NORC's discussions with CCHN and its members produced a number of findings related to overall enablers and barriers to health IT adoption.
Network culture, dynamics. Discussants noted that CCHN's efforts to leverage its influence as a group and work directly with vendors on behalf of its members amounts to a significant enabler for health IT adoption. In particular, health centers noted the importance of having a trusted source of knowledge on vendors and access to experts who could translate specifications and infrastructure requirements for adoption of a particular software application into the practical terms of costs, resources and time required for successfully adopting that application.
They also appreciated the network's help in negotiating with vendors and helping hold vendors accountable to the terms of agreements following the purchase of a system. Most of the health centers we visited agreed that they would not be able to afford similar IT leadership within their organizations. Finally, while the health centers we spoke with were not always on board with every network initiative, they genuinely appreciated the ability to interact with other health center colleagues on use of IT for quality improvement.
Grant support. Grant support was also an important enabler for CCHN members. Health centers in the San Diego area and the network itself rely heavily on grants for new initiatives. Grant writers employed by health center members play an active role in CCHN's funding committee and the network ensures that health centers have agreed to apply for specific grants before moving forward with them. In addition to the i2i Tracks grant described above, CCC is currently benefiting from a HRSA e-prescribing grant that has allowed the network to expand an existing pilot program. The Los Angeles Department of Health Services contracts with CCC to provide support to its health centers. CCC is also contracted by San Diego County for project work. Additionally, CCHN brings centers together as a network to apply for network-only grants. While these grants offer useful and significant revenues for CCHN, some noted that they occasionally create collaboratives that centers would never pursue absent grant requirements. These health centers find that grant requirements may encourage collaboratives that do not make sense in that the requirements could force them to work with health centers that are far less advanced in terms of health IT.
Health center members also rely on grants for covering startup costs, standalone applications such as i2iTracks, implementations at individual health centers and staff training. For obvious reasons grants are primarily seen as an enabler of health IT adoption, however some San Diego respondents noted down sides to grant-funded adoption of health IT. One health center that had purchased a practice management system jointly with other health centers as part of a HRSA grant awarded several years ago noted that grant funds have been useful for initial costs, but ongoing maintenance costs of their practice management system, had proven unsustainable. Additionally, grants have a significant impact on the timing of EMR implementation, with some grants forcing health centers to implement along a strict timeline. Another health center noted that two percent of their Section 330 grant went directly to health information technology expenses.
Finding the right people. Some health centers reported that IT professionals with experience in working with related applications were particularly helpful in implementing new EHR systems. A number of health centers indicated that in preparing for the adoption of EHRs, they had shifted from having a lower skill level technical support staff member to an information technology director with analytic skills. One member health center relied heavily on the experiences of their medical director who had worked with a NextGen EHR in a previous setting. The medical director's experience proved useful to the health center in navigating the EHR marketplace and to the wider network through the Physicians' Council. Health centers also benefited from the experience and expertise offered by CCHN. In some cases, the network was able to help health centers with information technology needs without charging service fees. Some discussants noted that their experience with older practice management systems made them more aware of their information technology needs and the importance of specific concerns such as integrating various information systems.
Cost. Cost was not a significant barrier for many of the health center members NORC visited. This is partly attributable to the fact that most health centers had opted to implement i2iTracks and had not moved to implement an EHR. The fact that CCHN had been successful in securing grant funding for a number of initiatives may have also helped to reduce costs for health center members.
In a broader sense, some health centers were optimistic that their eventual implementation of an EHR would not be devastatingly costly. One health center explained their justification for pursuing a new EMR/PM system, saying, "It's costing us more by not doing this." This health center leader felt that they would benefit greatly from increased efficiencies, fewer lost charts and better data accessibility. Further, she felt it might be possible to repurpose billing rooms and potentially reassign staff currently working in the billing department. Health centers that had been using the MegaWest system pointed out that the ongoing maintenance costs associated with that system were prohibitive. Some saw the prospect of moving toward a new integrated EHR/PM system as a way to reduce ongoing costs over their current MegaWest configuration.
Operation Samahan, a member center located near the United States/Mexico border pursued an open source PM/EHR solution called ClearHealth to avoid costs associated with other EHRs. This center's billing and IT director outsourced much of the development of the application to various programmers around the world and the center claims they have been able to keep costs low. As with most open source efforts, however, the true costs are hard to measure given that researching, implementing and managing development in an open source environment requires a very knowledgeable, motivated individual (in this case a very motivated computer science major who happened to be working at the health center's billing department) and if such an individual is not available to the health center by serendipity, finding and paying for such a person may be cost prohibitive.
Workflow and Training. The site visit to San Diego offered us really only one opportunity to discuss a recent EHR implementation in a health center. Vista Health Center implemented a new NextGen EHR product in 2007 and discovered several unanticipated challenges from having to support specialized training for providers with no prior computer knowledge at all to re-designing basic processes including patient intake, history and physical exam administration and prescribing. The costs associated with these challenges were hard to quantify, but ultimately the health center experienced a greater than 10 percent productivity loss that is ongoing over a year after implementation.