Case Study Reports
Oregon
Philadelphia
Boston
Southeastern Kentucky
Virginia
New Hampshire
Florida
Community Health Center Information Systems Assessment: Issues and
Opportunities
Findings from Oregon Site Visit
Submitted to the Office of the Assistant Secretary for Planning and Evaluation and Health Resources and Services Administration, US DHHS
NORC at the University of Chicago
January 2004
Table of Contents
1.0....... Introduction and Background
1.1 Site
Visit Objectives
1.2 Oregon
Safety Net Programs
1.3 The
OCHIN Initiative
2.0....... Site Visit Methods
2.1 Site
Visit Process and Logistics
2.2 Respondent
Characteristics
2.3 Site
Visit Tools
3.0....... Key Site Visit Findings
3.1 OCHIN
Development and Early History
3.2 Motivation
of Early OCHIN Partnerships
3.3 Health
Center Information Systems Capacity
3.3.1 OCHIN IS Infrastructure
Characteristics: The ASP Model
3.3.2 Systems Infrastructure
at OCHIN Partner Health Centers
3.3.3 Applications &
Data Management Systems
3.3.4 Health center IS
decision-making process
3.4 OCHIN
Non-Partner IS Characteristics
3.5
Stakeholder Experience with OCHIN
3.5.1 Collaboration with
the Larger Oregon Safety Net Community
3.5.2 Important Systems
Functionalities and Satisfaction
3.5.3 Organizational and
Process Experiences with OCHIN
3.5.4 Perspectives on Next
Steps: Data Warehouse and EMR
3.6
Challenges Moving Forward
4.0....... Conclusions
Appendix A: Example Site Visit Interview Protocol
Appendix B: Health
Center IS Characteristics
Table
NORC at the University of Chicago (NORC) is pleased to present this site visit report describing methods, key findings and conclusions from Oregon for “Community Health Center Information Systems Assessment: Issues and Opportunities.” This project is sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services (HHS) and will assess the status of health information systems (IS) at the nation’s HHS-funded consolidated health centers (hereafter referred to as “consolidated health centers”). Results from this study will help guide a range of HHS projects focused on infrastructure at consolidated health centers and, more broadly, HHS policy relating to the United States health care safety net. The study will also help identify research and development priorities as they relate to consolidated health center use of IS. The project involves collection and analysis of information on the characteristics of systems applications and technical infrastructure currently in place at consolidated health centers. Findings from the project will focus on unmet IS related needs and models for successful use of IS within consolidated health centers and the communities they serve.
Site visits to seven communities with consolidated health centers around the country form the major data gathering activity of the assessment. Additional assessment activities include a comprehensive environmental scan summarizing findings from available published and unpublished sources on issues related to consolidated health center use of IS, discussions with a series of 15 experts (or “thought leaders”) with experience in the financing, development, support or design of health center IS and structured interviews with a set of 25 consolidated health centers across the United States.
The Oregon site visit involved telephone, email and in person exchanges with 30 respondents representing 18 institutions involved in the primary health care safety net in the State of Oregon. Findings from these activities help identify issues and opportunities facing health centers in Oregon, particularly with respect to the activities of the Oregon Community Health Information Network (OCHIN), an independent non-profit consortium of safety net health centers and stakeholders founded in the year 2000 and supported to date through short term grants awarded by the Bureau of Primary Healthcare (BPHC) and other federal sources. OCHIN’s mission is to improve health centers’ use of IS for clinical and administrative purposes and to facilitate dissemination of high quality health care and public health data on a community, State and Regional level. Overall, the site visit explored two main themes: (1) the state of IS use among consolidated health centers in the State of Oregon, and (2) the sustainability, replicability and effectiveness of OCHIN as a model for maximizing benefits of IS for health centers and other stakeholders in a particular State or region.
This report is organized into three main sections:
Site visits such as this one represent an important opportunity to guide HHS efforts to maximize benefits from use of IS in primary health care settings. Oregon presents a particularly interesting setting for our first site visit due to the State’s history of progressive thinking and organization around health care and public health issues. The State Primary Care Office and the Office of Medical Assistance Programs have worked closely with the consolidated health centers and the Oregon Primary Care Association (OPCA) to address issues of health care access, cost and quality of care for Oregon’s safety net community. The formation of CareOregon, the State’s largest Medicaid managed care provider, in the 1990’s represents a recent example of safety net stakeholders working together in Oregon. CareOregon, formed through a cooperative venture involving safety net providers in the State, has assisted consolidated health centers work with the State’s Office of Medical Assistance Programs (OMAP) to continue serving low-income populations following adoption of Medicaid managed care. More recently a range of senior State health officials have shown strong interest and involvement both in OCHIN and in other infrastructure-related initiatives affecting the State’s consolidated health centers. CareOregon has also played an important role in the early development of OCHIN by serving as the consortium’s first organizational home.
Safety net providers and the populations they serve in Oregon. The 30-plus consolidated health centers comprise the major portion of safety net providers in Oregon. These include community health centers, health care for the homeless centers, Indian/tribal health centers, rural health centers and school-based health centers. While many of consolidated health centers are located along the Western edge of the State, a number of consolidated health centers are located in rural parts of the state south and east of Portland. The populations served by these health centers differ substantially in terms of insurance status, demographics and chronic disease prevalence. The consolidated health centers also vary significantly by number of sites, dedicated clinical and administrative staff, total clients and total encounters per year.
Oregon’s consolidated health centers and their associated networks fulfill their mission by serving the State’s uninsured, underinsured, Medicaid beneficiaries and other vulnerable populations. In 2002, approximately 14 percent or nearly one half million Oregonians were without health insurance. According to a 2002 OPCA report on safety net gaps, primary care safety net clinics in Oregon serve 27 percent of the uninsured population and 15 percent of the Medicaid population over the course of a year. Over 60 percent of Oregon’s Medicaid population are enrolled in one of the state’s 14 fully capitated managed care plans.
OCHIN is a non-for-profit consortium of health centers and health safety net stakeholders created in 2000 following a state-sponsored study that recommended enhanced use of IS to improve the organization, coordination, financial stability and management of safety net health centers. OCHIN is governed through its Board by the directors of participating consolidated health center organizations as well as the directors of the Oregon Primary Care Association (OPCA) and State Primary Care Office. OCHIN’s partnering consolidated health centers reflect the full diversity of health safety net providers in Oregon described above. All of these centers receive funding under Section 330 of the Public Health Service Act.
The full OCHIN membership currently includes 23 organizations and agencies that serve Oregon’s safety net population. As described above, OCHIN describes its mission as increasing access to IS to improve administrative and clinical functions at primary care safety net health settings and to increase access to high quality information on the populations served by the safety net for planning and policy. OCHIN’s primary accomplishment to date has been to design, develop, and maintain a regional, HIPAA-compliant, high-speed data network for its member health centers. As part of maintaining this network, OCHIN administers a system of central servers using an application service provider (ASP) type model to provide full featured practice management to a growing number of consolidated health centers throughout the State and region. To provide this software, OCHIN has partnered with Epic Systems, Inc., a health information software vendor whose products are typically used in high-end health care provider settings such as elite academic medical centers. In addition to the practice management software, OCHIN plans to implement an electronic medical records (EMR) software system to allow systematic tracking of clinical data as well as a comprehensive data warehouse that will allow policy makers, providers and other stakeholders to access near real-time data on the health status and health care utilization of the safety net population. OCHIN’s development and technical infrastructure, as well as other issues relevant to the initiative’s sustainability, replicability and overall effectiveness, will be described in later sections of this report.
This case study involved a series of preliminary phone conversations and subsequent on-site structured interviews with key stakeholders in the Oregon safety net. We contacted consolidated health centers in and around Portland, identifying senior leadership and IS staff to query on administrative, management, clinical and technical issues related to IS use at their health centers. We also contacted stakeholders who could provide distinct perspectives on Oregon’s legislative, governmental, and cultural environment relevant to the safety net and OCHIN, including key leadership at OCHIN itself. We list key respondent organizations and their role in the State in Table 1 below. Our respondents included:
We spoke with stakeholders in the two largest population centers with in the state, Portland and Salem, as well as stakeholders in the more rural areas of Oregon. To streamline logistics, we organized our site visit to coincide with the Northwest Primary Care Association (NWPCA) conference in Portland on October 18th through 22nd. This allowed us to speak in person with leadership from health centers across a larger geographic spread than originally anticipated.
In the preliminary phases of the site visit planning, we contacted OCHIN leadership to describe the goals of the study and secure their assistance with identifying respondents and developing a data collection approach. These contacts provided key background materials on OCHIN’s efforts and assisted in identifying a wide range of relevant potential respondents. We also made extensive use of State websites and contacts provided by ASPE, HRSA and Oregon state officials to ensure the site visit would capture the full range of health center and stakeholder experience and knowledge.
Preliminary phone conversations. Prior to the site visit itself, NORC conducted approximately 20 half-hour telephone conversations with a range of health center and state government stakeholders. For many of these respondents, the initial telephone conversations served as an important opportunity to introduce the study and help focus the development site visit instruments. In other cases, initial telephone conversations were conducted with key officials or stakeholders who provided important context and background for this report independent of data gathered during the site visit itself.
Site visit activities. The site visit itself was conducted by six NORC staff on October 21st and 22nd, 2003. Each team of two staff members consisted of a senior staff lead (either a NORC Senior Vice President, Project Manager or Systems Expert) and a project Research Assistant. The site visit team consisted of two members of NORC’s Information Technology Department who have extensive experience in health IS, and four members of NORC’s former Health Studies Department who have broad expertise in health care and public health issues related to vulnerable populations. During the site visit, the NORC team conducted 17 total interviews involving 28 respondents. The interview localities were primarily in or around Portland, but we also talked with respondents in Salem, Tillamook County (near the Oregon shore), Oregon City, and Cornelius (several miles west of Portland). Two interviews were conducted by telephone with OCHIN partner consolidated health centers outside of Oregon: one with Pike Market Health Center in Seattle, WA and another with Santa Cruz County Health Department in Santa Cruz, CA.
Table 1 below describes the respondents interviewed during the site visit and provides some brief background on each organization that participated in the study. We have categorized health center respondents using OCHIN’s terminology:
Table 1: Overview of Respondent Organizations
Respondent Organization |
Type |
Description |
Consolidated Health Center Respondents |
||
| Multnomah County Health Department | IPM partner | Multnomah County Health Department is both a county health department and consolidated health center located in Portland, OR. It is the largest consolidated health center in the state. In 2002, the consolidated health center served 52,569 patients in 233,342 annual visits. |
| Klamath Open Door Clinic | IPM partner | Klamath Open Door Clinic is a stand-alone rural community health center and consolidated health center located approximately 280 miles south of Portland in Klamath Falls, Oregon. It has two sites that service around 4,500 patients annually and saw 17,230 encounters in 2001. |
| Tillamook County Health Department | IPM partner | The Tillamook County Health Department is both a rural county health department and consolidated health center located in Tillamook County, Oregon. Its five sites served around 6,000 patients with 20,437 encounters in 2001. |
| Virginia Garcia Memorial | IPM partner | Virginia Garcia Memorial Health Center is a stand-alone consolidated health center centered in rural Cornelius, Oregon. Their five sites serve 15,000 patients annually with 48,402 visits in 2001. |
| Pike Market Medical Clinic | IPM partner | Pike Market Medical Clinic is a stand-alone consolidated health center located in Seattle, WA. The site provides around 25,000 visits to 3,500 patients annually. |
| Ochoco Community Clinic | IPM partner | Ochoco Community Clinic is a small-sized stand-alone consolidated health center located in central Prineville, Oregon, making it the Eastern-most IPM partner. Its rural site provided 1,900 patient visits in 2002 and is expanding. |
| Clackamas County Health Division | IPM partner | The Clackamas County Health Division is a public health division that also provides primary care services and is located in Oregon City, OR. The site served 11,070 patients in 2002 in 29,230 visits. |
| La Clinica del Valle | Collaborator | La Clinica del Valle is a federally supported stand-alone community/migrant health center located in rural Medford, Oregon. Its three sites service around 7,800 patients annually with 25,137 encounters in 2002 and it is expanding. |
Respondent Organization |
Type |
Description |
|
Consolidated Health Center Respondents (continued) |
|||
| Outside In | Collaborator | Outside In is a stand-alone consolidated health center serving primarily homeless youth, located in Portland, Oregon. Its one site saw 7,700 patient visits last year. It is a member of the Coalition of Community Clinics, a network of 11 small, community-based providers that serve the needs of vulnerable populations in the Portland metropolitan area. | |
| Santa Cruz County Health Services Agency | Collaborator | The Santa Cruz County Health Services Agency is a large department in the county of Santa Cruz, California which houses two consolidated health centers. The Agency is in the process of becoming an IPM partner. | |
| Northwest Human Services | Outside OCHIN | Northwest Human Services is a stand-alone consolidated health center located in Salem, OR. The two health center sites served 10,000 patients in 38,959 visits in 2002. | |
Non-Consolidated Health Center Respondents |
|||
| Oregon Community Health Information Network | State — leadership | The Oregon Community Health Information Network (OCHIN), is an independent non-profit collaborative of consolidated health centers and other stakeholders that works to strengthen the health care safety net through improved IS and management services. | |
| CareOregon | Medicaid Managed Care Plan | CareOregon, a (501(c)3) is Oregon’s largest Medicaid managed care plan with over 80,000 members. It served as OCHIN’s administrative home until September 2003. | |
| Oregon Primary Care Association | State — Public Health | The Oregon Primary Care Association (OPCA) is a non-profit advocacy and member association that offers technical assistance to its safety net consolidated health center members to increase their efficiency and quality and to help them operate as a business. OPCA had a role in writing the original Community Access Program (CAP) grant for OCHIN’s initial funding. | |
| State Primary Care Office | State — Public Health | The State Primary Care Office (State PCO), and specifically its health systems planning division, helps determine where shortages of health professionals exist in the state as well as where under-served populations exist. | |
| Office of Medical Assistance Programs | State — Medicaid | The Office of Medical Assistance Programs (OMAP) manages the medical and dental services of the Oregon (Medicaid) Health Plan. OMAP helped develop the data infrastructure and helped to finance the OCHIN program. | |
| Office for Oregon Health Policy and Research | State — Public Health | The Office for Oregon Health Policy and Research (OHPR) is a state agency that provides health research, health policy analysis and technical expertise to the Governor, legislators and communities. | |
| Oregon Department of Human Services | State — Public Health | The state Department of Human Services (DHS) sets public health policy and provides administrative and technical assistance to county health departments and other local collaborators who deliver services in the community. | |
| Wallace Medical Concern | Urgent Care Center | Wallace Medical Concern is a private, non-profit clinic that caters urgent care services to low-income, uninsured populations. The clinic is located in Portland, OR. The clinic receives no federal funding, provides only urgent care services, and does not bill for its services, and is therefore being treated as an outlier for the purposes of this summary. | |
We developed structured but open ended data gathering tools for the site visit to (1) allow for targeted, systematic collection of relevant information and (2) capture the overall richness of respondent experiences. Telephone discussions and in-person interviews with respondents were conducted using discussion guides and a tabular form was emailed to IS staff at respondent health centers to facilitate collection of standard information relating to infrastructure and technical capacity.
Discussion guides. Preliminary versions of the discussion guides used for the site visit followed from a generic site visit protocol developed earlier in the study and reviewed, modified and approved by ASPE and HRSA. As noted above, informal pre-site visit conversations with respondents allowed us to incorporate information gathered during those conversations into tailored discussion guides for each interview. For each scheduled interview, the NORC team prepared materials that outlined our preliminary knowledge of the respondent and highlighted outstanding questions to address during the interview. Respondents who had experience with OCHIN were asked about the impetus behind OCHIN, the characteristics of the participating health centers versus the non-participating centers, the stakeholders’ experiences with OCHIN and Epic, and the potential for replicating a system like OCHIN in other regions of the country. Examples of discussion guides and preparation materials used in the site visit are included as Appendix A.
Gathering data on health center IS.To gather information about the health centers’ IS infrastructure; we designed a short table with fields relevant to various aspects of a health center’s network, data and technology. This table was distributed to the various health center respondents prior to the site visit. Several of the sites returned very helpful information, including diagrams of their local or wide area networks (LANs or WANs), examples of written policy statements, a classification of support issues compiled by the center’s help desk, examples of paper-based records, and information about applications used to manage clinical and practice management data. The table used to gather these data is provided as Appendix B.
This section summarizes major findings from information gathered as part of the site visit. Because of OCHIN’s importance in ongoing systems-related improvements among consolidated health centers in Oregon, much of this section is dedicated to describing the development, administrative processes and technical characteristics of the OCHIN network. This section also describes the IPM partner and collaborator consolidated health centers’ experiences with OCHIN. Finally, the section includes an extensive discussion of our findings related to the technical and operational characteristics of IS at the health centers themselves, including software, hardware, networking, procedures and staff resources. This discussion is based on reports from health centers that are not current OCHIN IPM partners as well as those that are OCHIN-affiliated.
We begin by describing the environment from which OCHIN emerged and key aspects of OCHIN’s early history, including the impetus behind the development of the collaborative. We focus also on the organizations that helped establish initial goals, direction, and a longer term vision for the consortium.
Early leadership. Key stakeholders in the creation of OCHIN included the OPCA, CareOregon and consolidated health centers in the State of Oregon, notably the health center run through the Multnomah County Department of Health. These organizations headed the development of a steering committee composed of themselves as well as leadership from relevant offices within State government. Several members of this steering committee were interviewed as part of our site visit. Under the organizational umbrella of CareOregon, the steering committee applied for and secured a Community Access Program (CAP) grant that allowed them to hire staff and begin the process of developing the consortium in late 2000. In addition to citing the need for improvements in safety net health center administrative systems, the original CAP application emphasized OCHIN’s potential to collect and distribute high quality information on the health status and health care experience of vulnerable populations through a coordinated central data warehouse.
Organizational goals and focus. OCHIN’s original steering committee believed that it was important to maintain the consortium’s non-profit status and to focus on reaching out to different primary care safety net providers across the State and region. OCHIN sought to collaborate with consolidated health centers rather than other providers such as hospitals or private group physician practices. After securing CAP funding, the OCHIN steering committee brought on Mike Leahy (then a consultant with the Tillamook County Health Department’s consolidated health center) as Executive Director. The steering committee also prioritized the procurement and implementation of a sophisticated practice management system that could improve administrative efficiency and facilitate HIPAA compliant data exchange for the State’s 30-plus consolidated health centers and other safety net providers. The decision to prioritize practice management coincided with Multnomah County’s ongoing independent effort to select a practice management system vendor for their own consolidated health center. Over time, Multnomah County merged these activities with those of the health centers represented in the original OCHIN steering committee.
Vendor selection and initial implementations. After gathering the initial IPM partners and deciding to prioritize the procurement of a practice management vendor, the new OCHIN staff developed a request for proposals and evaluated the 25 responses they received. The first tier of evaluation focused primarily on functionality and workability of proposed solutions. The question of affordability was reserved for subsequent phases of the selection. Following an initial review of proposals, three vendors were selected as finalists including Epic (the ultimate winner) and NextGen.
The final selection process involved a live product demonstration by the three finalists, after which each consolidated health center in Oregon was given the chance to hear presentations from the finalists and fill out score cards. This process resulted in Epic’s selection as OCHIN’s software vendor. Several respondents mentioned that Epic was selected primarily for its extensive experience with marquee private group practices such as Kaiser Permanente and the Cleveland Clinic and because it would be able to provide an electronic medical records (EMR) system, which remained one of OCHIN’s goals. It should be noted that some of the OCHIN leadership was familiar with Epic from previous experiences and actively sought out Epic’s bid and was instrumental in capturing the software company’s attention. To date, seven IPM partners have “gone live” with the new integrated practice management platform in over 50 clinic sites and the partnership continues to expand within and beyond Oregon. Multnomah County Health Department plays a central role in hosting and supporting the main OCHIN server.
Plans for expansion. While the group of initial IPM partners allowed OCHIN to begin operations and secure additional funding, OCHIN’s leadership and current IPM partners acknowledge the need for further expansion to ensure an independently sustainable model capable of financing access to software and associated services. The current scope of the practice management initiative (involving seven IPM partners and more than 500,000 encounters per year) is substantially subsidized through temporary grant funding from HHS. At the time of vendor selection the OCHIN Board understood that — given the cost of the Epic product — longer term viability of the network would require establishing partnerships with safety net health centers outside of Oregon. At the time of the site visit OCHIN had one out of state IPM partner (Pike Market Health Center in Seattle, WA) and another implementation was planned for late 2003 (in Santa Cruz, CA).
Future direction and funding. The consortium is continuing to expand service and product offerings to individual health centers. In addition to two years of initial funding through the CAP program, OCHIN recently secured three additional grants, each focused on an important component of the consortium’s practice management and anticipated EMR offerings. In particular, immediate plans include at least doubling the annual volume of practice management visits managed by the Epic software by 2006 and developing an EMR product to be rolled out to alpha and beta sites in FY 2005. Early indications suggest that it will be possible to work with OCHIN to incorporate the existing BPHC software used in monitoring care delivered as part of the Health Disparities Collaborative project into a comprehensive EMR.
OCHIN continues to work towards implementing a safety net data warehouse for Oregon, but the consortium does not currently have adequate funding or resources to develop or manage the systems necessary for collecting patient data from the non-partner health centers that do not use the Epic software and integrating these data with that of the IPM partner health centers to form the basis of a patient- or encounter-level data warehouse. Currently, administrative data on patient encounters from IPM partner health centers is captured in a master patient index (MPI), which OCHIN leadership describes as a precursor to the data warehouse and a potentially rich source of utilization and administrative data related to safety net care in Oregon. The MPI currently includes data on the approximately 400,000 patients who obtained care via IPM partner consolidated health centers over the last two years.
Organizational affiliation and governance. CareOregon served as the administrative home for OCHIN in its initial two years of existence. In particular, CareOregon served as the grantee organization for the original CAP grant that supported OCHIN. At the time of its creation and subsequently, both CareOregon and OCHIN agreed that the formal legal relationship between the two organizations was a temporary arrangement that would last only long enough for OCHIN to become a viable, independent entity. At the time of our site visit, OCHIN was going through a legal separation with CareOregon that has subsequently been finalized.
Separation from CareOregon was possible at this time because of additional grants secured for the consortium through other IPM partner consolidated health centers and organizations. In conversations following separation, OCHIN leadership indicated that their new independent status will result in greater freedom for OCHIN as it seeks to establish its own viability as a financially independent safety net provider network. As before, OCHIN is governed by a board of directors including leadership from State officials, consolidated health centers, the OPCA and CareOregon. In addition to being one of OCHIN’s IPM partners with representation on the Board of Directors, the Multnomah County Health Department houses OCHIN’s centrally located servers and support staff. Many of OCHIN technical staff are former employees of either CareOregon or Multnomah County.
As described above, OCHIN commenced practice management software “go-lives” with several consolidated health centers in late 2002 and early 2003. OCHIN established independent service agreements with these “integrated practice management (IPM) partner” health centers. These agreements describe the Epic-related implementation services that are to be provided by OCHIN, including:
In addition to shouldering the cost of start-up at their site(s), under these agreements, individual IPM partner health centers are required to pay a $1.04 per-encounter fee for use of OCHIN services. This is a subsidized rate; the actual estimated cost per visit is $1.75 per-encounter.
The current IPM partners are comprised of four smaller stand-alone consolidated health centers and three clinics affiliated with county health departments. These IPM partner clinics differ substantially across important characteristics such as total number of annual encounters, demographic characteristics of patients served and payer mix. The largest health center, Multnomah County based in Portland, experiences close to a quarter million encounters per year, while the smallest health center — Ochoco Community Health Services, located in the rural geographic center of the State — experiences fewer than 2,000 encounters per year. Although each of these IPM partner health centers came to OCHIN with different technical infrastructure characteristics, varying levels of systems expertise, and distinct support needs, they had similar reasons for partnering with the consortium including those described in the bullets below.
Several of the health centers that chose not to become IPM partners were still interested in some form of collaboration, especially with the data warehouse and the EMR. Non-Partner respondents highlighted several reasons for deciding not to participate, including satisfaction with existing systems and costliness of Epic. Some health centers expressed concerns regarding the long-term viability of OCHIN. Many of the non-IPM partners are still involved in the OCHIN collaboration and have some input on the direction of future OCHIN ventures such as the data warehouse or EMR. The few centers we spoke with who were not involved with OCHIN at all were very small or were located in the less densely populated Eastern portion of the state.
One of the central project goals is to learn more about the IS-related expertise and infrastructure at HHS funded consolidated health centers. Oregon is a particularly interesting case because of the role OCHIN has played in providing previously unavailable opportunities for consolidated health centers to access state-of-the-art practice management software.
As described in the introduction, OCHIN currently delivers the Epic practice
management software and related services to its IPM partners via the application
service provider or “ASP” model. Under this model one central vendor,
OCHIN in this case, maintains and hosts all of the hardware and software
necessary to support a complex application, such as the Epic Practice management
system. Users, such as consolidated health centers, access the software
using a web browser on the user’s desktop or another user-friendly
“thin client”
application .
The application that OCHIN’s IPM partners use to access the Epic software
is a Citrix thin client. IPM partners access the application over T1 lines
that allow for high-speed network connection. Through the thin client
application, users at consolidated health centers can enter data relevant
for each encounter to their health center and generate/access reports, bills
and schedules based on data previously entered.
The use of thin clients in the ASP model minimizes technical support and
maintenance requirements at the health centers themselves. The multiple
high-speed connections to and from the host (i.e., the OCHIN data center)
create a Wide Area Network (WAN) that gives consolidated health centers ready
access to the Epic practice management application and provides for efficient
transfer of data from a desktop at the health center to the central location
where it is securely stored and maintained. The health center can then access
the same data in the form of reports or other materials. We note that the
centralization offered by the ASP model provides important benefits in the
case of OCHIN. For example, it facilitates for collaboration across consolidated
health centers and access to resources that a single health center would
not be able to amass on its own. However, there are some downsides
to the ASP model particularly in situations where each user site has
substantially different needs or inadequate connectivity. We provide more
detail on opportunities and challenges posed by the ASP model later in this
report.
Although the ASP model reduces requirements for the procurement, management, and maintenance of technology at each health center site, it does require health centers to purchase and maintain (with the help of OCHIN) some key internal technical components. In addition, most IPM partner health centers also maintain a systems infrastructure independent of their use of the Epic Systems practice management application supplied through OCHIN. Systems infrastructure characteristics at IPM partner health centers are described below.
Infrastructure related to the ASP connection to OCHIN: Wide Area Networks
(WANs).The ASP model arrangement requires some level of technical capacity
on the part of each health center. For example, site workstations have to
be configured with the Citrix clients, secure connectivity has to be procured
and maintained, and the site must be able to maintain a good working relationship
with their Internet service provider (ISP). In many cases, OCHIN has been
able to provide technical support to health centers that needed assistance
with initial startup desktop and connectivity configurations.
All of the IPM partner health centers maintain a high-speed, secure connection
to OCHIN which includes necessary security technology in addition to the
high-speed T1 connection lines. In addition to being on the OCHIN WAN, most
of the IPM partner consolidated health centers have multiple sites which
are networked together using the building blocks of network connectivity:
high-speed lines, routers, firewalls, virtual private network (VPN) technology
(for secure networking using the public Internet), and some form of remote
access. A subset of the sites belong to a collaborative named Community Health
Network of Oregon (CHNO), which is also funded via an HHS grant and provides
network application services such as Internet connectivity, email services
and clinical indicator tracking to its safety net clinic collaborators.
Infrastructure related to internal connectivity: Local Area Networks (LANs) and basic communication services.Within the four walls of a site, the IPM partner health centers typically operate LANs which connect file servers, email servers, and other networked applications detailed in the following section. In order to manage basic center communication and file sharing, each IPM partner operates these LANs along with certain communication systems such as telephone services. If the health center is part of a county health department, such as the Multnomah County consolidated health center, the health center can sometimes “piggyback” on the county infrastructure for these services, thus reducing the center’s responsibility for their construction and maintenance. Although, some health centers report that the requirement to use a county network infrastructure can present a burden. Other health center respondents that were not affiliated with a health department demonstrated a high level of sophistication in this area. For example, the Klamath Open Door Clinic operates its own WAN to connect two sites, participates in the OCHIN WAN, and maintains a LAN and several servers as well as networked applications. We note that prior to practice management implementation, OCHIN did assist some IPM partner health centers with their internal network setup this service was particularly valuable for rural health centers.
In this section we describe applications typically used at IPM partner health centers to collect, manage, and use clinical and practice management data. Discussion includes both software maintained through OCHIN and software developed or procured independently by IPM partner health centers.
Practice Management Application Functionality.All of OCHIN’s IPM partner health centers use the Epic practice management application, which is tailored to meet practice management needs of the health care safety net as recommended by the Bureau of Primary Health Care (BPHC). Especially useful functions included billing and claims management, scheduling, reporting, and the MPI described above. As the Epic practice management system was not designed to address clinical data acquisition or management functions such as immunization tracking, additional technology solutions will be necessary to meet these goals.Many IPM partners have been able to use different applications to track encounter results, send lab orders and receive lab results, and maintain disease registries.
Health Center Custom-Developed Applications.Many Oregon health centers create custom applications to meet their individual needs, either by programming entirely new software, as in the case of Multnomah County, or by creating custom versions of databases using widely available software. Smaller consolidated health centers reported using Microsoft Access to create applications that manage discrete clinical data items such as obstetrics care, screening interventions, or to track inventory of donated pharmaceuticals dispensed to uninsured clients. Also, health centers in Oregon often develop interfaces (described below) to integrate data from Epic and their custom-developed databases to produce reports that combine clinical and practice management data.
Federal and State-based Software Applications.A number of health centers reported that they manage clinical data items as part of the BPHC’s Health Disparities Collaborative, using the Patient Electronic Care System (PECS) and Cardio Vascular & Diabetes Electronic Management System (CVDEMS) software provided by the BPHC. These systems allow each health center to create and maintain registries of patients with specific chronic illnesses; the data is used for monitoring and informing the care of individual patients, supporting continuous quality improvement efforts at the health center level and for reporting purposes to the Collaborative.
Several centers also use state-based tracking programs that are unaffiliated with the Epic practice management suite. Two of the most common were the Immunization and Record Information System (IRIS), which is used to record immunization services provided by health departments across the state; and The Women, Infants and Children Information System Tracker (TWIST), which offers scheduling, paperless charts, and case management modules in order to collect data and coordinate services provided to clients in the Women, Infants and Children (WIC) Program.
Epic interfaces.A significant area of application development is the building of interfaces from Epic to other systems, whether they are in-house systems or third-party systems. For example, health centers may use an interface to transfer billing data into specific formats for electronic claims that are not handled via Epic/McKesson. Other health centers required interfaces to be built for reporting to local health departments or other funding sources. Multnomah County has developed software that interfaces with Epic in part to replace functionality that was lost when the county discontinued use of a mainframe-based application that integrated management and clinical data that they had developed in house. Part of this effort was to develop an interface to Epic that allows for data exchange between Epic, a nursing triage system, and a reporting system.
Other applications. While the applications and data management processes described above are those most relevant to the current project and site visit, respondents also reported use of certain applications to aid in general management. Particularly, a number of the health centers are using Micro Information Processing (MIP) accounting software as their primary financial package. Sites also generally use Microsoft Office applications such as Word or Excel (or equivalent applications) for general productivity purposes.
Overall, we find that health centers in Oregon engaged in significant application development to support various clinical and administrative data needs. Much of the relevant data resides in disparate systems where integration with Epic is not possible without significant effort; and it is clear that the existing applications do not contain all of the clinical data being managed with paper records. Many informants expressed a strong desire to have an EMR integrated with the practice management system which would give them greater support with their clinical data needs and quality improvements needs.
In addition to gathering and reviewing information on systems capacity and infrastructure at consolidated health centers, site visit activities focused around understanding organizational decision making processes and tools used by consolidated health centers to guide their systems investment and maintenance activities. We found that consolidated health centers were aware of the need for better planning around systems at their health center, but had not yet adopted specific policies or tools. Most health centers indicated that their thinking in this area is evolving in tandem with increasing opportunities to collaborate with neighboring health centers on application acquisition and infrastructure through OCHIN. Specific findings with respect to budget and application selection issues are described below.
Budget decisions.Overall, our findings suggest that health centers spend less than five percent of their total annual expenditures on IS. This figure is lower than those seen in many comparable primary care health settings that serve the general population. We note, however, that some IPM partners indicated a dramatic (one year) increase in percent spending on systems in 2003 as they had to invest in hardware and connectivity upgrades necessary for the practice management implementation.
Notably, respondents suggested a link between their organizational affiliation and willingness to invest in systems resources. Consolidated health centers that are part of the county infrastructure may benefit because county governments often operate a single information system that works across all administrative and service agencies. Under this scenario, the cost of system maintenance and support is spread across a wider group of organizations is often funded out of central county budgets rather than out of individual agencies. While access to the county infrastructure may be more efficient, in some cases we found evidence that this connection to the county government IS may not be functionally useful, such as when there is insufficient county level investment in systems. Additionally, independent consolidated health centers face much greater incentive than county-based health centers to actively to monitor their bottom line and assure against write-offs at the end of a fiscal year. This often leads to a more frugal approach by these health centers to investments not directly related to revenue generation.
Applications decisions. While most health center Executive Directors we interviewed acknowledge the need for systematic, strategic thinking at their health center around systems issues, including decisions regarding applications investments, most reported no formal processes currently in place to facilitate this. IPM partners report learning a great deal about vendor procurement and evaluation practices following their experience with the practice management procurement and ongoing discussion regarding EMR. Health centers also report that regulatory (e.g., HIPAA) and reporting requirements (e.g., UDS) drive many application implementation activities.
In this section we focus on the IS characteristics of non-OCHIN partner health centers that we interviewed. As the needs of non-partners and IPM partners are quite similar, we focus here on key differences between the IS characteristics of non-partners and the IPM partners.
Northwest Human Services (NWHS).NWHS in Salem, Oregon has developed a similar practice management system to the OCHIN/Epic solution in terms of functionality. Like Epic, their system includes scheduling, billing/claims, reporting, and accounts receivable. While there were several reasons that they decided not to implement Epic’s IPM software, one was that they believed that NextGen, their alternative practice management software vendor, could be better tailored and customized for their health center. The center’s executive director along with the IS staff and the board selected NextGen based on an extensive proposal review process including discussions with vendors, consultants, and an attorney for contract negotiations. They experienced a successful rollout to multiple sites, including trainings for IS staff and users. NWHS reports satisfaction with the support, cost and on-going relationship with the NextGen vendor. However, the respondents noted that they still appreciate the benefits of collaborating with the OCHIN members.
Coalition of Community Clinics.Two of our health center respondents, Outside In and the Wallace Medical Concern, are part of the Coalition of Community Health Clinics, a network of 11 small, community-based providers that serve the needs of vulnerable populations in the Portland metropolitan area and its suburbs at low or no charge to clients or outside payers. While some of the coalition members are consolidated health centers, most are smaller “free clinics” funded through local sources. Of key interest to our discussion is the Coalition’s use of a system of Microsoft Access-based databases created by its database administrator. Each clinic has an Access-based database system, tailored to their organization’s needs, that has common data features which enable to health centers to produce annual reports and other necessary functions. The Access-based system at Outside In provides the primary functions of billing, claims processing, and reporting (including the UDS reporting capability). Respondents at this clinic, while seeing the value in the collaborative nature of OCHIN, feel that using Epic is not feasible for the smaller clinics that make up the Coalition.
As part of the site visit we sought to gather and assess objective information on the satisfaction of consolidated health centers with applications, services and administrative procedures developed and implemented by OCHIN’s board. We note that many of the findings included in this section are taken from the comments of operational or administrative staff that have direct experience working with OCHIN software applications and processes. We also include the experience of non-provider based stakeholders within the State.
Stakeholders from various State government agencies, the OPCA and CareOregon consistently expressed enthusiasm for OCHIN’s existence and accomplishments to date. Overall, non-provider stakeholders indicated that OCHIN’s approach to collaboration among safety net providers in the State serves an important, previously unmet function. In particular, respondents from OMAP, the State’s Medicaid Office for health care services, and CareOregon complemented OCHIN and credited the network for improvements in the quality and efficiency of Medicaid billing in the State. Payer respondents also indicated that OCHIN can act as a useful liaison between payers and the providers to clarify issues related to how services were recorded in the system for a particular encounter.
Respondents from the State Office of Primary Care and OMAP agreed that the availability of a data warehouse populated by combined practice management and EMR data and covering primary care safety net providers in the State would be invaluable to public health policy. In Oregon, as in that nation as a whole, understanding the health and health care utilization characteristics of low income clients is a central challenge facing policy makers. In particular, the ability to track safety-net users across primary care encounters would allow for better targeting of outreach and provider resources to increase quality and minimize the costs associated with providing primary and preventive care for this population. Depending on how well OCHIN is able to integrate data from other government-funded service providers the data warehouse may be able to enhance officials’ ability to understand the extent of uninsurance or underinsurance in the State on a local level. Because representatives from these organizations have been involved in OCHIN from the start and continue to be involved in the consortium, they expressed a strong belief that the direction and goals of the network are consistent with the priorities and requirements of safety net health care providers in the State and of the larger public health, public policy and research community. Stakeholder respondents also expressed confidence in the motivation, ability and dedication of OCHIN staff.
Scheduling. The scheduling functionality of Epic was generally thought to be an improvement over the legacy practice management systems. Our respondents were especially pleased at enhanced functions like a module that allows patients to be scheduled to a specific room and care provider at the center. The software was also praised for its sensitivity to concerns specific to consolidated health centers, such as a mechanism that verifies that each patient has a paying agency affiliated with them (if applicable). None of the centers we spoke with had major complaints regarding this aspect of Epic’s functionality.
Electronic Claims Submission. Many centers using the Epic suite reported that their accounts receivable and cash flow are now more predictable due to the standardization of electronic claims submission. Respondents praised special features of the system such as built-in logic that allow identification of potential coding errors. We were told that the Epic software permits better identification of coding inaccuracies before the claims are mailed, increases the likelihood that insurance claims are mailed at all, and improves the centers’ chances of receiving grants because grantors take the centers’ robust infrastructure as a signal that the practice is managed effectively.
Although respondents recognized that the ability to submit claims electronically is a great improvement from the centers’ legacy systems, certain respondents desired a more streamlined billing process. Some reported that having OCHIN as an intermediary (between health centers and claims clearinghouses/payers) tends to slow the process down and that in the past OCHIN has not always submitted claims to payers or McKesson on a standard, predictable schedule.
Issues with custom billing. Because there are so many variations in how centers bill their patients and payers, Epic has had to customize its system to accommodate centers’ individual needs, such as adding different modules for sliding fee schedules. This customization process presented occasional difficulties during its implementation. For example, one consolidated health center reported problems with the sliding scale system they use to accommodate their vulnerable patient population. Because they did not have time to adequately test the application during Epic’s implementation at their center, there were some gaps left in the system relative to their needs and the center experienced financial setbacks as a result. These issues have now reportedly been resolved. Other clinics have experienced some problems with electronic claims submission to Aylers, which is the contractor the Oregon Public Health Department uses to distribute payments specific to the Family Planning Expansion Project (FPEP). In these cases as well, the respondents indicated that they would have liked more time to assess the requirements of the health centers pre-implementation.
It should be noted that billing complications were not attributed solely to the Epic system. One respondent noted that providers do not always fill out the paperwork correctly (for example, certain items are not always coded properly), which results in delayed or insufficient payment. Also, several of the billing issues mentioned by respondents were attributed to the process of implementing a system of Epic’s capacity in health centers. In general, respondents recognized that billing problems were often not the result of poor management on OCHIN’s part or inferior quality of the software: they assumed that the difficulties the health centers had experienced would inevitably arise in the course of launching a specialized IS collaborative.
Out-of-State issues. Some OCHIN centers, especially the out-of-state IPM partner in Seattle, WA, experienced difficulties when billing claims to Medicaid programs. In customizing the system for use by the Pike Market Medical Clinic of Seattle, OCHIN was not always able to identify potential problems or differences in the Medicaid billing office requirements or processes ahead of time in order to avoid delays or complications. For example, in Oregon, procedure codes must be bundled to be submitted to their Medicaid office for payment. Washington’s Medicaid office, however, does not recognize bundling. Early on this issue resulted in some payment denials for the health center. Although this problem has largely been resolved, Pike Market still reports issues with the billing component of the practice management system, which has resulted in declining cash collections and rising accounts receivables. Currently, Epic is customizing its system for use in the California consolidated health center and may be able to avoid some the complications it has faced in its implementation in Washington.
Networking with OCHIN. Initially, establishing and maintaining a secure, efficient connection with OCHIN posed an important challenge, particularly for smaller health centers with little existing systems infrastructure and no in-house technical expertise. One site reported some initial difficulty in setting up Citrix clients during Epic’s implementation in their center, but that issue has apparently been resolved. Likewise, some sites reported initial difficulty configuring connectivity with the OCHIN WAN, but they attributed this difficulty to typical start-up difficulties with a new service initiative and did not report serious ongoing incidents.
Reporting. While many health centers indicated that ease of reporting was an important consideration in their decision to join OCHIN, health centers meet with mixed results when using Epic to report. When probed on the issue, most centers indicated that they found the software complicated to use but were able to produce more accurate and tailored reports than with their previous system. Centers that lacked a dedicated technical staff reported the most problems. For example, one center trained three staff members to use the Clarity reporting system, but due to its complicated structure, these staff are often still not able to generate even simple reports that are used system-wide. If the center needs to produce more complicated reports, it is completely dependent on OCHIN staff and technical support. Additionally, the Pike Market Medical Clinic in Washington reported that the data requirements differ by state or locality and often the information that is compiled for Epic’s canned reports is not the information that is required by the State of Washington or City of Seattle. Other centers had concerns with Epic’s canned reports as well, stating that they do not cover all the necessary data requirements.
Centers that did have IS staff knowledgeable about Epic’s Crystal reporting system experienced fewer setbacks when producing reports and often saved time on presenting the data they need to get funding. For example, the Tillamook County Health Department has a reporting group composed of members who each have experience generating a specific type of report, so that when that type of report is needed the job is assigned smoothly. Several centers employing staff with some technical expertise observed that Epic’s reports offered more flexibility than their legacy reporting system did, so that they could choose to submit higher quality, more accurate and tailored data to the county or state. This level of accuracy often helped centers in receiving valuable wrap-around payments designed to fill the gap between the capitated payments and the actual cost of managed care patients served by the health center.
HIPAA compliance. Although the HIPAA compliance aspect of the Epic system was not generally a driving force behind the IPM partners’ decisions to join OCHIN, it was often noted as an attractive feature. Utilization of the McKesson Clearinghouse relieved the pressure on health centers to develop a solution around HIPAA data exchange procedures with their payers. This relationship ensures that centers are compliant with HIPAA standards relating to transactions and codes sets. Respondents at the Klamath Open Door Clinic also noted that many of the legacy software vendors were unable to provide documentation of HIPAA compliance to the health centers, so the Clinic felt greatly relieved to be working with OCHIN, Epic, and McKesson, who have supplied such documentation.
In-house IS resources. It should be noted that many of the health centers best satisfied with the Epic system and its technical functionality were also centers who had some internal IS staff (or at least staff who were knowledgeable about IS systems). While the OCHIN and Epic support staff were able to help centers take full advantage of the functionality of the software, the process was greatly expedited if there was a member of the health center team who was knowledgeable and capable of manipulating the system and fixing simple problems. While some of the smaller centers (such as Klamath Open Door Clinic) had qualified and expert individuals that facilitated their use of Epic, other smaller centers who did not have staff dedicated to working with the Epic software were less satisfied with both the technical aspects of OCHIN as well as the organizational and process aspects detailed below.
Collaboration. Overall health centers were very pleased at opportunities
for collaboration afforded through OCHIN. Many stated that prior to
OCHIN there was little exchange related to IS between health centers in different
counties. OCHIN provides ample opportunities to network with other health
centers and share best practices. For example, OCHIN organizes specialty
workgroups where representatives from different health centers and technology
experts participate in regular conference calls. These forums allow
health centers to joint troubleshoot over specific functionalities and regularly
share new knowledge on a range of technical issues. The OCHIN Board
of Directors, where health center executives can discuss current issues as
well as the future path of OCHIN, provides another opportunity for collaboration.
Not all centers were entirely satisfied with the collaboration process. One
of the smaller IPM partners remarked that they were not as influential in
the Board’s decision-making process as were the larger consolidated
health centers. Another IPM partner located far away from Portland
noted the difficulty of collaborating on the Board through phone conferencing.
Training and support. The quality of training and support provided by OCHIN was reportedly mixed. During Epic’s implementation stage, many of the stakeholders appreciated having OCHIN/Epic technical support included in the package, and felt confident that this support would be responsive to their needs. Several health centers noted that OCHIN was doing as much as it could in terms of providing adequate support to its existing IPM partners and that its “track-it” system and helpdesk were effective and very responsive. Others believed that they were being left behind due to OCHIN focus on expanding to other centers.
In the months following the implementation of the Epic suite, more issues with the quality and availability of support and training surfaced. IPM partners that do not staff a systems expert and rely exclusively on OCHIN for support can face substantial delays in service. As a result, smaller size clinics such report relying on temporary staff to fix problems that they had anticipated OCHIN support staff would handle. Even larger centers often complained that the support process was not always as accelerated as they had hoped. Also, certain respondents noted that the differences between centers, such as those that are stand-alone versus affiliated with a local health department, were not always taken into account in the training modules. While several centers were dissatisfied with the delays in the OCHIN support process and the necessity for continuous training, the centers did appreciate their ability to support each other though networking and workgroups involving IPM partner consolidated health centers.
Customizations. As with similar ASP models, OCHIN requires payment from individual health centers for specific customizations they request. Once the customization is paid for by one health center all IPM partners can access its benefits. Under this scenario, smaller health centers have a strong disincentive to request customizations they believe will be requested by larger health centers down the road. Respondents from some health centers reported that they sometimes did without necessary customizations, waiting until Multnomah County decided that it needed the customization and was willing to pay for it. Several respondents agreed that it has been important for the success of OCHIN to have an IPM partner consolidated health center as large as the Multnomah County Health Department, which is able to invest significant resources towards customizing Epic’s software towards the needs of the participating consolidated health centers. Problems arise where customizations for the smaller health centers do not mirror those for Multnomah County. For example, the mix of managed care and private payers at smaller, rural health centers in the Eastern portion of the State is very different from Multnomah County’s leading to different billing format or reporting requirements.
Connectivity. Some respondents raised concerns related to connectivity. Rural health centers occasionally experience minor disruptions in their T1 connection to OCHIN. While many of these problems are now being addressed, it is important to note that connectivity was a barrier to satisfaction for certain health centers during the beginning of the implementation process.
Cost. In the start-up phases of OCHIN, most of the IPM partner respondents realized that the costs of using Epic would be significant but chose to invest the money anyway, and now believe they receive good value for their investment. There were some concerns reported with unexpected fees, such as the software licensing fees that OCHIN required its IPM partners to pay during the implementation process. Others expressed concern about the rise in per-encounter costs for existing IPM partners, which have been implemented in order to bring other centers into the collaborative. For most of the IPM partners, however, fluctuating costs did not seem to lower the health centers’ satisfaction with their participation in OCHIN in the long run. Other centers noted that the per encounter cost of Epic for smaller or rural health centers may become prohibitive over time as these centers expand their encounters. We also note that cost was an important reason for non-participation in OCHIN cited by those health centers that are not part of OCHIN.
All stakeholders report they eagerly anticipate the implementation of both the EMR system and the data warehouse. Health centers are interested in the EMR because the many types of software that they use to track patients and services could be consolidated into a single EMR system, facilitating administrative duties. The centers are also excited by the prospect of coordinating a clinically-based, uniform set of data that they can supply to legislatures and the state and federal Departments of Health and Human Services. They believe this data system will help them improve the quality of care they give to patients on a regional scale, and will help them direct resources to where they will make the most impact.
Other stakeholders from state agencies and the Medicaid managed care plan expressed their interest in and anticipation of the EMR system. Members of the State Primary Care Organization as well as CareOregon indicated that the EMR system and the data warehouse would allow them to more accurately track and collect data about their low-income and uninsured patient populations, which tend to be very mobile. The ability to track these patients would help the agencies set better standards of care for this population, providing improvements not only in quality of patient care but also in cost efficiency.
The following paragraphs highlight challenges identified for OCHIN and health centers from the discussion above. In addition to operational challenges we describe those challenges related to their perception by the larger safety net and public health policy community in Oregon.
Supplementing and enhancing existing application functionality. While most the Oregon health centers indicated that the Epic application provides them with the important functionalities required for compliance with federal rules and efficient administrative management, many report that important enhancements to existing functionalities are required. In particular, health centers with no dedicated IS staff reported an interest in seeing a more user-friendly reporting and billing systems, that would allow non-technical health center staff to more independently create specialized reports and billing formats as necessary. In addition, almost all health centers indicated being ready and willing to move forward with EMR and clinical decision support applications, stating that clinicians for the most part were eager to begin using these types of systems.
Capacity of data storage and WAN infrastructure. OCHIN has made substantial investments in server and network technology to secure data storage and transfer capacity that exceeds current requirements. However, expansions to additional IPM partners and addition of applications may, at any time, lead to steep increases in capacity requirements. This is a particular challenge because, to date, OCHIN has successfully acquired adequate technology and communications services at discounted pricing because of active planning on their part and their ability to “sell” vendors on the importance of their mission. There is no guarantee that these types of arrangements will be available moving forward.
Collaboration under the ASP model. As mentioned above, the ASP model offers both substantial benefits and some potential problems for collaborations like OCHIN. The two primary pitfalls are processes surrounding customization and release strategies. ASPs work best when all of their customers’ needs are identical; this keeps custom application development to a minimum. When customers require customizations, as the health centers have, one of two approaches can be taken. The ASP can either build customizations on a per-customer basis, or the ASP can require that all customers agree to the customizations (in essence, treating all customers’ needs as identical).
OCHIN has elected to work with the latter approach requiring “free” customizations to be agreed upon by all IPM partners. In the event that one IPM partner requires specialized customizations that are not relevant to a broader group of stakeholders, they must fund the customization on their own. This is particularly difficult for smaller health centers that have needs distinct from larger centers, limited internal systems resources to implement reporting customizations on their own, and fewer resources to draw on to fund special customizations.
Cost of OCHIN to health centers. Most health centers that decided not to become IPM partners in OCHIN cited cost as the largest barrier to joining. Both the start-up cost and the per-encounter cost required by OCHIN were especially burdensome for smaller health centers. The start-up costs include Epic’s fees, licensing costs and any necessary hardware upgrades, which can cost centers anywhere from $50,000 to $100,000 depending on how many licenses are needed and how many upgrades need to be performed. The centers also have to pay a $1.04 per patient encounter fee. This per encounter cost can increase during periods when OCHIN is expanding to another health center.
Some, such as La Clinica del Valle, a consolidated health center in Medford, OR, stated that their concerns about joining OCHIN were partially related to the per-encounter costs, which created a disincentive for their goals of expansion. While this is a typical pricing scheme for ASP models such as OCHIN, it is one that health centers are unfamiliar with and which can become a barrier to participation. Even larger-size health centers that had more resources, such as Northwest Primary Care in Salem, OR, had reservations about participating in OCHIN because they believed there was no way to ensure that costs would stay below a certain threshold. In other words, being a part of the collaborative forced them to lose total control over their cost structure and they would be unable to control overall costs individually.
Future expansion and solvency.OCHIN’s structure necessitates that the program expand substantially to maintain financial viability and achieve independence over time. Ideally for OCHIN, the total patient population served by their IPM partners (existing and new) would at least double its current numbers. This expansion will require working with health centers both outside of the state and potentially outside of the entire Northwest region. However, this expansion is not guaranteed: OCHIN has accrued a substantial and early market share, but Oregon’s second largest consolidated health center has declined to participate in the network. Furthermore, as the experience from Seattle demonstrates, out of State providers pose special challenges to OCHIN because of differences in Medicaid billing requirements by State as well as problems with establishing a healthy collaborative atmosphere when IPM partners are too geographically distant for regular, in person meetings. Some health centers felt that the current model for achieving financial solvency through expansion is not realistic and leaves the network financially exposed in the medium to long term.
Service delivery (e.g., training).Although feedback about OCHIN from participating health centers was generally positive, several raised concerns about the organization’s record of providing program support and training to center staff. This was particularly an issue among smaller health centers, which tend to have little internal systems expertise and depend heavily on OCHIN’s IS staff. Reports indicated that key services, such as training, are of mixed quality and in need of improvement. At the same time, OCHIN will need to expand their business in the future to provide EMR to the IPM partners and collaborators, putting stress on their in-house systems personnel and financial resources.
Support from non-provider safety net stakeholders. Although by and large complimentary, stakeholders from government, payer organizations and associations were acutely aware of challenges facing OCHIN related to expansion to smaller health centers and maintaining a balance between a robust system and a costly system. They acknowledge a tension within OCHIN in terms of how best to simultaneously achieve a stable financial model, robustly meet the disparate operational needs of safety net providers in the State and support public health policy. One respondent expressed the sentiment that OCHIN’s longer term success depends on its ability to hold and consolidate gains as they are made in addition to looking ahead towards their next project.
In this section we briefly summarize key conclusions following from this report with an emphasis on areas relevant for federal funding and policy making. Additional conclusions related to the replicability of the OCHIN model, challenges facing Oregon consolidated health centers and OCHIN moving forward will be discussed at more length after subsequent site visits and other project activities have shed more light on these issues.
Overall IS infrastructure among consolidated health centers in Oregon. The consolidated health centers visited as part of this case study all demonstrated substantial use of IS and systems for key functions. All those included had ample access to desktop hardware and basic software used in most professional settings. There were substantial differences in terms of connectivity, access to networks and data maintenance capabilities across consolidated health centers. Beyond the obvious factors such as total patient served, number of sites and annual revenue, we found that a few key factors can affect the type of infrastructure at a health center and their ability to make use of what they have.
As described above, affiliation with a county health department allows some health centers to more efficiently access some level of technical infrastructure and networking, though the level of function provided by counties, particularly in rural areas, may fall short of the consolidated health centers needs. Furthermore, health centers that staff or have some access to even one dedicated IS employee report far fewer problems with use of networked applications such as Epic compared to those who rely on outside vendors or ASP-providers (e.g., OCHIN) to trouble-shoot and handle connectivity or applications related problems from a distance. In particular, we found that technology solutions for safety-net providers in Oregon often relied on the idea of collaboration and leveraging technical resources and expertise across providers. Aside from OCHIN, we see this with CHNO and the efforts of the Coalition of Community Clinics described above.
Vision and acceptance of OCHIN from relevant stakeholders. One of the striking features of the materials provided by OCHIN (mostly applications for HHS grants) and generally validated through discussions with health centers and other safety net stakeholders in the State was the network’s strong vision around which all stakeholders could take part and organize. All respondents agreed with OCHIN’s approach of addressing systems needs of health centers while simultaneously addressing information needs of public health stakeholders. This agreement around vision has led to good, active collaboration from both the health center and public health community. Although some respondents questioned specific aspects of the network’s decision making processes and pricing policies, all agreed on the importance of a comprehensive, collaborative vision for improving using health IS to improve the health and health care of vulnerable populations.
Satisfaction with existing products and services. Although, overall IPM partners indicated satisfaction with their organization’s participation in OCHIN, particularly from the perspective of enhanced opportunities for collaboration and the prospect of a centrally administered EMR, the preceding section’s discussion clearly demonstrates some lack of satisfaction with specific aspects of the practice management software and services provided by OCHIN. One common theme was that operations staff at health centers felt that OCHIN needs to do a better job of understanding existing workflows and requirements at IPM partner health centers and, particularly, how the needs of smaller, stand-alone or rural health centers differ from the needs of larger, county-based health centers such as Multnomah County. These issues may be indicative of the early stages of a complex implementation. One positive sign, according to OCHIN respondents, was the lack of connectivity problems during the start-up of their newest IPM partner health center in recent weeks.
Integration with Medicaid or public health systems. Although OCHIN has spent considerable effort reaching out to State Medicaid and public health officials and complies with accepted transfer standards (e.g., HL7), as of yet, there has not been a successful initiative to link the 400,000 MPI with Medicaid or state public health systems. This is in part due to the fact that they currently collect only administrative data, with very limited and incomplete information on procedures and diagnoses. In addition, there is some evidence that Medicaid systems in Oregon, and other States, are outdated and significant upgrading will be necessary before data can be integrated in a useful way with outside databases. Still, this is an issue that is of importance both to OCHIN and State officials with whom we spoke, particularly as OCHIN moves toward rolling out a data warehouse and EMR application.
Sustainability. The issue of OCHIN’s long to medium term
sustainability remains open. To date, they have been largely financed through
HHS grant programs designed to provide start-up costs for community-based
consortia to improve quality and efficiency of health care delivery, with
the idea that over time the activities of the consortia will be self-sustaining.
Although OCHIN has shown strong motivation in leveraging start-up financing
from a number of federal grant programs (often by having different IPM partners
take the lead role on different grants), achieving longer term financial
viability through expansion of partnerships exclusively among safety-net
primary health care providers is clearly a more difficult challenge.
Importantly, OCHIN has and continues to make important strategic decisions
that will influence their ability to meet this challenge. For example, by
selecting a higher end vendor they have effectively priced out some of the
smaller and rural safety net providers in the State. OCHIN acknowledges this
and has considered development of an “Epic-lite” package that could
be offered to these health centers at lower cost. Additionally, because OCHIN
has made the decision not to accept partnerships from private group practices,
they will need to continue to effectively build partnerships with out of
State health centers. Aside from the challenges of inter-state collaboration
described earlier in this report is the issue that OCHIN will not be able
to count on the automatic buy-in and support from non-provider safety net
stakeholders in other States unless they actively pursue this end.
Replicability. OCHIN’s success in dealing with challenges associated with building a broad-based coalition of disparate health centers and stakeholders around a comprehensive safety net health information system is encouraging with respect to replicability of this model in other settings. It is important to note, however, that Oregon was somewhat ideally positioned for a network of this type because of the state’s long history of partnership across the safety net and between the safety net and state/local health departments. The best example of this was the establishment of CareOregon in the 1990s to help consolidated health centers continue to serve vulnerable populations that were moved to Medicaid managed care. In addition, the time was ripe for a solution such as Epic in Oregon given that there were a number of consolidated health centers concurrently looking to replace an existing system or establish a robust practice management system.
A fair amount of resource investment from the local safety net community itself (e.g., Multnomah County, CareOregon and OPCA) was necessary before the network could secure start-up funding from the federal government and OCHIN benefited by finding an early organizational home within CareOregon. Finally, all respondents complimented OCHIN’s early leadership and attribute much of the network’s success to the efforts of individuals to see the project through. In particular, respondents felt that OCHIN is aided by its staff’s ability to find “next best” or good solutions when the optimal route is ruled out for one reason or another. As the network moves forward, it will be important to assess the extent to which early service and functionality problems reported by out-of-state or rural partners are resolved in the near future, as this will inform the federal government’s understand of the feasibility of implementing this type of network across a demographically diverse group of providers.
Appendix A. Examples of site visit discussion guide and preparation materials
Tillamook County Health Department
9th Street and Laurel
Avenue, Tillamook,
OR
Phone: (503) 842-3900
Respondents
John Robinson, Executive Director
-Mr Robinson also sits on the OCHIN Advisory Board.
Ron Wallace, Assistant Administrator
Jeff Underwood, IS Coordinator
Interviewers: Mike Tilkin and Alana Ketchel
Logistics
We will be meeting with John Robinson and Ron Wallace, an assistant administrator
at Tillamook County Health Department as well as Jeff Underwood, the IS contact
for the center. We will meet with them at their building on the corner
of 9th St. and Laurel in Tillamook, OR. We were instructed to leave
approximately 1 hour and a half for travel. John Robinson warned us
that he might be called away for another meeting he might have to attend
but we will at least be meeting with Ron Wallace and Jeff Underwood.
We previously spoke with Darlene Dannis, finance manager, via phone.
Further directions: Take Highway 6 into Tillamook, come to the 101 and hang
a left at the 2nd stop light. We will be coming into town one-way and
will watch on the left for 9th St. where we will hang another left.
After we pass the 101 coming the other way, their building will be on the
next block at the corner of 9th St. and Laurel.
What we know
Tillamook County Health Department
Clinic Address: 801 Pacific Ave., PO Box 489, Tillamook,
OR 97141
Phone: 503-842-3900
Web Site:
www.co.tillamook.or.us/gov/health
Additional Sites: Rockaway; Dental Clinic, Tillamook;
Cloverdale
Clinic Type: Federally supported Community Health Center
Services Provided:
Patient Profile
| Patients 2001: | 6,086 |
| Number of visits: | 20,437 |
| Ethnicity | |
| Hispanic | 15% |
| White | 83% |
| Amer Indian/Alaska Native | 1% |
| Asian | 1% |
| Payment | |
| Medicaid | 20% |
| Medicare | 9% |
| Uninsured/private pay | 45% |
| Commercial Insurance | 26% |
Staffing
Total Staff: 35
2 Physicians
2 Nurse Practitioners
1 Dentist
1 Dental Hygienist
What we want to learn
PROTOCOL
Note: skip questions answered above such as those in italics
Center/Systems Background Information
Applications Dimension
Which of these practice management functionalities are currently not available, but needed? Which ones do you have access to but don’t use?
Technology Domain
Process Domain
Location Domain
Organization Domain
Environment Domain
Items for Follow-up, If we don’t already have
them.
Center/Systems Background Information
Applications Dimension
Data Domain
Technology Domain
OCHIN Integrated Practice Management Centers
Note: skip questions answered above
Information System Characteristics
Applications Dimension
Technology Domain
Process Domain
Data Domain