Discussants provided substantial detail on their experience working with the network, implementing and using health IT applications including practice management and EMRs. In this section, we summarize these experiences in the context of barriers and success factors associated with health IT adoption and use. We note that, as in prior site visits, several areas highlighted below may be considered to be both barriers and success factors in different respects.
Timeline for implementation. Some health centers indicated that the implementation timelines that they pursued for implementation of EMR and PM systems are sometimes unrealistically compressed. One health center indicated that in order to prevent complications from having data for one grant year in two systems, they set up a plan to cut over to a new EMR and PM system in January of 2008. CPH was able to negotiate with Henry Schein to purchase licenses and rights to implement the MicroMD practice management application across a series of health centers in the Fall of 2007. While health centers saw advantages to moving to MicroMD over their legacy practice management systems, most of which were inadequate, some discussants indicated that the implementation process was far too fast.
Training and support. CPH employed one trainer two support individuals using accepted approaches including “train the trainer.” Some health centers indicted the need for more support. As an example, one health center noted that staff did not receive an agenda ahead of the planned training session and that they did not receive guidance on how best to set up forms and templates. Discussants also noted limited capacity to provide support in general and that there were many questions that remained unanswered or are not answered in a timely manner.
Some expressed frustration that the support model for the EMR, which requires members to go directly to CPH, was different than the support model for practice management, where CPH is involved in coordination but not directly responsible. These discussants felt that it would be better if they were able to go directly to the vendor for all support concerns. Numerous respondents indicated that CPH staff was not always prepared or able to handle their questions. However, several noted that their biggest problems relate to connectivity losses which can be a result of an individual providers’ internet connection. Other areas of concern included the lack of use of common EMR templates across health center users and difficulty re-creating reports following software upgrades.
Expertise at the health center level. Network leadership noted that some frustrations related to connectivity and user support may be due to the lack of IT expertise and experience at the health center level. They note that many calls coming in to user support are for basic connectivity and problems with software use that are best handled through a more robust IT staffing at the center site itself. They estimate that up to two thirds of the problems related have to do with basic errors with the use of computers or connectivity and hardware problems that are the responsibility of the health centers.
Governance and collaboration. While network officials indicated that CPH is governed by a board of directors that is made of member health centers, some health centers were not aware of the extent to which they had leverage over the direction and operations of CPH and indicated they were not sure when or how often the board met to provide oversight.
Some mentioned that the focus at the network level seemed to be geared toward meeting the requirements of Greene County Healthcare whose leadership overlaps with that of CPH. Health center officials also indicated some concern regarding the strength of the collaboration across CPH members. Discussants partially attributed both turnover and distances between members health centers for the lack of a robust exchange of lessons learned and best practices across the consortium. Interestingly, not all health centers we spoke with indicated that they know that they have a seat on the Board of Directors overseeing CPH.
Relationship with Henry Schein. Health centers indicated both advantages and disadvantages to working with Henry Schein products. Most understood the value of having a relationship with a single vendor for practice management and EMR. However, some also noted the fact that these are three separate applications (EMR, PM and dental) that require external interfaces to pass data. Network leadership noted that Henry Schein is currently working on integrating the practice management and EMR application to operate as a single application by integrating the databases associated with the two applications.
Laboratory interfaces. As part of its EMR implementation CPH supported the establishment of bi-directional interfaces between clinical laboratories providing laboratory tests to member health centers and the MicroMD EMR products being employed. While health centers indicated that the lab interface was an important functionality that improved the efficiency of ordering and receiving results, they indicated that the implementation of the interface proved problematic because it does not allow automated reconciliation between the tests orders and results. This leaves health centers unable to confirm that all tests result in valid reports back from the laboratory without a separate reconciliation process. That additional reconciliation process requires staff to print out each requisition ordered via the EMR and each result reported back through the interface and manually verify that a result was received for each test.
Efficiency. Health centers noted that EMRs have helped improve their clinical documentation, but that they have also resulted in a decrease in the number of patients seen by a health center in a given period following EMR implementation. They noted that at the start of implementation, productivity is reduced on average by half. Even after a year of use, they still experience a decrease in productivity relative to their pre-EMR state. Additionally, after operations return to “normal” and all providers are fully trained in use of the application, health centers note that the increased focus on documentation occasioned by use of the EMR results in lower productivity overall.
Staff turnover. Health centers also noted challenges associated with turnover at the health center level among leadership and clinicians. One health center NORC visited experienced a near complete turnover of leadership including Executive Director and Medical Director in the midst of planned conversion to the EMR, leaving the new team feeling not well equipped to manage the implementation. In other cases, health centers noted the challenges associated with training new providers in use of the EMR as they come on board in the period following implementation and initial training.
Retaining talent at the network and health center level. Health centers noted the limited capacity for training, implementation and support of health IT applications at the network level. They noted that financial considerations and difficulty in recruiting and retaining staff could contribute to these issues. In particular, health centers gave the example of a programmer who had been employed by the network who was skilled at creating and running custom reports from the CPH data warehouse based on health center requirements who left the network when her spouse switched jobs and moved to Durham. The health centers and the network both acknowledged that hiring and retaining high caliber professionals in the network has presented challenges. Network leadership also noted similar or potentially greater problems recruiting and retaining IT talent at the health center level.
Lack of standard use of templates and forms for quality improvement. One shortcoming of CPH that was acknowledged by both network leadership and health centers was the lack of dedicated network-level clinical leadership to provide additional resources and support for quality improvement efforts tied to the EMR at the health center level. In particular, health centers noted that there were a number of customizations and templates and clinical reminders that they have designed and implemented individually and that there was relatively little guidance provided by network leadership regarding appropriate use of templates. For example, one health center noted that they had implemented a reminder in their pediatrics department to prompt providers treating patients with asthma to consult the patient’s asthma action plan.
While health center leaders could not gauge providers’ receptiveness to clinical decision support functionalities such as this, it is important to note that some within CPH have taken steps toward integration of QI efforts into the new health IT environment. Beyond this, network leadership indicated that while the central goal of EMR implementation is quality improvement, they have not been provided adequate resources to support clinical improvement efforts across their members. The network also noted a general philosophy of EMR use that suggests that use of an EMR is optimized when individual sites and providers are able to develop customizations and use forms that meet their particular needs.
Support for billing issues. Discussants at health centers noted some important challenges with respect to billing from the MicroMD practice management system for which the network and Henry Schein have not posed adequate solutions. One in particular relates to problems with entry of multiple types of primary payers which is a common requirement for health centers, as there may be different primary payers for their patients depending on the type of service being provided (e.g., the dental care primary payer could be different that primary payer for medical care). One health center indicated that they were not aware of a solution for this issue other than to generate offline claims. Another health center noted that there is an unreasonable lag in working with Henry Schein, CPH and the billing clearinghouse employed by Henry Schein to trouble shoot and resolve problems with unpaid claims. The example provided was of a claim where the non-payment was due to a simple inversion of a key number, but the issue took the clearinghouse and Henry Schein over six weeks to identify.
Network infrastructure. Despite the challenges and barriers described above, health centers universally acknowledged the importance of the network as a means to achieve substantial economies of scale and provide for a stable hosting and back-up environment. Most acknowledged that they would likely not have implemented EMR without the assistance of the network and that, while they experience challenges with use of the EMR, they believe that their health centers have and will benefit from EMR adoption. This is primarily due to the perceived potential for EMR to facilitate quality improvement and the increasing imperative among funders and others to demonstrate improvements in care using EMR-based reports and analysis.
Data warehouse. Most health centers noted that they found the data warehouse concept employed by the network to represent a useful approach to aggregating data and allowing for detailed analysis. They indicated that the data warehouse was a rich resource with potential for sophisticated use as part of reporting and QI. While the data warehouse contains significant amounts of clinical data (especially for Greene County Health Care, the first center to implement the EHR) use up until this point has been limited to populating center specific reports generated out of the warehouses’ Cognos reporting software and not a network-wide quality improvement or benchmarking initiative. Even so, this is a significant improvement for CPH members.
One center noted that reporting was nearly impossible before the EMR and data warehouse, indicating that their reports had included little to no actual clinical data. Additionally, this center’s peer review process benefited enormously from the increased accessibility of provider-level data. Health center leaders noted that they target a number of key measures with the primary measure of interest rotating each month. While one center described utilization of clinical data for quality improvement, health center leaders across CPH’s membership also noted some issues associated with use of the data warehouse.
These included difficulty obtaining accurate reports that are well formatted and documented now that the former lead programmer is no longer an employee of the network and difficulty importing existing data into the current SQL database Network leadership notes that health centers are often not in a position to identify what they need by way of reporting in a timely fashion and that many health centers cannot put aside the funds necessary to support substantial reporting to be conducted on a short turn around basis by the network.