As described above, we applied a tiered-qualitative approach described in the original proposal. Overall, our approach hinges on seven detailed case studies conducted in targeted geographic regions where we spoke with health center stakeholders in person and over the telephone regarding their experiences with IT implementation and use. Prior to the case studies we conducted an environmental scan including a review of printed and published materials, discussions with thought leaders, and a detailed summary of practice management systems employed by health centers.
Findings from the environmental scan were used to develop the specific approach for case studies and to identify potential sites. Following each case study we submitted a detailed report outlining major findings and lessons learned. Finally, we conducted an analysis of findings across the environmental scan and all case study reports and synthesized findings and methods in the current report. In the paragraphs below we describe key features of the three project phases.
Because the body of literature relevant to IT use and adoption among health centers is relatively limited, we conducted an environmental scan, completed between February and September 2003, which included review of both published and unpublished materials relevant to key study topics. Materials summarized in the environmental scan were gathered through formal searches in health services research databases such as PubMed, paired with searches of popular, non-peer reviewed publications using Internet search engines such as google.com. Searches were conducted using a range of subject-level key words crossing “community health centers” or “FQHC” with words such as “information technology”, “HIPAA”, “practice management”, and “electronic medical or health records”.
Additional sources were identified by contacting individuals at relevant organizations to gain access to unpublished information or publications that were not readily available through public sources. These organizations included HRSA, BPHC, the National Association of Community Health Centers (NACHC), state level primary care associations (PCAs) and others. Overall, we reviewed content from over 100 documents including peer-reviewed articles, market reports, program notices, government evaluations, provider association newsletters, requests for application and other relevant sources.
In addition to review of secondary sources, the environmental scan included loosely structured, one hour discussions with thought leaders in the field of IT and health centers. The 16 thought leaders included consultants working with health centers, health center staff, network representatives, associations and Federal government officials from BPHC and the Veterans Health Administration.
Finally, the environmental scan included a targeted analysis of four practice management systems that cater to the health center market. On direction from ASPE, we focused on practice management because at the time that the environmental scan was conducted in 2003, relatively few health centers or health center networks had made substantial progress with EHR — with increasing EHR activity as the study progressed. Discussion of practice management systems for the environmental scan was based on a detailed review of vendor websites and targeted thought leader discussions. The full environmental scan report is included in this report as Appendix A with key findings highlighted in the Background section of this report.
Findings from the environmental scan informed the second major phase of the study involving in-depth case studies. Site visits supporting each case study were conducted at seven communities or states across the nation from October 2003 through September 2004. Each case study entailed a series of in-person and telephone discussions with leadership and staff members at health centers, health center networks and other stakeholder organizations such as PCAs, public health departments and Medicaid offices. Thought leaders consulted for the environmental scan suggested candidate sites based on the presence of Section 330 health centers that had made progress in their use of IT as part of their local or regional network. ASPE and HRSA made the final site visit selections. Each case study represents a somewhat different functional and organizational model to allow for meaningful comparisons.
Prior to site visits, NORC staff conducted preliminary phone conversations with health center and state government stakeholders to introduce the study and identify appropriate respondents. Site visits lasted one or two days and respondents for structured discussions at each site were identified through a combination of government leads, leads from other respondents, and targeted literature and web searches. Teams consisted of at least one senior staff member and one research assistant primarily responsible for taking notes. One of the case studies, in Kentucky, involved a series of detailed telephone calls with key stakeholders but did not include an on-site component. Overall, we conducted discussions with over 120 respondents from among health center staff and other stakeholders.
Data was collected using instruments tailored to each respondent that allowed us to collect detailed, qualitative data on key topics. Each guide included background information on the respondent and highlighted outstanding questions for the team to address. ASPE and BPHC approved the guides prior to initiation of the site visits. In addition, NORC submitted technology inventory forms to health center respondents prior to each site visit as a supplement to data collected through the discussions. The forms consisted of a short table which took a “snapshot” inventory of the health centers’ networking, data and technology capacity. The data collected revealed the degrees of variation in health IT capacity based on differences in size and health IT sophistication among respondent health centers.
Exhibit 1 below lists respondent groups consulted for each case study including health centers, health center networks and other stakeholders. Network leadership generally included the President, Chief Executive Officer (CEO) or Chief Information Officer (CIO) of the network and other network leaders. Health center respondents included administrators such as the Executive Director (ED) or Chief Financial Officer (CFO) as well as information systems staff. In addition, we spoke with clinicians and other end-users of technology, such as billing clerks.
Exhibit 1: Respondent Characteristics by Case Study
| Case Study Sites | Respondent Characteristics |
|---|---|
| Oregon October 2003 (2 day visit) |
|
| Philadelphia, PA February 2004 |
|
| Virginia February 2004 |
|
| Southeastern Kentucky February-March 2004 |
|
| Boston, MA May 2004 |
|
| Southern New Hampshire May 2004 |
|
| Southern Florida September 2004 |
|
If key respondents were unavailable during the time of the site visit, the team conducted follow-up discussions with the respondent after the site visit was complete. Additional inputs to the findings from each case study included the review of documentation that respondents made available to the team during the discussions.
We queried individual health centers on their overall approach to health IT, technical capacity and systems, major uses of systems and any challenges they face in adopting technologies. Network directors were asked about the origins and organization of the network, how health IT fits into their goals and mission, and any challenges they faced or currently face in adopting systems. Other stakeholders were asked about their involvement with health center IT initiatives, uses of data produced by shared systems, and their role in future safety net health IT initiatives. Themes covered across respondents are described in further detail below.
After each case study was complete, findings from preliminary phone calls, site visit discussions and follow-up activities were analyzed and written into draft case reports submitted to ASPE and HRSA. Once comments were received, NORC revised each document and submitted it in final form. Each report drew richly detailed findings and lessons learned from stakeholder discussions. These case study reports are included in this report as Appendix B.
Our findings should be interpreted in light of the fact that we focused, by design, on early adopters of IT and health IT among health centers. While some of the barriers encountered by sites visited for this study may be mitigated over time through standards development, increased access to publicly funded capital, a more stable vendor market and better incentives for adoption (e.g., pay for performance), the majority of the challenges described in this report will be encountered by any health center that attempts to enhance their use of IT and health IT. In addition, we note that these challenges may be greater for health centers not studied here because they likely lack the characteristics that made this group early adopters in the first place.
Following a discussion of background, we present findings both at the health center network level and the individual health center level and explore different, but viable models for the adoption of IT in health centers. We describe the health centers’ experiences with implementing and using IT systems, including the various barriers and incentives affecting the implementation of such systems. Our conclusions focus on benefits and challenges associated with health center network activity, critical success factors for health centers implementing IT, special lessons learned from early experience with EHR and issues for future study.
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