Exhibit 4: Dimensions of Network Variation
As mentioned above, case studies focused largely on the activities of leading edge health center networks that had demonstrated some progress in implementing IT across health centers in a community or region. In this section we describe case study findings on the network level. We begin by providing background on the origin of health center networks, as well as their key characteristics and functions as they relate to IT implementation. We then describe a scheme for categorizing studied networks that demonstrates the link between their structural characteristics and the networks’ functions, successes and challenges.
The efforts studied here are part of an ongoing trend toward health center network activity beginning in the mid-1990s. Although health center networks have existed in various forms for decades, several motivating factors have encouraged network formation and activity over the past 10 years. Health system changes such as widespread provider consolidation, the movement towards Medicaid managed care, and policies that require health centers to maximize collection from third party payers have created new incentives for network formation to help health centers adapt, often through collaborative adoption of IT. In addition, several Federally-funded programs, described above, have encouraged network formation and network-level investments in IT. Exhibit 3 found on Page 14 summarizes key activities of health center networks we spoke with for each of the seven case studies.
Given their common origins and requirements, Section 330 health center networks strive to achieve similar goals, ranging from improved operational efficiency on an individual health center level to improved health of the safety net population as a whole. Four of these major goals and their relationship to IT are outlined in the bullets below.
Although networks by and large form for similar reasons and with similar goals and governance structures, there are important characteristics that distinguish some network models from others. The seven networks we studied represent various organizational and service delivery models. Key areas of variation include horizontal versus vertical collaboration, the extent to which networks have centralized functions previously operated at the health center level and the role of partnering community health stakeholders. We found that these structural components of health center networks often drive prioritization of network objectives as well as key challenges and success factors. An overview of networks investigated and key activities of each are summarized in Exhibit 3 below.
Exhibit 3: Health Center Network Overview
Networks Investigated |
Network Model | Key Partners and Members | Ongoing or Planned Activities | Major Revenue Sources |
|---|---|---|---|---|
| Oregon Community Health Information Network (OCHIN) |
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| Health Federation of Philadelphia (HFP) |
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| Community Care Network of Virginia (CCNV) |
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| Southeastern Kentucky (SKYCAP) |
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| Boston HealthNet (HealthNet) |
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| Community Health Action Network of New Hampshire
(CHAN) |
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| Health Choice Network of Florida (HCN) |
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Networks studied exhibited a variety of business and operational models. In the paragraphs below we describe key aspects of network governance and partnership models as well as the major functions health center networks undertook.
Formal governance. We observed a relatively consistent formal governance model across the networks we investigated. These networks are typically governed by a Board of Directors comprised largely of leadership from their member health center organizations. As such, the activities of health center networks, under most circumstances, are controlled by health center Executive Directors. In some cases, respondents indicated that larger health centers that contribute more resources to the network wield greater influence on the Board of Directors than other health centers.
In addition to the Board of Directors, some networks use a series of committees, comprised of both network and health center staff dedicated to specific network priorities or functions. For example, networks that worked on EHR implementation such as Boston HealthNet and the Florida Health Choice Network (HCN) tasked clinical committees and workgroups with reviewing and customizing software prior to roll-out. In addition, networks that provide centrally maintained applications usually have an IT committee where support issues are discussed. In addition to making recommendations to the Board and leadership, committees serve as an important forum for health center staff to provide feedback directly to the network, discuss problems and share lessons learned.
Executive leadership. A feature common to most networks visited is the presence of a single, network-level entrepreneur who served, in name or function, as the network’s CIO. This individual, usually someone with an extensive background in IT from larger provider systems or staff model managed care organizations, provided expertise, leadership and vision around IT not accessible to most independent health centers. In most successful cases, this individual works with health centers to develop a program of collaborative activities, to procure and manage IT vendors, to establish a revenue model using a combination of health center contributions and outside funding, and to attract technical staff necessary to support network activity.
Evidence of strong CIOs was found in the most centralized networks including the Oregon Community Health Information Network (OCHIN), Florida’s HCN and the Community Health Action Network (CHAN) in New Hampshire. Health centers in these networks were very familiar with the CIO and often contacted that person directly when they required assistance. They emphasized that the CIO champion was a crucial factor in providing the impetus to move the group to adopt clinical systems. Typically, health center executives who sit on the Board of Directors are responsible for final sign-off on all network investments. However, these Boards rely heavily on the network leadership to present analyses and recommendations that drive these decisions.
Integration model. We found that health center networks varied considerably in the extent they functioned as integrated decision-making bodies where systems decisions affecting individual health centers were made on the network level. For example, at the Health Federation of Philadelphia (HFP) a process to select a single networked practice management application led only to the selection of a “preferred” application with health centers opting to go on their own rather than give up that level of control to the network. Instead, HFP decided pursue a data warehouse project that would integrate data from individual health center systems.
On the opposite end of the spectrum, HCN in Florida was able to achieve agreement from its core members to hand over control of all of their software applications, data and financial operations (including billing and accounting) to the network and operate under a true shared CFO/CIO model. We found that the level of integration that networks were able to achieve relates to a number of factors, including how they are prioritizing objectives of network formation, the type of partners involved and the historical relationship between partnering organizations. Each of these issues is explored below.
Collaborative history. Well integrated networks were often located in communities that had a more collaborative history than others. CHAN’s health centers, for example, credited their success in adopting a robust system to their small size and highly collaborative environment. Health centers in Boston reported a long history of working together and cooperating with safety net hospitals even while they engage in some competition for patients.
In some cases, such as HFP, networks have been unable to forge member consensus around single applications for practice management or EHR or to convince health centers that these applications are best supported on the network level. Some health centers in Philadelphia acknowledged that there is some reluctance to collaborate because of underlying competition among health centers. In these cases, the networks focus on providing general guidance to health centers and fostering collaboration. Such networks also often work to integrate data from across health centers using interfaces or manual data entry.
Horizontal vs. vertical integration. Most of the networks we visited were horizontal collaborations among ambulatory primary care providers, forming around regionally located health centers, many of which have prior relationships with one another. Within these horizontal collaborations, however, there can often be one member that leads in terms of contribution to the network. This was the case for both OCHIN and HCN. In other cases, regional primary care associations were the convening force that brought health centers together and serve as the center of gravity for the network.
Boston HealthNet and the Southeastern Kentucky Community Action Program (SKYCAP) are key exceptions to the mode of horizontal partnerships. Boston HealthNet is the only true vertically-integrated network we visited, with Boston Medical Center (BMC), the major safety net hospital in Boston that formed after the merger of Boston City Hospital and Boston University Medical Center, providing a strong anchor for the network. BMC, given its resources as a large inpatient institution, often shaped network decisions such as adopting the EHR system being used at the hospital. BMC also has substantial incentive to bring together a coalition of health centers and invest in network development as health center referrals represent a large portion of BMC admissions.
SKYCAP represents a different model where both health and social service providers are connected in a loosely organized structure. Although, the SKYCAP program includes both ambulatory clinics and hospital Emergency Departments, we did not find evidence in this case that including multiple provider types increased incentives for network participation or investment.
Public health involvement. As mentioned in previous sections, several networks forged horizontal partnerships with the wider public health community, such as with Departments of Public Health or Medicaid Managed Care insurance providers. OCHIN and SKYCAP demonstrated the strongest ties to public health stakeholders, attempting to exchange data with these stakeholders with the ultimate goals of improving the tracking of disease outbreaks and other public health trends, and coordinating care among various providers including health centers, hospitals and public health departments. While public health stakeholders were often involved in the consortia of such networks as HCN, OCHIN and CHAN, models of streamlined data exchanged between public health and health centers had not yet been achieved.
Overlapping in networks. In investigating the seven health center networks described in Exhibit 3 above, we came across additional networks engaged in similar activities in the same general geographic area. In some cases, these represented sub-networks or smaller collaborations within networks that were based on historical partnerships among a smaller group of health centers (usually two). This occurred, for example, in Oregon, where two OCHIN health centers were funded by the BPHC for collaborative activities under an organization called Community Health Network of Oregon (CHNO) and some Boston HealthNet health centers located in Boston’s Dorchester community shared a single practice management system.
In other cases, these networks operated on a similar scale as the network we investigated, but in a slightly different geographic region and using a different model. For example, in addition to HCN, we noted the presence of the Community Health Center Alliance (CHCA) in Florida, which provides a networked practice management application and data management capacity for health centers slightly north of HCN’s core health centers. CHCA is a less integrated model for collaboration, offering fewer centralized services to health center members. In the case of Virginia and New Hampshire, other health center networks (the Richmond Enhancing Access to Community Health Project and New Hampshire Community Technology Partnership) had missions that were potentially complimentary to the ones studied, but we found little evidence of collaboration among these networks at the time of the case study.
We observed a clear link between network characteristics, described above, and their functionality, with less centralized networks performing fewer services and exhibiting less likelihood of adopting shared systems. For example, less integrated models observed in HFP and SKYCAP faced both financial barriers and lack of buy-in for integration from health centers. These networks served largely as a forum for health centers to convene and communicate with one another. The following paragraphs highlight the many functions that the studied health center networks served, identifying the operational models more or less conducive to specific functions.
Coordinating and convening. As mentioned earlier, many health centers entered into networked relationships to garner better market power for the health center community. Therefore, one of networks’ main functions is to convene leadership across health centers to identify priorities and common needs around IT. Respondents across all sites praised their network’s ability to convene health centers to share best practices in application implementation and use.
Networks also served to represent the needs of their health consortium to negotiate with vendors, to leverage funding opportunities and to lobby resources for health centers in relation to other safety net providers. This is especially applicable in networks which included a large inpatient institution, such as Boston HealthNet, where the network was able to lobby for resources from the safety net hospital using the health centers’ combined leverage. However, we also saw the HFP network take on that function, representing health centers at city-wide coalitions and acting as an advocate for health centers with Federal, state and local governments.
Vendor evaluation and group purchasing. Once networks identified a common need and technology solution, network staff usually initiated the vendor selection and evaluation process. In some cases, such as OCHIN and CCNV, the network determined system requirements and wrote a formal request for proposals, evaluated responses and selected vendor finalists to demonstrate their product. While this process involved input from stand-alone health centers, network staff spearheaded the task using pooled resources. In other cases, the vendor selection process was more informal. For example, staff at SKYCAP worked directly with a local vendor to develop a customized electronic client tracking software.
Network staff often took on negotiations with vendors to secure an affordable and reliable system for their members. Through this method, networks were often able to acquire certain customizations (e.g., interfaces) that member health centers would need due to disparate IT capacity or configurations. In addition, some networks secured training and system maintenance add-ons from vendors based on their size and skill in negotiation. After our visit, OCHIN successfully acquired a state-of-the-art EHR at a price markedly lower than an individual health center could have negotiated.
Centralized IT implementation. Relatively centralized networks initiating shared systems provide a high level of support to health centers during initial startup and in maintaining remote access to network applications. Networks rolling out these systems expressed a great desire to ensure that the systems were implemented successfully. Boston HealthNet and CHAN, for example, deployed their EHRs following large-scale private donations earmarked for the purchase of EHR software licenses. With license costs subsidized, the network targeted its resources towards procuring network staff to manage the implementation of the technology in member health centers, and providing additional staff, training and IT expertise to facilitate a minimally disruptive implementation. Other networks, such as OCHIN, provided some support to their health center members during implementation by sharing network staff among health centers.
Training and user support. Networks provided critical IT support for those centers who did not have their own dedicated IT staff or whose staff were not adequately trained to support some network applications. In two of the networks visited, the vendor agreed to provide support to member health centers by making available their system experts when troubleshooting was necessary. Several networks provided a HelpDesk function to centralize the daily IT support that centers need during and after implementation of a major information system. In two cases, networks purchased staff time from the vendor for a certain period during and after implementation to assist and train health center staff in using the applications.
Hosting networked applications. Often, individual health centers are unable to provide the space and expertise required to store and maintain servers and to host applications. Networks take on this role in a variety of ways. CCNV, for example, relies on a vendor data center while OCHIN and HCN host and maintain their own data servers. This allows the health centers to access vital applications through a desktop PC, with an internet browser and connection, without physically maintaining the servers. The network assumes the burden of ensuring proper maintenance of the central servers. Costs can therefore be spread among multiple parties.
Data management. As mentioned earlier, one of the main goals of all the networks was to facilitate reporting on grant activities as well as to facilitate the production of customized reports on other areas of interest. Networks sought to enhance health centers’ access to their own vital, administrative and clinical data. Networks that administered shared applications made data from these applications available to health centers centrally. In addition, some networks regularly generated standard health center-level and network-level administrative reports and provided these to the centers. To support development of other reports, some networks helped health centers to collect, clean, and transform data housed in disparate applications to develop a common data warehouse. Many of the networks that created data warehouses described this set of activities as among their most complex and time-consuming.
Centralized administrative functions. As mentioned earlier, the networks visited primarily help health centers achieve administrative benefits through the enhanced use of IT. Networks providing centralized practice management applications often expanded their scope of services to include functions such as centralized claims processing. Most networks offer a liaison service to a claims clearinghouse capable of handling electronic claims submissions in a HIPAA-compliant manner. The use of clearinghouses aims to reduce the administrative cost of submitting paper claims and decreases the turnaround time on processing. Of networks investigated in this study, HCN provides the best example of centralized administrative functions, where a network-level executive serves as the centers’ Chief Financial Officer. The Community Care Network of Virginia (CCNV) also provides some centralized administration through a central billing office that several member health centers use.
Although all networks investigated shared similar goals and basic governance models, we observed important variations in the path chosen to achieve network goals. In particular, networks differed widely in terms of their financial and operational model (level of integration, level of financial contribution from health centers) as well as their approach to partnerships. We found that, in many cases, these variations drove the types of functions and services provided by health center networks or the way in which different functions were prioritized.
In order to illustrate important differences among network models and demonstrate the relationship of these differences to actual network function, we divided the seven health center networks investigated as part of this study into three groups described in greater detail in the bullets below. Health center characteristics relevant to each of these models are presented in Exhibit 4 on the following page.
All thought leaders and stakeholders consulted in producing this report agreed on the importance of focusing on health center networks as the locus of advanced health center adoption of IT. While the reviews from health centers regarding their network participation were not uniformly positive, most reported important benefits that networks have over individual health centers in leveraging IT. For example, respondents from HCN indicated that they can relatively easily convene senior executives from WebMD to negotiate around functionality and price, and usually get a swift response from the vendor when problems arise. HCN respondents also noted that they have worked extensively with WebMD to customize the application for health center uses and that the relationship has helped WebMD’s efforts to increase market share among health centers. The health centers involved agreed that it would be difficult to see WebMD developing this same sort of partnership with an individual health center.
Some reviewers have referred to selected health center networks as application service providers (or ASPs). ASPs are third-party organizations that manage and distribute software-based services and solutions to customers across a wide area network from a central data center. Unlike typical ASP’s however, health center networks investigated were in the majority of cases governed by the health centers themselves and did not operate as for profit-enterprises organizationally independent from their customers. While in the private sector market, ASPs are decentralized organizations providing a menu of services at fixed prices remotely, health center networks tend to work very closely with individual health centers and develop user fees and dues that accommodate health centers’ financial circumstances. Finally, beyond providing software and data management services, networks often provide additional services such as billing and accreditation. Among health centers visited for this project, the majority are investing in IT, at least in part, through membership in their local network.
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