The Office of the Assistant Secretary for Planning and Evaluation (ASPE), in close collaboration with the Health Resources and Services Administration (HRSA), contracted with NORC to conduct an assessment of information technology use in ambulatory care health centers whose funding is administered by HRSA’s Bureau of Primary Healthcare (BPHC). As the culmination of that effort, this final report describes how some of the nation’s Federally-funded health centers use information technology (IT), including applications which assist in directly improving the quality, safety, efficiency and effectiveness of health care (health IT). Health centers, which provide a crucial source of medical care for under- and uninsured populations, also represent an early laboratory for health IT implementation, use and impact among ambulatory health care providers. This project assesses the experiences of certain health centers and health center networks implementing IT programs, and describes the challenges faced by both health centers and health center networks in adopting IT, achieving gains from the use of IT and sustaining those gains over time.
Findings from this study will inform efforts to improve health center use of IT and provide guidance to decision makers interested in understanding the broad potential for health IT to improve the way health care is delivered in the United States. The report begins with a description of NORC’s study methods for the project as well as a detailed background on the project’s purpose and the health center program history and environment.
Project activities were conducted using a tiered-qualitative approach divided into two separate but interrelated phases: 1) an environmental scan, and 2) a series of seven case studies focusing on a set of geographically dispersed health centers and health center consortia with ongoing IT implementation projects. The environmental scan phase involved discussions with 16 thought leaders and key informants knowledgeable about IT and the health care safety net, and a review of published and unpublished documentation. Findings from the environmental scan supplied the basis for setting up the subsequent project activities, including the selection of case study candidates.
The second major phase of the study involved in-depth case studies of seven sites around the U.S. These case studies entailed a series of meetings with stakeholders at health centers and health center networks identified as “leading edge” — those that offered the greatest opportunity for providing policy-relevant lessons learned and informing sustainability and spread of gains from IT implementation. Candidate sites targeted for case study selection were communities maintaining several Section 330 health centers, including IT-savvy health centers and networks. The final sites selected were in the states of Oregon, Virginia, New Hampshire, Florida, and Kentucky, and in the cities of Boston, MA, and Philadelphia, PA. Overall methods included meetings with 120 respondents across 38 health centers and seven health center networks. Meetings covered a range of topics, including health centers’ approaches to and uses of IT, perceived barriers and enablers to technology adoption, participation in networks, and network governance and organization. Detailed case study reports were prepared for each site describing findings and lessons learned from each site visit.
Final analysis activities, which culminated in the current report, drew from findings and themes across all project activities. Findings are discussed at two levels — the health center network level and the individual health center level. We explore health centers’ and networks’ experiences with implementing IT, and describe the different models for IT adoption along with issues relevant to sustainability, replicability and public policy in this area.
The current project will inform policy efforts to encourage the implementation of IT to achieve efficiency and quality of care objectives. Federally sponsored health centers form a key part of the nation’s health care “safety net”, delivering primary care medical services to vulnerable populations. Special data and administrative requirements, including tracking and reporting on their patient populations, maintaining patient-specific data, and supporting disease registries for vulnerable populations, make health centers a prime target for implementing health IT applications. Over the past several years many health centers have chosen to band together to form networks that provide access to these IT applications, business services and technical support. Network development has also been spurred by systems-related grant programs, many of which are funded by the Bureau of Primary Health Care (BPHC), the Agency that provides base funding for the health centers themselves.
Health centers have quickly caught on to technology’s potential for improving efficiency and quality of care. In addition to the factors described above, external trends — such as the increasing rate of IT investment in health care overall and the Bush Administration’s health IT initiatives — have contributed to the fast growth in health centers’ adoption of IT. Electronic Health Record (EHR) adoption has been especially noteworthy. Multiple health centers in three of the seven case studies had implemented an EHR between the start of our study in 2002 and completion of our last site visit in 2004. Findings presented here will assist policy makers as they seek to build on early IT adoption among health centers and other providers.
Findings from the case studies are analyzed on two levels: the health center network level and the individual health center level. Overall, the case study findings provide insight into why leading edge health centers and health center networks wanted to invest in IT and what they experienced. In doing so, the findings offer substantive guidance for ASPE and HRSA with regard to policy on IT adoption among health centers. Key themes emerged in several areas.
First, it is clear that several health center networks, formed in response to an increasing emphasis on decreasing the cost of care, have relied on the coordination of IT services as an important strategy for meeting efficiency objectives and providing value-added benefits for their members. Network models, goals, and provision of services differ substantially, with some adopting an incremental approach in rolling out practice management systems for their members and then moving to electronic health records (EHR), while others adopt EHR first or concentrate on building community data warehouses.
Core network functions include convening local stakeholders, directing vendor selections, centralizing IT implementation and support, and administrative management. Many health centers reported receiving considerable benefits from their network membership, but positive experiences were not universal and we observed that networks face ongoing challenges in maintaining buy-in from their stakeholders and ensuring long-term sustainability.
Health centers in general are increasing their centralized planning for and investment in IT systems. Access to systems is widespread, although the majority of health centers we spoke with had acquired such access through their local health center network. The predominant uses of IT include practice management systems, which are perceived to promote financial stability and efficiencies, and EHR systems, which address quality of care, disease management, and practice workflow. Buy-in for adoption of both these technologies is widespread among health centers, and satisfaction with the applications implemented among the health centers we spoke with was overall high.
In synthesizing lessons learned from the case studies, we focus 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.
Network Benefits and Challenges. Overall, findings confirm that health center networks can be successful vehicles for the adoption of IT in the safety net. Networks help health centers to finance costly technologies by accessing grant money over and above the Section 330 grants. In addition, we found substantial evidence that health center networks provide human and technology resources through economies of scale that health centers could not afford on their own. Networks offer health centers access to executives skilled at the vendor evaluation, management and procurement processes and are able to leverage market share to hold vendors to a high standard. Finally, networks serve as important forums for sharing best practices among health center members. For communities working to share data through community applications and data warehouses, the network model was particularly suitable to gather buy-in and build infrastructure for such a system. We found that network formation would not be possible without funding specific to encouraging collaboration among health centers.
In addition to these important benefits, networks face a number of difficult challenges in fulfilling their mission. Networks often struggle to meet the diverse requirements of their member health centers in terms of financial resources, IT capacity, infrastructure and vision. Successful networks featured a centralized, collaborative framework that was central to establishing a common vision and strong buy-in among its partners. Networks that focused on building applications to collect store and centrally maintain data from individual health centers faced difficult technical, financial and legal challenges. They were pressed to prove clear benefit to individual health centers in order to ensure participation and realize the goal of data exchange at the network level and beyond.
Rural networks faced especially difficult challenges in building and accessing community-based applications because of resource and infrastructure constraints. Overall, realizing robust, measurable public health and financial benefits from EHR and health data exchange remain opportunities for the future among those health centers consulted. Formal data sharing relationships among hospitals, public health agencies and Medicaid are slow in evolving and networks still require a sustained level of public funding for the training, initial implementation and ongoing support necessary to realize benefits from their software.
EHR-specific Lessons Learned. Successful early adopters of clinical technology offered several lessons for future funders and implementers of EHR. Case studies demonstrated the importance of having not only buy-in, but significant involvement from clinicians at all phases of an EHR implementation to ensure the technology’s smooth integration with clinical work processes thereby allowing clinicians to realize clear benefits from using the system. In order to support the purchase and implementation of such systems, the network required three levels of substantial funds: seed money for start-up, money to build infrastructure and transition workflow, and funds for the ongoing maintenance of technologies. The networks we studied all relied on outside funding to support ongoing maintenance and future systems purchases.
Some health centers that implemented EHR were able to quickly translate resulting improvements in patient outcomes, although the ability to accurately quantify a return on investment on the institutional level is still underdeveloped. Future safety net providers looking to adopt health IT systems may benefit from a riper environment for adoption given its recent emphasis in the policy arena. Adoption efforts would be especially enhanced by the development of data standards, more “usable” software and more available funding to consortia of community providers. However, advances will be balanced by sustained challenges of developing a collaborative and functional network model and overcoming fears of data sharing.
Critical Factors for Success. Despite the many organizational and cultural models employed by these early adopting networks, we did find several factors closely associated with successful adoption of IT among health centers. Networks that understood the relationship between clinical and administrative applications, particularly implementing a robust practice management system as a backbone to implementing an EHR, were more successful in achieving a seamless exchange of information between the two systems.
We found that more integrated networks where there was strong buy-in for shared systems generally managed a smoother implementation of the technology. More decentralized networks sometimes could not achieve consensus necessary to procure shared institution-level applications, focusing instead on combined systems such as data warehouses and external client tracking systems which have proven difficult to implement. Another important aspect determining the networks’ success was the need to build trust through strong leadership. Only those network leaders experienced in large scale IT design and roll out and highly skilled at customer service were able to implement common practice management and EHR applications across centers.
Key Issues for Future Study. This study has elucidated important lessons learned for adoption of IT, including health IT, among health centers and health center networks. A number of areas that merit further investigation to assist policy development include studying the feasibility and sustainability of promoting a network model, analyzing coordination and overlap among health center networks and attempting to quantify the value of health IT systems relative to their costs. In addition, it will be important to follow examples of successful networks as they work to wean themselves from large amounts of outside funding to support ongoing operations.
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