Conclusions
Health centers consulted for this study demonstrated substantial progress
in the use of health IT to meet important financial, administrative and clinical
goals. Although challenges persist, our findings validated initial observations
by some thought leaders that health centers represent fertile ground for
health IT adoption among ambulatory providers.
The experience captured in this report represents important lessons learned
for future investments in health IT among health centers, health center networks
and other ambulatory care providers. We attempt to synthesize these lessons
learned focusing on key issues relevant to the current policy debate, including
support for health center networks and EHR adoption. We also describe areas
for future research and analysis.
Overall, findings confirm that health center networks can be successful vehicles
for the adoption of health IT in the safety net. Health center networks
successfully acquired systems and innovatively harnessed them for the improvement
of operations, both administrative and clinical.
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Access to funding. Individual health centers most often cited cost
as the main barrier to purchasing IT. Network formation allows health centers
access to grant money above their Section 330 grant. We found that networks
often were able to secure a number of Federal grant programs simultaneously,
often by having different member organizations take the lead role on different
grants. In two cases, networks benefited from private donations that would
not have necessarily been made to individual health centers.
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Leveraging resources and expertise. We found substantial evidence
that health center networks take advantage of economies of scale to provide
resources that health centers could not afford to procure individually. These
benefits apply to basic purchases such as software licenses or service time
from vendors as well as structural issues such as the ability to attract
skilled technical staff. Individual health centers often reported that they
found it challenging to find IT staff that had adequate training for complex
systems issues. The ability of networks to afford IT staff with the
necessary expertise (e.g., on building interfaces, mining practice management
and EHR data, building databases, and customizing systems) was critical to
individual health center satisfaction with their technology.
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Vendor selection and management. We found that health centers benefited
greatly from having access to network executives who were skilled at the
vendor evaluation, management and procurement processes. Aided in part by
economies of scale, respondents mentioned that network executives were often
in a much better position than individual health center Executive Directors
to characterize their requirements in an RFP, negotiate favorable terms and
hold vendors to a high standard for technical assistance, customizations
and other services.
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Collaboration and coordination with other health centers. We found
that funding specific to coordination and collaboration across health centers
was important to improvements in their use of IT. Several health centers
noted that networks offer important forums to share best practices, allowing
centers to troubleshoot specific functionalities and share new knowledge
relevant to technical, administrative and clinical challenges. Networks brought
together providers with similar needs and common goals. In some cases,
networks have been able to build an infrastructure for sharing data through
community tracking applications and data warehouses. While networks that
seek to integrate functionality across centers meet with varying levels of
success, it is clear that without funding to promote collaboration and
coordination among health centers network development would not be possible.
In addition to these important benefits, we found that health centers faced
a number of difficult challenges in fulfilling their mission.
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Meeting diverse requirements of health centers. Because health centers
differ substantially operationally and culturally, networks often face the
challenge of addressing a diverse set of needs through a single operational
model. Network leadership recounted the difficulty in identifying systems
and governance structures that met the needs of both larger, more sophisticated
centers and smaller centers. More decentralized networks that were
unable to build a strong collaborative framework tended to be less successful,
as health centers were not fully bought-in and did not share a common
vision. These networks were often unable to overcome health centers’
tendency to compete with each other or the fear that their interests would
not be addressed in a network structure.
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Building and using community based applications. We noted that networks
which focused on building applications to collect, store and maintain data
from individual health center applications in a single community faced difficult
challenges. The process of building interfaces to allow data exchange across
two non-interoperable systems was both time-consuming and costly. Networks
reported that vendors were often resistant to release code to interface
developers and even when they had access to the right information, turnover
in the system of any individual health center meant significant setbacks
to these data integration projects.
We found that health center participation in community data warehouses was
contingent on some promise of benefit to the individual health center. For
example, health centers that felt they could already access and analyze data
effectively through their practice management system were unlikely to contribute
proprietary data to a warehouse that would only offer slight improvements
in ease of reporting.
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Setting up networks in rural areas. Rural health centers and networks
faced special challenges in building and accessing community-based
applications. Rural centers often have limited budgets for IT, less
sophisticated IT expertise than urban centers and difficulty in purchasing
off-the-shelf systems due to highly specific requirements. In terms
of technical challenges, rural initiatives are often unable to access high-speed
Internet connectivity needed to use networked applications because of low
availability in rural settings. Urban-based networks will likely rely
on the improvement of infrastructure in rural areas in order to incorporate
rural centers into their network. Progress was being made to this end during
the course of the study; for example, SKYCAP’s goal of sharing
client tracking data among its community-wide partners recently improved
with the spread of high-speed Internet connectivity in that region. In addition,
OCHIN leveraged improvements in access to high speed connectivity in rural
parts of Oregon to expand its membership.
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Achieving vertically-integrated data sharing model. Most networks
in our study were horizontal collaborations among geographically linked
ambulatory primary care providers. Only Boston HealthNet formed a true
vertical collaboration, revealing both real and perceived barriers to achieving
a model shown to be fairly successful for early IT adoption. In order
to form a successful vertical relationship among the city’s major safety
net hospital and health centers, Boston HealthNet was fortunate to already
have an established relationship among these institutions, as the health
centers supplied a large portion of the hospital’s patient base.
Despite this fortune, the network still had to overcome the barriers of finding
interoperable software that met the needs of both the large inpatient institution
and ambulatory health centers in addition to mitigating the reluctance on
the part of both the health centers and the hospital to share data due to
perceived concerns of a breach of privacy and a resulting loss in market
competitiveness. Even with its success, Boston HealthNet and other
networks attempting to forge a vertical collaboration face the ongoing challenge
of prioritizing resources and meeting the technical needs of a very diverse
clientele.
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Population health functionality remains a future goal. Health
center information sharing initiatives with hospitals, public health agencies
and Medicaid are slow in evolving, although most networks felt that building
those connections would be an important part of future activities.
Networks that had fairly strong ties with public health stakeholders in their
region, such as OCHIN, were able to build a collaborative vision for using
IT to improve the population’s health and were beginning to work toward
a population-wide data warehouse for the safety net population, however formal
linkages with Medicaid or state public health information systems had not
yet been achieved in any of the networks.
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Achieving sustainability. Network leadership across each case study
noted that financial self-sufficiency is not a near-term possibility for
their organization. Even in cases where one-time private donations
facilitated the purchase of software licenses, networks required a sustained
level of public funding for the training, initial implementation and ongoing
support necessary to realize benefits from the software.
From the health center networks that achieved the implementation of an EHR
we drew several lessons for future funders and implementers of technology.
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High level of clinician satisfaction and adoption observed in successful
networks. Case studies demonstrated the importance of having not only
buy-in, but significant involvement from clinicians at all phases of an EHR
implementation. Because EHR implementation changes clinical work flow in
profound ways and must be customized across a number of dimensions to support
efficiency as well as improved quality of care and safety, clinical leadership
must be involved in making core design decisions at the earliest phases.
Once systems were implemented, clinicians tended to see clear benefit in
using the systems and preferred electronic entry to paper records, citing
that they “wouldn’t go back”.
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Three levels of substantial funds are required. Health centers
implementing EHR reported three significant investments that accompanied
the rollout of their systems: seed money for start-up, money to build
infrastructure and transition workflow, and funds for the ongoing maintenance
of technologies. Seed money is used to purchase software and licenses,
hardware, implementation assistance and technical staffing that health centers
reported was as critical as the software application itself. Ongoing
funds are critical to help health centers implement and transition smoothly.
For example, post-implementation health centers must continue to adjust tools
to increase usability and allow centers to leverage the new functionality.
None of the networks had achieved self-sustaining funds to pay for ongoing
maintenance and future systems purchases, and will rely on outside funding
until that is achieved.
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Impacts of technology use can be quickly demonstrated. Respondents
suggested that fairly soon after implementation, EHR systems can lead to
improvements in patient outcomes. While these benefits have a real impact
on an individual health center level, achievement of broader public health
benefits is still limited by the absence of robust data sharing with public
health agencies, hospitals, Medicaid and other ambulatory care hubs.
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Opportunities and challenges for future initiatives. The health
center networks studied here were early adopters of health IT, providing
lessons for other networks that will follow suit in adopting technologies
to improve operational efficiency and clinical effectiveness. However
the challenges these initiatives faced as early adopters may decrease in
the near to long term, especially given the recent emphasis of the President
in leveraging health IT adoption for the improvement of health care
quality.6 Practice management and EHR software
will likely become more robust and the adoption of data standards may increase
the level of “built-in” system interoperability, eliminating the
need for costly customizations and extracts for data exchange. In addition,
the success of the network model as a driving force for health IT adoption
may spur more funding for new collaborations from Federal and private
sources. Despite this ripe environment for adoption, future initiatives
may still have to overcome organizational barriers to forging collaboration
among health centers and vendors as well as reluctance to data sharing.
While case studies demonstrated that there is more than one model for successful
implementation, we did find several factors closely associated with successful
adoption of IT among health centers.
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Understanding the relationship between clinical and administrative
applications. Depending on the immediate need articulated by health
centers, networks took different approaches towards prioritizing between
practice management and EHR. Overall, we found that having a robust practice
management application was a necessary first component to implementing an
EHR, as the full benefit from both applications comes with the ability to
seamlessly exchange information between the two. Even in networks where EHRs
were pursued in the absence of networked practice management system, each
participating health center did have a successful practice management
implementation that they were able to then interface with the EHR.
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Structure of the network impacts function and success. Across
the seven sites, we observed a link between the operational model of the
network and their success in implementing clinical technologies. We
found that more integrated networks where there was strong buy-in for shared
systems generally managed a smoother implementation of the technology.
Health centers in less integrated networks sometimes could not agree on shared
systems, focusing resources instead on systems such as data warehouses and
external client tracking systems which have proven very difficult to implement.
We illustrate the relationship between network and function and relative
success in Exhibit 5 below.
Exhibit 5: Level of Integration and Function
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Building trust through strong leadership. We found that strong,
skillful leadership played an indispensable role in building trust and
successfully implementing IT on the network level. For example, highly skilled
and charismatic network leadership in Boston, New Hampshire and Florida were
able to garner trust and buy-in not only for membership into the network
but to pool resources for the purchase of common, centrally-housed practice
management and EHR systems through which data could be exchanged. These
leaders demonstrated not only a strong skill for fostering collaboration
but also expertise in key areas such as selecting vendors and building
sustainable business models for health center IT investments. Strong
leadership was also the keystone to building a vision for systems adoption
that facilitated the evolution towards a unified goal of quality improvement
for the safety net population both at the network and health center level.
In addition to strong leadership, consortia also benefited from a high level
of collaboration among consortia partners and public health stakeholders.
CHAN, for example, credited a large part of its success to the health
centers’ consistent desire to exchange data, overcoming challenges other
networks faced in building members’ buy-in and trust.
While the current study has elucidated important lessons learned for adoption
of health IT among health center and health center networks, we identify
a number of areas that merit further investigation to assist policy development
moving forward.
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Feasibility and sustainability of promoting a network model. While
networks represent an important opportunity for health centers, we found
evidence that not all health centers are bought-in to an integrated network
approach. For their part, we found that even the most successful networks
are not self-sustaining financially and may not be for a significant period
of time. Additional work may be required to understand the level of access
health centers currently have to health center networks, the issues around
health center buy-in for an integrated network model, opportunities for networks
to obtain sustainable funding through non-grant sources and the potential
role of incentives created by changes in Federal policy.
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Health center network gap and overlap analysis. Health centers
around the country currently have different access to networked services
depending on geographic location and resources available. While some geographic
areas may not have any network activity, in the areas we visited for their
study we often found three or more Federally funded health center networks.
Although their activities were usually complimentary (and in some cases
overlapping), we observed limited coordination and collaboration among networks
in the same geographic area. Additional analysis may systematically catalog
overlap and gaps in network access for health centers around the nation in
an effort to facilitate broader access to networks and optimize future
investments.
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Value relative to cost. As in other health care provider settings,
health centers implementing health IT, and EHR in particular, struggle with
the task of understanding the value of these investments relative to their
costs. While health centers, as mission driven organizations may be less
concerned with the bottom line for their institution, they are required to
make responsible decisions with public resources. Also, understanding value
of health IT relative to cost in health centers (where health IT purchases
may be subsidized) offers a valuable opportunity to learn about the cost
effectiveness of these tools in other ambulatory care settings. As most health
centers do not have the resources or expertise to conduct rigorous internal
evaluations incorporating initiative costs and comprehensive benefits, external
research can play an important role.
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How to foster sustainability. While several health center networks
have exhibited important successes in encouraging health center IT adoption,
none indicated that they were moving comfortably toward self-sustainability
under their current course. Even the most successful networks investigated
struggled with the question of how to maintain an adequate level of resources
as well as an exclusive focus on health centers while moving towards a
self-sustaining financial model. The vision for some has been to expand to
include non-health center providers as customers. Future analysis may focus
specifically on options for achieving self-sufficiency working within market
conditions. Pay for performance or other payer driven incentives specific
to the use of EHRs may offer opportunity for these analyses.
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Considerations for future research. Because efforts were made to
identify “leading edge” networks for this study, findings presented
here do not reflect the state of the “average” health center. However,
as the first study focused on health center use of IT generally, we have
identified important methodological and substantive considerations.
Methodologically, it is clear that any future efforts to assess IT use among
health centers should consider an array of relevant respondents, from network
leadership and staff, to administrative and clinical leadership at health
centers. Because we found that health centers use a variety of models for
staffing in IT, with relatively few employing a CIO, identifying appropriate
respondents who can speak to how day to day technology decisions are managed
will continue to pose a challenge that will need to be addressed on a individual
basis with each health center.
Our study also highlights the important issues for focus in future studies
of IT use among a representative sample of health centers (e.g., future efforts
to survey health centers). For example, it will be critical that any such
study consider a wide range of the structural barriers and enablers identified
here such as history of network participation and collaboration with other
health centers and access to executive level IT management staff. In
addition to staffing and capacity, it is clear that gaining clinical benefits
from health IT implementation requires sustained investment at multiple stages,
from planning, to workflow and culture re-design among clinicians, implementation
and ongoing improvement. As such, it will be critical to understand health
centers’ plans for financing IT implementation and determining the scope
of necessary outside investment. Finally, future research should ask how
health centers make IT investment decisions to identify the extent to which
health centers are equipped to assess the value of these investments relative
to their mission.
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