In this section we review specific barriers and enablers to health IT adoption and information exchange among safety net providers in San Francisco. We begin with enablers.
Funding. SFCCC and its members have benefited enormously from private funding sources, primarily foundations, in the acquisition of IT systems. Funders include: Kaiser Permanente, Tides Foundation, California Endowment Foundation, CalRHIO (funded by Blue Shield of California Foundation), California Wellness Foundation, California Pacific Medical Center, St. Luke’s Hospital and Foundation, San Francisco Foundation, Cisco, Wells Fargo, McKesson, Chiron and various other foundations. These grants have been integral in bringing new applications to SFCCC and its members and facilitating ongoing collaboration with DPH, the state Medi-Cal office, UCSF and the San Francisco Health Plan.
SFCCC leadership. SFCCC has also provided valuable leadership on key health IT issues for its members. Their advocacy efforts have shaped policy at all levels of government and have proven especially successful when collaborating with other CHC networks in the state [NEED EXAMPLES]. They have also been able to pull SFCCC members together to address common issues, including health IT. While the consortium has had a relatively limited role in directing individual centers’ health IT decisions, they have offered specific applications like i2i Tracks and eReferrals and will continue to facilitate discussions about more shared applications (including the possibility of an EHR) in the future. SFCCC also offers staff resources to its members to handle issues like continuous quality improvement and technical support. These are functions that may be too expensive for some centers to devote full FTEs to. This has proven especially helpful for health centers that have little experience or capacity in the area of health IT.
DPH collaboration/ Healthy San Francisco impetus. Ongoing collaboration between SFCCC and DPH, especially around Healthy San Francisco has made for successful health IT adoption. In the past, DPH and SFCCC saw each other as separate entities. DPH had no compelling reason to be interested in SFCCC centers. With SFCCC’s help, member centers now have read and write access to DPH’s LCR system. Use of i2i Tracks has cemented this collaboration. Finally, by serving as an active partner with the State on Healthy San Francisco and One-e-App, SFCCC has forged a strong bond with the Medi-Cal office as well. Without these successful collaborations, health IT efforts would be more fragmented and less useful for SFCCC members.
Despite the enablers listed above, a number of barriers have prevented SFCCC and its members from further health IT adoption. While SFCCC has exerted leadership and found common funding opportunities for its members, SFCCC health centers have also pursued many opportunities on their own. For example, SFCCC centers use 10 different practice management systems, making the prospect of moving toward a shared EHR all the more difficult.
Varied center missions. While they occupy the same general space, SFCCC centers’ missions and patient populations differ widely. This has become a point of contention in standardizing data elements across health centers and with other partners. For example, Lyon-Martin may need to list transgendered individuals on their systems, but other health centers or partners may not see the need to build in this functionality. These kinds of individual needs and the fact that many SFCCC members are not FQHCs make shared health IT more difficult.
Infrastructure Problems. One of the biggest barriers for SFCCC members involved connectivity and infrastructure problems. The LCR system was built on a network architecture over 20 years ago that was intended for use only by DPH and was not meant to handle large data files. SFCCC noted that the LCR in its current form had exceeded electrical capacity at its server farm, signaling significant overuse. Health centers visited by NORC had problems accessing the LCR and were often booted from it.
In addition, health centers adopting EHRs, such as Glide, are finding that their connectivity and physical environment is not conducive to adopting advanced IT applications. Infrastructure problems have slowed the system to a high degree, causing extensive frustration among Glide staff members. Also, SFCCC leadership acknowledged that connectivity through traditional means is difficult in San Francisco due to extensive Internet traffic and an aging infrastructure. They noted that they are working on securing funding to establish a new fiber optic network dedicated to safety net health care computing in the city.
Anticipated and unanticipated costs of implementation and participation in community programs. As in many other cases, cost remains a significant barrier for SFCCC centers both in terms of adoption of their own systems and for participation in community-wide initiatives. Glide Health Services, which has implemented Centricity, indicated that they had seen large drops in productivity resulting in higher costs of care reported in their UDS. Additionally, Glide has had to train volunteers and many nursing students on the system, amounting to a significant investment of time and increasing the number of necessary licenses for the center beyond what they had originally anticipated. SFCCC centers have also experienced increased costs in working with Healthy San Francisco and One-e-App. While these centers are reimbursed for care provided to Healthy San Francisco patients, One-e-App eligibility workers are generally funded by individual health centers. South of Market and Lyon-Martin both cited costs as one of the primary reasons they had not already implemented EHRs.
Duplication. While SFCCC members enjoy access to various information systems, using these systems can be frustrating in some cases. Many SFCCC health center leaders explained that there is little communication between the LCR, centers’ practice management systems and EHRs, i2i Tracks and One-e-App. This means that information could be different for a single patient between these systems (e.g. outdated address or vaccination records) and health center staff must often take it upon themselves to reenter the same data in 3-4 different systems. Signing in to each of these systems and ensuring adequate access to computer terminals can also be time consuming and difficult. Some mentioned an OpenLink data aggregator to sort through duplicate data, but in many cases data reconciliation becomes the responsibility of SFCCC members and staff. Without rigorous efforts in this area, health IT systems could become inaccurate, resulting in lower provider trust and usage.