There are several important conclusions that we draw from our site visit to Boston. First, there is some confirmation of the assumed value of vertical integration for a variety of reasons outlined below. In addition, we see continued evidence of the challenges inherent in using EHRs for QI initiatives such as those that focus on following and tracking care to patients with specific conditions. Finally, we see support for the value of a functionality-rich version of HIE focused on safety net providers in urban areas. We describe each of these concepts in greater detail below.
Benefits of vertical integration. Aside from the considerable economies of scale that are achieved when health centers form networks, this site visit demonstrates a couple of the specific benefits associated with a vertical integration between a safety net hospital and health centers in a given market. First, discussions with health centers and BMC indicate that having the hospital on board was essential to helping mediate trust and competition issues that are natural among health centers in the same market. The fact that all Boston HealthNet health centers had something to gain from collaboration with BMC and BMC gained from collaboration with these health centers made it more likely for the health centers themselves to work together. In addition, BMC’s contribution of IT staff and expertise were the primary drivers of the Centricity EHR initiative and many indicate that it would have been unlikely to have received a grant for EHR implementation absent the participation of the hospital.
Demand for a safety net HIE. Discussions in Boston suggest considerable demand for a safety net focused HIE that is based in BMC. While there are significant challenges associated with working with GE Centricity to design and implement an application that will work well for health centers and meet basic needs, there does seem to be a commitment from BMC to invest in a more robust program of HIE with health centers moving forward. One challenge will be the cost associated with integrating East Boston Health Center.
East Boston, like the other health centers, is very eager to participate but is wary of the costs associated with getting Epic to participate in the exchange. They also indicate that Epic is currently not capable of or willing to generate the full CCD message for patients included in their EHR databases so significant work would have to go into compiling generic HL7 messages into the CCD format for inclusion in the CIE warehouse being contemplated by BMC. Not surprisingly, the greatest demand for the CIE is coming from health centers that want greater connectivity to specialty providers and a better view into the care delivered in inpatient settings and ED’s where there is high demand for instant access to basic information such as blood type, allergies and medications for patients that walk in unexpectedly due to an acute event.
The costs of meaningful use. As policy makers begin to add more substance to topics surrounding the definition of meaningful use of EHRs for the purpose of determining eligibility for payment incentives, health centers in Boston offer a prime example of the challenges and opportunities inherent in using EHRs for systematic quality reporting and improvement, the value of exchanging data and the investment and costs inherent in successfully improving quality through an EHR.
The East Boston example demonstrates that using an EHR to accurately track patient populations requires more work on the part of providers, sophisticated design of workflow and reporting templates and a more substantial outreach function. In other words, there are a number of important costs that go well beyond the cost of a successful EHR implementation. The example of health centers using Centricity demonstrates that providers can achieve successful adoption and recognize convenience benefits of using the EHR especially as it relates to connectivity with labs and pharmacies with a baseline level of investment. However, it also shows that an entirely different level of commitment, investment and focus is needed to use EHRs to replicate the role that registries play in traditional QI models that use panel-based approaches to manage chronic illness.
 PECSYS and CV-DEMS registries are chronic disease registries used to track and manage targeted population with chronic illnesses.