This section includes a discussion of areas where the Alliance has made important progress, but where some aspects of their experience demonstrate barriers and challenges to making the most out of their health IT activities.
Technical infrastructure. One infrastructure-related challenge that was mentioned by some participants was related to a decision early on to equip some clinical workstations with a thin client desktop, as opposed to a full desktop PC. When this decision was made at two of the early adopting sites, the sites experienced poor performance with using the thin client workstations, this caused both reduced productivity and increasing user frustration. However, according to the network, this issue was diagnosed as being an issue having to do with the software and not thin client set up. The only other infrastructure issue that was mentioned was the productivity loss created by a lack of a single sign-on to workstations and applications. (This, in turn, is caused by limitations in the currently implemented version of the EMR product.) It is unclear whether "single sign" on would result in significant productivity improvement, however, our discussions suggested that having this feature would improve perceived system efficiency. Network leadership notes that some infrastructure issues that arise are inherent to the challenge of delivering centrally hosted applications through different health centers that have different network attributes.
Resistance to changes in workflow. One important change in workflow that is typically required by EMR adoption is a different approach to charting. During planning and implementation phases the Alliance noted some important differences in charting practices across member health centers. Using the older paper based systems health centers differed in the extent to which they promoted a culture of charting immediately following the patient encounter verses maximizing clinic time to see patients and charting during non-clinic hours. Use of an EMR typically requires enhanced charting at the point of care or immediately following the encounter. One health center reported having difficulty regaining their normal volume of patients because of difficulties with charting during or immediately following a visit.
This center may have been a less attractive candidate for a quality-driven EMR implementation, since other prerequisites for EMR implementation (e.g., sufficient time for an "EMR-proficient" physician to finish charting) were not in place at the time of implementation. In addition, this health center reported greater problems with the EMR user interface relative to other centers.
Cost and sustainability. As with many health centers and networks, the Alliance operates on what it considers to be a very "lean" budget, approximately $2.2 million annually. It was clear from our visit that the staff at the Alliance work extensive hours, in some cases more than twice what would be considered full time. It is not clear if this level of work is sustainable over a long-term or what level of revenue will be required to reduce the number of requirements put on staff at the Alliance. Most of the health center respondents noted that they were concerned about whether the Alliance would be able to continue providing the same level of service as they look to expand, given that current staff seems to be stretched. Also, while most health centers that participated in the discussions indicated they understood the rationale behind plans to expand EMR users supported by the Alliance, some also indicated that if the Alliance was not facing an imperative to be self sufficient, they may be more likely to ask the Alliance to take on a broader role in coordinating administrative and billing functions to achieve even more economies of scale among the core Chicago members.
Training. While extensive effort was put into training in both the laboratory and in real-clinic simulations, some discussants felt that the "big bang" approach to rolling out all EMR functionality at one time in a single site was less than optimal. Some noted that they would have preferred to rotate through a site that was using EMR for a period of time before having to adopt it in their home site. One unsolved challenge to date has been the ability to find a training approach to ongoing "advanced/special topics" training for the system that staff will consistently devote the time to attend. It has been much easier to accomplish initial training efforts than to find a way to help the users continue to find ways to gain ever increasing value from the vast functionality of the system.
HIE and use of standards. While the staff at the Alliance expressed great optimism and interest in participating in a comprehensive, standards-based HIE mechanism, such as a state-wide Regional Health Information Organization (RHIO) or a loose affiliation for data sharing among ambulatory and acute care safety net providers in the Chicago area, to date, broader efforts to achieve local or regional HIE in Chicago have been stalled. The Alliance's Director of Operations and Clinical Informaticist noted that he is very active with the Health IT Standards Panel (HITSP) and is a member of standards development organizations (SDOs) and is optimistic that standards based exchange will occur in the region with the Alliance playing the role of leader.
The only significant RHIO-type activity undertaken by the Alliance has been in relation to a major hospital system that shares many patients with the Alliance. That hospital system is currently planning the implementation of an internal HIE, designed to let its disparate clinical IT systems share data with each other. At the urging of the Alliance, this hospital system is considering designing this HIE so that it could be opened up to external providers such as local FQHCs in the future. However, this effort is moving very slowly due to a lack of seed funding to perform the initial strategic and operational planning. Notably, we did not find evidence that health centers exchange data with each other; this is primarily due to the fact that these health centers offer parallel services to different niches within Chicago's undeserved population. To date, the Alliance has been involved in other more localized efforts, such as the bi-directional exchange of vaccination data with a state registry as well as use of lab interfaces described below.
Lab interfaces. In the context of their EMR implementation the Alliance has begun to engage in one form of HIE. Their EMR implementations involve the establishment of a bi-directional interface with clinical laboratories that serve their member health centers in Chicago. These interfaces, which support both lab ordering and integration of results with the EMR, are critical for the use of EHRs for quality improvement.
The Alliance reports that setting up interfaces with various laboratories has proven difficult due to the use of proprietary product based interfaces rather than universal standards being used by both the EMR and the clinical laboratories and the lack of commercially available interfaces that work without significant customization. Because each health center may work with several distinct laboratories, the need to create one to one interfaces between each health center, health center sites and the laboratory creates a substantial technical and administrative burden that gets considerably higher as the Alliance seeks to expand beyond Chicago.
The demands associated with monitoring interfaces once the interfaces were put into place are also considerable, as relatively minor changes in process at the laboratory side can result in orders not being received or results not being delivered or being delivered incorrectly. Every problematic transmission of laboratory results represents an often crucial piece that must be manually handled; this delays the EMR, the provider and the patient from acting on those results. Additionally, the Alliance reports that for each interface in use, on average problems arise once every other month.
E-prescribing (eRx). Notably, eRx was not an initial component of Alliance's EMR implementation. The imperative to pursue eRx increased earlier this year due to new state requirements that will require the use of tamper proof prescription paper for the transmission of prescriptions to pharmacies or, alternatively, e-prescribing. Alliance and health center staff cited the desire to move to eRx using the Centricity system to avoid the cost of tamper-proof prescriptions. However, they noted that the vendor was not able to provide this functionality in the required timeframe. In follow, up exchanges, the network has indicated that they ultimately worked with a vendor to come up with a plain paper solution to the tamper proof paper issue and that it is still not clear that the benefits of pursuing eRx outweigh the costs at this time.
Value of the data warehouse. Network staff noted that the decision to develop and employ a data warehouse was largely driven by the complex reporting requirements necessary to support quality improvement in a health center environment. The various dashboard reports referenced above are generated through the data warehouse. Although health centers are able to run reports out of their local EMR database, most indicated that they rely on the Alliance to generate reports coming from the data warehouse for tracking key performance metrics. In particular, the data warehouse allows for aggregation of data for the purpose of making baseline comparisons across health centers. In addition, discussants noted that that the data warehouse allows for more efficient analysis of specific populations as would be possible through registries. While there was substantial cost associated with designing and implementing the data warehouse, the network noted that GE was supportive of the effort. Similarly, there are some costs associated with managing the data warehouse, but most discussants referenced the data warehouse itself or its functionality as a key benefit of the Alliance's activities to date.
Supporting long-distance implementations. As noted above, beginning in 2007 the Alliance began increasing the number of health center members and provider users who are able to access EMR through their arrangement with the GE Centricity. Network staff note that they are still early in the process of supporting EMR implementations outside of Chicago. While they acknowledge the challenges associated with managing implementations from a distance, the Alliance notes that they have implemented measures to mitigate these challenges. First, they do not actively sell their services, but instead provide information to prospective members and then spend a fair amount of time evaluating prospective members to ensure that they share a basic philosophy around implementation and quality. They have also worked to employ staff that are close to the implementation site and have brought key staff from long distance members to Chicago. Still, the network acknowledges that there are unanswered questions regarding how best to integrate the SLA members and what level of integration is realistic.
Sustainability outlook. The Alliance leadership has initiated a sustainability plan. As part of this effort they contracted with an independent consulting and law firm to develop a business plan that would allow for sustainability. This business plan highlighted the need to achieve greater economies of scale to ensure that, in the absence of grant revenues, they could keep membership dues and user fees at a level that would continue to be affordable to safety net providers. The Alliance has specific goals with respect to growth in terms of members and users. While they have developed members and potential members to stay on track with their objectives to date, they note that the level of growth that they are looking for will require substantial increase in staffing at the network level.