As mentioned above, in conducting case studies, we visited or spoke with a total of 38 centers in seven different locations across the United States. Health centers visited differed substantially in scope of practice (number of patients and sites), management structure, and culture. While some centers we visited were large operations that treat more than 200,000 patient encounters annually and have deployed state-of-the-art practice management and EHR applications, others were small-scale practices supporting a few part-time providers, fewer than 2,000 annual encounters, and basic computing resources.
In this section we present project findings related to 1) health centers’ overall approach to IT, including planning and decision making strategies, resources dedicated by health centers to IT, and HIPAA compliance issues; 2) health centers’ information systems infrastructure, including hardware and software capacities as well as use of vendors; and 3) health centers’ primary uses of IT and health IT systems such as practice management and EHR applications. Before describing findings in each of these areas, in the bullets below we provide some key background information related to illustrate the differences among 38 health centers that were consulted as part of this project.
We queried health center leadership on how their center made decisions regarding IT and the level of priority afforded to IT in the organization overall. We also asked specifically about trends in IT spending and recent changes in their staffing and organizational approach to IT. Overall, we found that health centers’ approach to IT is evolving along with changes in reimbursement for health care delivery and regulation related to maintaining and exchanging health data. In addition, we found that health centers have increased their focus on disease management and quality improvement leading to increased demand for health IT.
IT Planning and Decision Making. Case study findings indicate that there is substantial variation in the extent to which individual health centers develop strategic plans around IT investment. While nearly all center leadership recognized the need for such processes and noted that a having a strategic vision around these investments was desirable, many smaller or mid-sized providers cited a lack of the resources (both financial and personnel) necessary for such planning. These smaller centers indicated that IT decisions were generally made on an ad-hoc basis, often when they were “forced” to make a change because the vendor discontinued support for the application they were using.
Larger centers were more likely to have developed formal strategic planning and investment initiatives. For example, one large Virginia health center’s Board of Directors had formulated — on the recommendation of the center’s CIO — a strategic plan that prioritized re-allocating budget allotments to permit systems upgrading, staff training in IT, and pursuing investment in EHR. A Philadelphia health center reported going through a lengthy RFP process for selecting a practice management vendor and indicated that IT represented the top budget priority for their center moving forward. Overall, however, we found that this level of planning represented the exception rather than the rule for health centers.
For nearly all the health centers visited, the Board of Directors made the final decisions on IT investments. In health centers with a dedicated CIO or manager-level IT staff (only nine of the 38), recommendations for investment generally came from these staff members and were developed out of some type of systematic planning process. In other centers, recommendations for IT investments were made by committees comprised of the health centers’ administrative, financial and clinical leadership. Increasingly, health centers reported relying on networks to make (or help them make) major IT decisions.
Budget for IT. Health center IT budgets vary substantially. For example, some health centers indicated that IT was the most rapidly growing segment of their annual budgets, while one rural health center in Kentucky reported having no funds to spend on IT and relying on a completely paper-based office. While it was not feasible to systematically collect financial data from each health center, on average, health centers reported spending between two to five percent of their budgets on IT. Respondents frequently indicated that during periods of early ramping-up in information systems investment, IT budgets dramatically increased for a short time.
Funding Sources. We found that health centers fund IT investments from multiple sources. Basic expenditures such as hardware, office software and connectivity come out of the centers’ institutional Section 330 grant, but nearly all of the health centers we spoke with had access to IT-related Federal or state grant money through their regional network. As described in the background section, the Federal government maintains several grant programs aimed at supporting specific aspects of health center information technology service provision, management, and infrastructure and most health centers (33 of 38) consulted took advantage of one or more of these programs. Importantly, in two of the seven case studies, Boston and New Hampshire, private donations have been targeted towards the purchase of software licenses, which was a critical driver for EHR adoption.
Support Staff Resources. Health centers reported that recent investments in IT have largely gone toward improving staffing. Only seven centers reported having no in-house IT expertise. Smaller centers employed only one IT staff person, frequently part-time, to manage technical issues. Nineteen health centers employed between one and three IT staff, while two centers employed 10 or more IT staff.
Three health centers outsourced some or all of their IT support services to local companies, instead of employing internal staff. Some of these centers had long-term relationships with such consultants, who were involved from the beginning of the center’s IT implementations and had worked with the center to develop customizations to its practice management system. Smaller centers generally reported experiencing more problems with systems implementation and ongoing support. IT issues that would have been minor problems for a large center with on-site technical support staff could easily become major stumbling blocks for centers lacking such expertise.
As would be expected given our approach to selecting cases, we found that many health centers counted on networks to supplement their in-house IT expertise. In general, larger centers with their own dedicated IT staff tended to report having better technical support and fewer implementation and maintenance issues with health IT systems, irrespective of whether they also received support from a network.
Chief Information Officers (CIOs). Of the 38 health centers we spoke with, four had an in-house, full-time, dedicated staff member described as a CIO. Dedicated health center CIOs provided vision for prioritizing systems investment, expertise for selecting and managing IT vendors, and managerial experience for the implementation process. Five other centers had senior IT staff with titles such as “IS Coordinator” or “IT Director,” whose duties included managing the two to four support or programming staff and providing some systems investment direction. While these individuals managed other staff they often did not share decision making responsibility on the same level as health center executives. Several of the remaining centers had access to CIOs through their network affiliation.
With almost no exceptions, health centers we spoke with were working with usable hardware and adequate access to basic software and connectivity. However, reflecting the diversity of health centers’ size, access to funding, and investment priorities, we found that the overall computing environment varied considerably from center to center.
Hardware and Connectivity. In addition to reporting adequate access to hardware, including computers, monitors, hard drives and printers, most health centers we spoke with (75 percent) reported operating in a networked computing environment. Smaller, individual site health centers tended to use basic local area networks (LANs) to allow for networked applications and file sharing with limited file storage and server capacity. In some cases, these health centers were not able to provide many applications over the network and relied instead on installing some types of software locally on user computers (e.g., accounting staff had accounting software installed on their computer). These centers also had basic Internet connectivity and could access applications housed at servers outside their walls through use of virtual private networks (VPNs).
Most centers connected to the Internet or point-to-point shared servers either through a dial-up, cable or broadband connection. Many of the health centers we spoke with upgraded their infrastructure in order to access networked software. In Virginia, for example, several health centers indicated recently upgrading connectivity to the Internet in order to facilitate their use of the practice management software provided through a VPN by their network. Centers that lacked high-speed connectivity tended to be rural or smaller health centers. These centers also tended to experience a higher level of disruption in service compared to others.
Health centers with greater access to resources often used wide area networks (WANs) to create a seamless computing environment across geographically separate sites. With a WAN, health center sites could also access shared applications through their regional health center network. These networks connected to their WAN using dedicated T1 line connections and had adequate server capacity to support administrative applications as well as basic computing needs such as printing and email.
Data Management Capabilities. Several of the health centers we spoke with are maintaining or contributing to master patient indexes (MPIs). Some larger centers with in-house applications expertise were able to build and maintain their own MPI, drawing data from their practice management systems and, in the most sophisticated centers, supplementing administrative data with clinical data from EHRs. Health centers used these sources for querying for UDS reporting and to produce reports used for making management decisions.
Most of the health centers we spoke to were contributing to data warehouses external to their center, housed either in their health center network or a public health stakeholder such as a County Public Health Department. In Philadelphia, for example, the network has developed a community-wide data warehouse which extracts data from the practice management systems of participating health centers. In Boston, members of Boston HealthNet contribute administrative and clinical data to the network through extracts built from their practice management and EHR systems. These warehouses then allow network staff to produce community-level and center-specific reports on cost, utilization or, in some cases, quality of care measures.
As summarized above, we found that health centers we spoke with had a usable IT infrastructure and used a variety of applications. In the remainder of this section, we describe the uses, functionalities, vendors, and health center experiences associated with selected health center computer applications including practice management, EHR and data warehouses.
The widespread use of practice management systems stems primarily from the
systems’ capacity to improve health centers’ billing
capabilities and streamline general day-to-day management operations. Practice
management applications are built to increase organization of billing data,
catch wrong or missing data elements from encounter records, manage patient
scheduling and check-in, facilitate eligibility determination, and coordinate
the electronic submission of claims.
As one health center respondent noted, “practice management is
all about billing” — the potential for maximizing collections
and payment options is key to health centers’ widespread investment
in the systems. As discussed earlier, health centers’ reporting
requirements (e.g., UDS reports) are also an important impetus for the use
of practice management. Most practice management applications marketed
directly to health centers have pre-designed reports meant to satisfy UDS
reporting requirements.
Practice management vendors. The most commonly utilized products for practice management applications in centers we visited were Epic (eight centers), Medical Manager (nine centers), GE’s Millbrook (four centers), and HealthPro (five centers). Among the few centers that had implemented an EHR, WebMD and Logician were the most frequently used. Consolidation between vendors, detailed in the environmental scan, is common. In the past few years, WebMD has acquired both Medical Manager and HealthPro. Occasionally consolidation creates difficulties for health centers who have invested in one system only to see it bought out and upgraded — sometimes leaving the health centers in a position where they are unable to afford the new version but are without support for their existing system.
Scheduling. Practice management scheduling functionalities were widely reported to be of good quality and extremely valuable to health centers. Many systems allow for double- and triple-bookings to accommodate transient patient populations and health centers were satisfied to have the ability to schedule patients to a specific examining room and provider. Most systems also target concerns specific to health centers. However, some health centers had complaints regarding the usability of the scheduling module included in their practice management application, indicating that it was difficult to view data on missed versus completed visits on the schedule itself.
Billing and accounting. Health centers generally indicated that their system’s billing and accounting modules were a significant improvement over prior systems they used. Claims are typically generated, sent, and reimbursed far more quickly with sophisticated practice management systems. Most applications pre-screen claims before they are sent out in order to catch coding errors — some health centers reported that their systems occasionally fail to catch wrong or missing data, resulting in large increases in accounts receivable and decreased payments until billing glitches were fixed, but most respondents expressed high satisfaction with billing functionalities. One respondent noted that “Commercial payers have never reimbursed as quickly as they do with the [new] system.” In addition, all practice management systems have also been designed by their vendors to streamline compliance with HIPAA Electronic Data Interchange (EDI) regulations.
Electronic claims submission. Some practice management systems also support electronic claims submission capabilities. In the health centers that made use of this functionality, we heard many positive reports about the systems’ success at making accounts receivable and cash flow more predictable, as well as about built-in logic to detect coding errors. However, not all systems’ billing formats accommodate Medicaid or other payers’ electronic submission requirements. Additionally, some payers have not set up a system to receive, process, and remit electronic billing and payments.
Reporting. Reporting capabilities are a key aspect of practice management systems. Health centers generate a wide variety of reports, from the basic to the very complex, and practice management systems are designed to accommodate a range of needs. Although most case study respondents were enthusiastic about the better quality and easy access of data managed in their system, some indicated that the reporting modules are not always user friendly. Designing and generating custom reports requires use of specialized applications such as Crystal Reports, which require a significant level of training to master. Because health centers often do not employ staff with these skills, they rely largely on networks or vendors to design needed reports, at substantial additional cost, delay and inconvenience.
Overall, the role of and rationale for practice management systems is clear: The applications are ubiquitously reported to be superior to the health centers’ prior systems; the return on investment from billing improvements is considerable; and HIPAA compliance is ensured by the vendor. Respondents agree that most functions perform smoothly and that the systems have made a significant difference in their accounts receivable, reporting capabilities, and day-to-day operations.
However, health centers still struggle with some functionalities and interoperability issues. Many cite difficulty with billing formats that accommodate Medicaid or other payers, and reliable, convenient and customized reporting can be difficult to obtain. Those centers with in-house technical staff trained in reporting software, as well as those in highly centralized networks with access to outside reporting expertise, tended to fare better with their systems’ reporting functions. In addition, most practice management systems are not interoperable, creating problems for health centers attempting to build a common data warehouse, given that custom-built interfaces are expensive.
Lastly, health centers respondents emphasized the importance of systems support and vendor management. Health centers that have responsive relationships with their practice management vendor are far better able to customize their systems and address problems, which greatly enhanced their overall implementation and daily use experience. We found that individual health centers often find it difficult to obtain a desired level of service from vendors. The considerable flux among vendors and products, discussed earlier, also presents a challenge.
At the start of this project, EHR was rare in health centers, but we witnessed increases in EHR investment as the study progressed. Three of the seven network sites we visited had begun the process of rolling out EHR systems in 2004 and all other health centers we spoke with expressed support for adopting EHR in the near future.
The EHR systems utilized by case study respondents provide a wealth of valuable clinical functions: the systems facilitate automated clinical assessment with built-in reminders for specified preventive and diagnostic services; allow for electronic communication with pharmacies and clinical laboratories; automate coding of clinical procedures, diagnoses and patient instructions; and support an electronic progress note. Some systems also notify providers of adverse medication interactions and facilitate patient tracking, diagnosis assistance, and electronic document and image management.
Health center respondents we spoke to that had implemented an EHR reported positive experiences with their particular system. For these health centers, the decision to implement EHR was aimed, to some extent, at improving the practice’s efficiency, workflow, and physician productivity. However, health centers focused on mission-related incentives to adopt EHR such as quality of care, effective management of chronic illness, and improved continuity of care. Although financial return on investment (ROI) may come in time, health center staff noted that financial gains, relative to systems costs for EHR, are difficult to demonstrate at the outset of implementation.
EHR vendors. Fewer EHR products are available on the market than are practice management products. The EHR vendor products used by this project’s respondents were GE’s Logician and WebMD’s OmniChart/OmniDoc, as well as the Dentrix oral health EHR. Most EHR systems are built to integrate with a particular practice management system marketed by the same vendor, and do not interface with other systems well. For example, to share data from different proprietary EHR systems or separate EHR and practice management systems, some health centers had resorted to building customized interfaces or re-entering data, both of which are frequently costly approaches.
EHR rollout process and training. Health centers’ approach to user training and EHR implementation varied considerably. Some networks opt for a slower, more deliberate approach than others. In Florida, which has opted for a slower approach, providers begin using the system with a small number of patients per day and gradually add more patients transitioning eventually, to exclusive use of the EHR. They report that this method facilitates take-up and limits productivity loss associated with the transition.
Other networks, where entire health centers were switched from paper to EHR overnight, reported adjustment periods of up to six months and planned for dramatic reductions in productivity during the initial roll-out. In all cases, staff and provider training was intensive early during roll-out and the first several months of using EHR. In some cases, EHRs were rolled out on a site by site basis within a single health center. This would allow each health center to address problems and ensure usability in a single setting prior to moving forward with a broader center-wide implementation. Respondents noted that providers transitioning to EHR almost uniformly grew to appreciate the systems’ benefits over time, in large part because of improved access to key data from the patient chart.
In many cases the roll-out model for EHR was influenced by factors of expediency and feasibility. For example, while the gradual approach employed by health centers in Florida proved beneficial according to respondents, they took this approach, in part, because health centers pulled together funds to buy software licenses one or two at a time (a combination of health center and network money was used to purchase the licenses).
Efficiency and productivity. Increased clinical efficiency and provider productivity were frequently cited as benefits of EHR. New Hampshire respondents reported that the piles of paper records previously taking up space on the physicians’ desks have been eliminated, making workflow more efficient. Transcription costs are also gone. Although New Hampshire and Boston health centers acknowledged experiencing some slowdown in provider productivity during implementation, most centers reported that as providers have gained familiarity with the systems, they have begun seeing similar numbers of patients as pre-implementation. None of the Florida health centers reported major problems with providers becoming comfortable using the EHR system after limited training and use. A provider from one health center noted enthusiastically that EHR has decreased the time it takes for him to review a patient chart.
Access to data and system stability. Both clinical and administrative documentation were reported to have improved dramatically with EHR. Many health centers agreed that EHR has improved the content of their medical records and the accessibility of reliable patient information. The systems allow each provider at a health center, or all health centers in a network, to generate reports assessing the progress of vulnerable patients (such as diabetics). One health center emphasized that the electronic reporting functionality has made it easier to complete and verify UDS reports. Providers in Florida also appreciated the ability to remotely access patient laboratory results and medications. One Florida health center reported that remote access to patient data was especially valuable after a hurricane forced the center to temporarily close. During this time, the health centers’ providers were able to treat their patients from an entirely different provider site with complete access to patient records.
Improvements in patient safety and care processes. Respondents reported important improvements in quality of patient care following EHR implementation. Health centers noted that electronic patient charts are far more legible than handwritten notes, reducing potential for error. For New Hampshire centers, medication management has been enhanced, lab results are now automated and more quickly accessible, the rate of compliance with screening exams for all patient populations has improved, and routine patient follow-ups occur more frequently. EHR systems with a tracking component improved outcomes for some health centers by systematically prompting follow-up for patients with chronic illness or patients indicated for diagnostic screening. At one Boston health center, follow-up features helped bring the mammogram return rate up to 80 percent. Other health centers have benefited from the e-prescribing function, which led to a reduction in the unsafe use of drugs that interact unfavorably with ACE inhibitors.
Links with hospitals and laboratories. EHR-facilitated electronic linkages with labs and hospitals have proven valuable to health centers. In Boston, the EHR has enhanced coordination of care between the hospital and health centers and increased the availability of patient information. In New Hampshire, linkages between the network’s members, local hospitals and a diagnostic testing facility allow the health centers to obtain encounter information when their patients visit one of the participating hospitals or need a routine laboratory test. However, these interfaces currently work only in one direction (the network’s IT system captures electronic data from the hospital and laboratory systems and imports it into the EHR).
Clinical outcomes improvements. Although many respondents were hesitant to point to concrete clinical outcomes improvements stemming from EHR implementation, some reported observing important improvements. For example, one Boston health center cited that after six months of reports and tracking of the diabetic population through their EHR, their HgbAlc measures decreased from 8.6 to 8.01 and the patients’ blood pressures had markedly improved. A Florida health center described a similar experience during the months following implementation. Because all of the EHR implementations studied as part of this project are at their early stages, respondents indicated that they expect to monitor and report on more tangible improvements in clinical outcomes in the coming years.
Barriers and challenges. Costs, training, and provider comfort remain the primary barriers to EHR adoption for most health centers. For all the reasons described above, EHR systems are prohibitively expensive for the average health center and those we spoke with that had implemented EHR noted that they would never have been able to do so individually — network membership provided the financial resources to invest in and support such sophisticated applications. Training providers and other staff to use EHR is an ongoing and costly process, one that networks are generally in a better position to coordinate.
Health centers also report that provider buy-in and the presence of clinician champions are extremely important for successful EHR implementation. Clinician champions at health centers who understand the potential for EHR to greatly improve the efficiency and quality of care and are willing to put in the arduous effort necessary for working with skeptical fellow clinicians to redesign care delivery are invaluable to such efforts. Providers’ learning and productivity curves can be slow during the implementation process, but most see the benefits of using EHR including improved efficiency and decision-support.
Costs and benefits. Health centers implementing EHR reported seeing immediate benefits. Respondents noted improved clinical and administrative documentation, better quality of patient care, greater reliability around patient records and services, and a variety of process and outcome benefits. Health centers also acknowledged the substantial cost associated with EHR. Aside from the financial cost of software licenses, health centers reported other significant start-up costs including procuring appropriate hardware and connectivity, customizing and designing the initial implementation of the software, building clinician buy-in and training users.
In addition, there are the ongoing costs of reporting, analysis and change management necessary for using EHRs to improve care delivered. Even in the most successful implementations, we found that robust buy-in and benefits from EHR implementation were experienced as a result of ongoing, detailed engagement and investment on the part of both IT and clinical staff to design, discuss and refine the EHR functionality and settings. Initial loss of provider productivity during the first six months after an “overnight” implementation is another type of start-up cost associated with EHR.
Respondents also acknowledged the difficulty in quantifying ROI from EHR implementation. While many feel strongly that the systems represent important savings through health benefits and decreased utilization over an extended period of time, health centers typically did not have adequate data to determine whether EHR has resulted in cost savings at an institutional level. Respondents pointed out that it is difficult to tie a dollar amount to some core benefits like the replacement of illegible handwriting with typewritten notes. Some New Hampshire centers reported that quality improvements hastened by the EHR have resulted in increased provision of services for which payers provide little or inadequate reimbursement. Respondents expressed optimism that the ROI was significant, but hard data on whether using EHR saves more than it costs health centers is not available at this time.
Two of the case study entities were actively involved in building and populating a data warehouse using practice management and EHR data. Respondents from both sites expressed enthusiasm about the potential of data warehouses for improving provision of diagnostic and preventative services to vulnerable populations, generating reports to inform management decision making, public health policy and research. Some respondents indicated that data warehouses are particularly useful given the lack of other sources on health care utilization and costs specific to the uninsured. However, building and maintaining an effective data warehouse presents difficulties for many health centers: applications across providers are usually not interoperable and developing interfaces between them is expensive and difficult, which poses problems for networks that look to build data warehouses that combine data from several different practice management applications. Other ongoing challenges include assuring data validation/integrity and non-duplication of patient records, as well as the need to program new extracts following practice management system turnover.
In addition to practice management, EHR and data warehouses, we found that health centers used other specialized computerized applications to track specific clients and services. Often, these systems were homegrown databases constructed using Microsoft Access or other common database tools and serving functions associated with specific funder requirements. Health centers involved in the BPHC State and National Health Disparities Collaboratives made use of Federal and state-developed disease registries, including the Patient Electronic Care System (PECS) and the Cardiovascular/Diabetes Electronic Management System (CVDEMS). Centers involved in the Disease Collaboratives are required to enter and submit data on a monthly basis, which they do through PECS, for their population of focus, such as diabetics.
Health centers involved in the Women, Infants and Children Program (WIC) also used specialized software called the Immunization Registry Information System (IRIS) to track immunizations provided and to contribute data to a community-wide registry. Of the health centers visited for this project, four reported using PECS, three used IRIS, and one used CVDEMS. Several health centers also built their own patient information databases using Microsoft Access, to track patients, conditions, and services rendered.
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