In this section we describe key findings from our discussions with health centers both in the context of their use of health IT broadly and in terms of their association with CHCN. To frame our discussion of health center specific experiences with health IT we present Table 1 below. The table lists health IT tools used by each of the centers visited by NORC. These applications include chronic disease registries, hospital and e-referral interfaces, PMS’, an eligibility verification application (One-E-App) and lab interfaces. Additionally this table shows the i2i Tracks go-live dates per health center visited.
Table 1: Health Center Health IT
||i2i Tracks Go-Live
|LifeLong Medical Care
Hospital and eReferral Interface,
Disease Registry diabetes, cardiovascular Merritt module diabetes cardiovascular registry module
Merritt eReferral Module
||April 29, 2009
|Tri-City Health Center
Hospital and eReferral Interface,
Merritt diabetes and cardiovascular registry module
||June 22, 2009
|Axis Community Health
||Next Gen PMS,
Hospital and eReferral Interface
Diabetes spreadsheet (used as registry)
||March 18, 2009
Health Center Experience with CHCN
Health centers we visited expressed satisfaction with the CHCN network and its services. They did, however, share some information on the limitations of specific applications that CHCN helps them use. The staff at Axis Health told the NORC team that there were activities that would have been insurmountable without the help of their network. They particularly noted CHCN’s very important support for their QI activities such as helping with the acquisition of i2i Tracks and with fielding and analyzing a patient satisfaction survey that has been used regularly by the health center.
They also indicated that CHCN was a great help when obtaining NextGen as their PMS noting that they “could not be as agile without CHCN.” Specifically they felt as though they would have been less successful in negotiating with vendors and visiting centers that have implemented products they themselves were considering. Lastly, the executive team at Axis told us that having the ability to share best practices from other clinics and avoid pitfalls due to shared experience was invaluable to their center. These themes were echoed at the other centers we visited.
At the time of our visit LifeLong was undergoing their i2i Tracks implementation which was scheduled to be completed the following week. They thought that the center by center implementation approach would allow CHCN to incorporate improvements and lessons learned along the way. The executive staff at LifeLong spoke well of their QI efforts facilitated through CHCN, such as the establishment of QI measures across the network’s health centers and the overall ability to see another center perform better and to incorporate strategies that will enhance LifeLong’s performance.
The executive staff at LifeLong noted that there are advantages to acting outside of a network and that there is a tradeoff for network participation, namely the speed of decision making. They explained their need for consensus among members has perhaps prevented them from having an EHR to date. They also noted that the i2i implementation helped put them in a far better position to implement an EHR because of the work they did on workflow redesign and coding.
i2i Tracks experience and anticipated experience. While they were still early in the implementation cycle, we were able to have conversations with health centers regarding their expectations and anticipated uses of the software. Health centers expressed enthusiasm for the ability to specify and pull data on different patient panels depending on their own priorities or depending on varying reporting requirements that come from funders. They also all noted that the ability to more precisely define panels could feed into their efforts to conduct effective outreach to these groups. Finally, they were also very interested in being able to benchmark their performance to other health centers.
Health centers did express some apprehension about their capacity to use the tool effectively. i2i Tracks provides a two day intensive training but there was concern voiced at some centers regarding turnover at their center and the potential cost of conducting ongoing training to accommodate that turnover. One strategy to address this concern will be the establishment of super-users or clinical champions responsible for conducting the bulk of the direct support to new staff learning to use the application. There was also a broad concern that the tool would be so popular that they would need more licenses than they currently have.
From an implementation perspective, there was confidence at all the centers we visited that i2i Tracks would be able to interface with their labs systems. Axis explained that i2i Tracks had previously created successful interfaces with all the leading PMS software products, including their PMS, NextGen. The same sentiments were shared at the two centers we visited that use Merritt. At LifeLong i2i Tracks is being interfaced with Merritt and concurrently they are working to interface i2i Tracks with the second of their two clinical labs. Currently they have an interface with Labcorp and in the near future they will also interface with Quest.
Much of the health centers’ enthusiasm for i2i Tracks stemmed from their sense that i2i Tracks represented a better and faster way to do QI reporting and information by gathering data on activities that already take place. For example, each health center we spoke with had a pre-existing registry or set of registries that were interfaced in a rudimentary fashion with their practice management system. This situation is notably different than those where the adoption of a new QI application leads to the need to find time and resources to move forward with a set of activities that did not take place prior to the system.
Experience with Practice Management. Four of CHCN’s members use a proprietary system called Merritt as their PMS. The other three centers in the network use HealthPro, Centricity and NextGen. The NORC team met with two centers using Merritt (LifeLong and Tri-City) and one center using Next Gen (Axis). According to staff at Tri-City, Merritt is a small customized proprietary practice management system. Merritt was described as “not the prettiest of PMSs” though it does perform certain functions well and is very useful for generating HIPAA transactions and supporting electronic billing and the necessary reporting for variety of health programs. Health centers also were pleased with the level of customization allowed by the application.
The move to Merritt was precipitated by a grant from the Tides Foundation that came from Y2K funding. At the time the PMS being used was Opus, which was a Merritt predecessor. The Merritt system is hosted by La Clinica de La Raza because La Clinica was the original health center that had installed Merritt and had customized its use for over 15 years. CHCN had developed a formal business plan and contract to establish a collaborative among the health centers, La Clinica, and Merritt Software. The Merritt system is physically hosted at La Clinica with separate databases for each health center. So, the Merritt-using health centers rely on at La Clinica for implementing customizations and for help getting the system back online or when users get locked out of the system. A Merritt users group is convened among the four health centers to share experience. Also general coordination and support by the CHCN network is included in the broad set of benefits health centers get from their affiliation with CHCN.
Axis Health, which decided to go in a different direction with their PMS, believes that their recent move to NextGen will help them implement new technologies like an EMR and i2i Tracks. Axis went live with NextGen in April of 2008 and reports having very limited experience with creating customized reports out of the system to date. Both NextGen and Merritt users noted some frustration that One-E-App is not interfaced directly with their practice management system and noted that One-E-App is often too cumbersome to use as it can take up to 45 minutes to check eligibility on an individual. All health centers noted that their next step in terms of EMR adoption would likely also affect the direction they go with PMS. The two health centers using Merritt noted that they were likely to move to a joint EMR/PMS product.
Hospital Interface and Electronic Referral. Health centers spoke favorably of CHCN’s role in helping them connect to hospitals. The executive staff at LifeLong explained that prior to the CHCN-facilitated interface, they had a very clunky connection to the County Medical Center but that CHCN is responsible for streamlining that connection, and further improvements are underway. At LifeLong the providers can use the web-based VPN into the hospital system and they are working out standard processes for when to use this connection. Health centers did note some frustration because of the access being limited to licensed providers. However, there was an indication that access would be made available to medical assistants in the near future.
There are some important differences in the way each health center uses or would like to use the VPN connections to hospitals. Some health centers rely on these connections primarily to facilitate referrals to hospital-based facilities for radiology, specialty care or other procedures and then accessing summary reports on the results of these interventions. Others focus on the benefits of being able to look up patient hospitalizations and or ED visits and print that information out prior to a medical visit.
Costs and Returns of Quality Improvement and IT. While none of the health centers we visited in Alameda County had implemented EHRs, there were still some important findings related to health IT investments and returns. Even prior to the i2i effort, health centers in Alameda County report having interfaces between their PMS’ and clinical laboratories as well as advanced registries that have facilitated active QI.
In each of the sites discussants were asked to describe returns on investment from their QI efforts and in particular those efforts involving IT. Though there were no reported financial returns health centers reported very important improvements over the last several years in terms of compliance with process measures such as regular LDL and HbAIc screenings for hypertensives and diabetics. LifeLong health center reports that they have been able to virtually eliminate differences in some treatment patterns (though not clinical indicators) across different racial and ethnic groups. We found that the health centers we visited had more dedicated QI team staff than health centers in other networks, in part through extensive use of AmeriCorps volunteers. We also found that health centers often had one or more FTE dedicated only to measuring and reporting on quality as opposed to the practice at many centers of making a very busy practicing clinician in charge of QI.
The health centers we spoke with indicated that IT and QI staffing represent a relatively small portion of their budget, between 5 and 6 percent in most cases. Health center administrators we spoke with discussed their decision to move forward with i2i Tracks rather than an EHR in economic terms. Most estimated that the software costs alone would have been close to 75 to 100 percent greater. Also, they noted that, as with any clinical implementation, the “soft” costs would constitute the largest portion of overall implementation expenses.
One health center estimated that $300,000 would be spent on licenses and interfaces for i2i Tracks (half of which they would pay for and the other half of which would come from the Tides grant), but that another $500,000 would be spent on staff time in planning, workflow redesign, training and other activities. They noted that this ratio of soft costs to licenses and hardware costs is even greater in EHR implementation, which means that EHR implementations extract a huge toll on the staff as well as the budget of a health center. Still, every health center acknowledged that they are actively reviewing EHR options in light of the Recovery Act incentives. We discuss this in greater detail below.
EHR and the Future Direction of CHCN
Prior to ARRA, conclusions from this site visit would have highlighted opportunities for health centers and networks to support real QI efforts using health IT that falls short of an EHR. The rationale for forgoing EHRs was made on two basic premises. First, there was agreement among CHCN and health centers that EHRs were not sufficiently advanced to allow for a cost-effective approach to implementation that would yield quality of care benefits in the medium term and that the costs both human and financial would be overwhelming. There was also the argument that having i2i Tracks would provide a basis from which health centers could move to EHRs and whet the appetite of clinicians for use of information systems to improve the delivery of care.
Given the recent legislation however, we end this report by discussing future direction of CHCN in light of ARRA incentives. While they are still confident that the decision to move forward with i2i Tracks will be useful, there is an increasing imperative to make sure that each health center and the network have a plan for adoption of an application that will allow them to engage in “meaningful .use” of a “certified EHR”, however those phrases are ultimately defined.
As noted in our report CHCN does not currently host any applications that are used for day to day operations at health centers. There is some discussion of the possibility of CHCN serving in a support, planning and consulting role. They would help each health center make a decision on EHRs that works for them, but also assure that the vendors selected can ultimately interface with the data warehouse set up by CHCN and other systems.
Health centers are also exploring the possibility of signing on to other networks that have hosted EHR solutions such as OCHIN, HCN, the Alliance of Chicago Health Centers or others. While this approach may work in terms of getting access to an EHR quickly, findings from our other site visits suggest that the training, workflow assessment and planning portions of an EHR implementation are made more difficult by distance and that use of EHRs for QI is a long term struggle that is also hampered to a degree by distance. They key question for CHCN moving forward may be if they can adopt a model where members look to their local network (CHCN) for vendor selection, implementation support and advanced reporting and data integration, while joining a separate, non-local network to access an EHR.