organizations such as Cleveland Clinic, Northwestern University Medical Center and other large healthcare enterprises. Epic is relevant to CHCs because the Oregon Community Health Information Network (OCHIN) chose to use its software as the basis for its networked practice management system. Part of OCHIN’s success story is the collaboration between OCHIN and Epic to create customized software based on CHC needs and requirements such as family planning and sliding fee scales. OCHIN noted that it would not have been feasible for Epic to have designed CHC-specific customizations had it not been for the aggregated buying power of the OCHIN network.
• Medical Manager. Medical Manager is a product that has historically been used and well-liked by CHCs. Nearly every thought leader we interviewed mentioned the use of Medical Manager at CHCs, and it has been known as one of the small handful of vendors who is receptive to the special needs and challenges of the CHC community. Perhaps the best example of a CHC network using Medical Manager is the Health Choice network in Miami, FL. The company was recently acquired by WebMD who is now marketing the former company’s products as the “Medical Manager System”. Signs of strain between the CHCs and WebMD have begun to show as a result of the transition, according to our thought leader interviews. One thought leader stated that Medical Manager was now becoming too expensive and noted that he encourages CHCs to network in order to be able to purchase it (although he did not make a recommendation as to whether or not they should purchase Medical Manager). Another thought leader stated that “HealthPro, WebMD, and Medical Manager have approximately 65 percent of the market . . . their growth is beginning to show in negative ways as many complaints are coming in from the field.”  WebMD has also acquired many other healthcare vendors relevant to CHC HIT including HealthPro, Resource America, Calyx, and Envoy. Resource America and Calyx are not discussed because it appears that WebMD is no longer marketing any of the products that those companies produced. Envoy (now “WebMD Envoy”) is perhaps the most notable of these purchases as Envoy is “one of the largest electronic claims and electronic payments transactions processor in the country” according to one thought leader.
• MDExchange. MDExchange is building what one thought leader termed a “community [master] patient index.” According to literature received from the vendor, MDExchange is a central repository in which care providers (e.g., hospitals, clinics) are able to register the presence of records related to an individual. When a physician accesses the MDExchange system, he/she can query all of the registered records and create a summary patient chart that combines information from multiple care providers.
• MDServe. While not primarily geared towards CHCs (as was the case with Medical Manager), MDServe has worked successfully with CHC networks in Maryland and Texas to create custom functions based on the needs of CHCs. In addition to advertising that the company’s product is “endorsed by the Technology Support Program of the NACHC.” The company offers its own success stories in the version of case studies of three implementations (Arizona, Georgia, and Texas).
• Healthcare Data Systems. One thought leader stated that CHCs in Indiana use one of two vendors: Healthcare Data Systems and HealthPro (see next bullet). While the thought leader praised Healthcare Data Systems’ “knowledgeable and helpful staff,” she indicated that the company may not remain in the market due to market forces (e.g., consolidations and closures).
• HealthPro. HealthPro is an example of one of the best of breed companies that was created specifically to meet the needs of CHCs; the general consensus was that this was good company to do business with because the people who worked there cared about CHCs. HealthPro no longer exists as a company due to being acquired by WebMD. Its product is being produced and marketed by WebMD as “HealthPro XL”. It remains to be seen how long that will be the case as WebMD is said to be steering its customers towards using the new version of Medical Manager. One thought leader indicated that when HealthPro was still in business that they had an unreliable track record with respect to providing quality training and that training costs were high.
• AAFP Open source EMR. The Open source EMR project is being sponsored by AAFP in order to test the hypothesis that an open-source web accessible model for electronic patient record software will markedly increase the use of this technology by clinicians. If successful, the Open source EMR would be made available to anyone who wished to implement it. If such a model is successful, it would likely be an idea candidate for use at CHCs. The most likely way for it to be successfully used at CHCs is in a networked environment; the CHC community could also combine its resources to create a specialized version of the product that incorporated special CHC requirements. At the time of our discussion with AAFP, they were in the process of bringing on practice management vendor partners to develop customized interfaces allowing integration of clinical and administrative data in settings using the Open Source EMR product. Notably, they had not been able to reach such an agreement with Medical Manager.

Themes for Additional Study

This document has presented findings from the first of three main project activities -- a comprehensive environmental scan including review of available printed materials and discussions with a limited group of thought leaders. Because of the unstructured nature of information in this area, we note that environmental scan findings are not intended to identify and definitively characterize all aspects of CHC experience with information systems. Instead, we have attempted to synthesize the background information on the characteristics of CHCs and health information systems as well as the easily available information on the success and challenges with design and implementation of health information systems in community health center settings. We have also characterized the overall vendor environment for clinic based health information systems and particularly those of specific relevance to CHCs. One of the main purposes of this environmental scan was to identify specific themes for further exploration during upcoming telephone interviews with 25 CHC and in-depth site visits with 7 of the 25 centers.  We describe topics for additional study below.

Medical Manager/WebMD and vendor relationships generally. While there are a number of companies that CHCs have used for systems issues, the dominant vendor of practice management software to CHCs has been Medical Manger. This seems to be a result of a conscious effort to acquire competitors and develop customizations, such as automatic UDS reporting. Though they have achieved a substantial market share the future for product upgrades and support services for Medical Manager remains unclear. Thought leaders indicate that Medical Manager is not planning on developing a HIPAA compliant upgrade to their existing system for CHCs. There is also speculation that WebMD’s goal is to move CHCs (and other customers) to web-based software platforms - this will likely pose a problem for many current Medical Manager clients with limited access to high-speed Internet connectivity. The CHC experience with Medical Manager may reflect the larger challenges inherent in building relationships with vendors, including the impact of market and vendor volatility and the difficulty involved in procuring and managing vendors in areas where CHC staff traditionally have little expertise. Assisting CHCs in the vendor procurement and relations process has been a priority of HRSA. Our environmental scan findings confirm the importance of expanding CHC capabilities in this area and, in subsequent phases of this study, we will investigate CHC-vendor relationships and produce recommendations to inform current federal policies and programs in this area.

Models for community collaboration on health information management. HHS’ vision for a National Health Information Infrastructure (NHII) requires CHCs to work closely with other community health and social service stakeholders. Use of a common platform for practice management and clinical data systems across providers in a community provides economies of scale and facilitates generation of aggregate data for administrative, public health and public policy purposes. Obstacles to this type of coordination include the challenge of determining how to equitably share management and cost burden of such a system across providers and instituting effective user-training across multiple settings and user types. Although the CAP and SIMIS programs have encouraged the growth of collaborative systems investment and planning, many thought leaders indicate that coordination in developing proposals and securing grant money through these programs, does not always translate into effective collaboration the programs themselves. One notable exception to this trend is the Oregon Community Health Information Network (OCHIN). OCHIN has been able to leverage affiliations with prominent Oregon CHCs and the State’s primary care association to forge a State-wide information management program for community health care delivery, including use of a CAP grant for implementation of a community-wide practice management program and well developed plans to apply for a SIMIS grant to implement a common EMR across the same group of providers. Findings from the environmental scan confirm that OCHIN has been able to establish a unique level of collaboration across community health center stakeholders. Subsequent activities including stakeholder interviews and case studies will assess CHC involvement in community-wide information systems initiatives, strategies used by CHCs to overcome the challenges of community wide or regional collaboration and opportunities to replicate success models for collaboration such as OCHIN in other locations.

Challenges and opportunities related to HIPAA compliance. As described above, CHCs face a substantial challenge related to compliance with HIPAA administrative data standards. Results from the environmental scan indicate that almost all CHCs requested extensions for the compliance deadline. Furthermore, Medical Manager’s CHC practice management software does not accommodate HIPAA requirements and there is no apparent effort underway to upgrade the software for HIPAA compliance. Policy makers at HHS face the difficult task of attempting to encourage and ultimately mandate compliance with HIPAA-related data standards, while supporting the efforts of community-safety net providers to enhance their use of electronic data systems generally. While HIPAA presents a daunting challenge for those CHCs who already use electronic data transfer for billing and reporting purposes, it may serve as an impetus for achieving common (compliant) data format and standards across health care providers. Furthermore, HHS efforts to support the use of HIPAA compliant data exchange models may facilitate the use of electronic data systems among CHCs that still rely on paper-driven processes for administration and billing. Subsequent phases of this project will include detailed investigation of CHCs plans related to HIPAA including strategies for overcoming barriers to compliance and new systems related opportunities that emerge from HIPAA compliance related efforts.

Wide disparities in use of information systems. Findings from the environmental scan confirm that there exist large disparities in the use of information systems for administrative and clinical functions at CHCs. While a main focus of this project will be to identify successful models of CHC systems design and implementation that may be replicable in other settings, the goals of the project also require some investigation of a representative group of CHCs. This group will include those CHCs, that, similar to other providers, demonstrate relatively limited use of electronic systems. Looking at these centers will allow us to describe in detail the basic resource and knowledge constraints facing small- to medium-sized community-based health care providers, including those rural CHCs that are not able to pool resources across a network of providers. In order to provide both a broad picture of CHC experience and opportunities with information systems anda thorough understanding of leading models for integration of systems into the management of CHCs, we plan on using a two-pronged strategy for selecting CHCs for the next stages of the project:  we will set aside some (e.g., 8-10) of the interviews to speak with a relatively representative group of CHCs, including those with relatively little access to advanced systems technologies. This will allow appropriate and accurate characterization of the overall CHC experience. With the remaining CHC interviews and subsequent case studies, we will focus on those CHCs, urban and rural, that have some demonstrated successes in information management. This will enable us to characterize various models of CHC IT experience and to compare these models in terms of consistency with the NHII vision, sustainability of progress and replicability in other settings. Furthermore, in looking closely at these CHCs and, in many cases, their networks, we will have the opportunity to assess the impact the various BPHC and privately funded efforts in this area and identify opportunities to enhance these programs over time. A table of potential sites for future study is included as Appendix 3 to this report. Appendix 5 outlines our plans for conducting the CHC interviews and provides information on Community HealthNet and other community providers in Indianapolis, IN the setting identified early in the project as a key target for a site visit.

ENDNOTES

HRSA, Budget Justification for the President’s 2004 Budget to Congress

Recent summary on legislative activity http://www.nachc.org/

Starr P. Smart Technology, Stunted Policy: Developing Health Information Networks. Health Affairs, May/June 1997.

DK Francies et al. Health Care Information Technology (New York: JC Bradford, 1999).

Bush, J. Open-Source Software: Just What the Doctor Ordered? Family Practice Management, June 2003. < http://www.aafp.org/fpm/20030600/65open.html#box_a>

EHR Interest Survey Results. American Academy of Family Practice, January 2003. < http://www.aafp.org/x19997.xml?printxml>

National Summary of 2002 UDS data from <www.hrsa.gov>

National Summary of 2002 UDS data from <www.hrsa.gov>

Recent summary on legislative activity http://www.nachc.org/

HRSA, Budget Justification for the President’s 2004 Budget to Congress

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