In this section we review enablers and success factors facilitating EHR implementation described by health center and network respondents.
Network culture and dynamics. The organizational culture of the four FQHCs that make up the Alliance has played a critical role in the Alliance's success in its initial launch of the EMR solution as well as in its current efforts to offer the EMR as a hosted service to other safety net providers around the country. The four FQHCs that operate the Alliance have worked together for over 12 years on Alliance-related efforts. They share strong professional relationships and a consensus-based approach to decision making. In addition, the staff at the Alliance all previously (and in one case currently) worked at one or more of the Alliance's individual FQHCs in provider, management and quality assurance roles. As a result, the Alliance's staff all have deep understanding of the on-the-ground realities of day-to-day operation of these specific health centers. One key player at the Alliance noted that the network was only able to successfully implement its solution because there was a good alignment of leadership at all of the FQHCs and external funding to support the initial implementation that all became available at the same time.
Federal grant support. The staff at the Alliance feel that ongoing support from HRSA and other funders is crucial for establishing the Alliance's health IT infrastructure and would also be crucial for ongoing operations. In particular, respondents noted that the labor costs for Alliance staff have been almost fully funded through grants from HRSA and AHRQ, without these grants this entire implementation effort would not have gotten off the ground. In addition to financial support, there were also examples of technical assistance, AHRQ and its resource center provided extremely critical guidance that played a key role in helping establish the capacity to provide a centrally administered EHR application to a range of sites. Finally, there is evidence that federal grants have served as a catalyst to motivate the EMR vendor to take a stronger role in the implementation of the EMR at FQHCs.
In the absence of knowledge that this funding will continue, the Alliance has developed an aggressive business model that calls for it to bring on more health centers onto its platform. However, should the Alliance fall short in this effort, it will not be able to internally fund its ongoing health IT needs based on current expenditure levels. On the other hand, if the Alliance succeeds in this effort, the additional health centers that sign up with the Alliance may eventually create a "profit," which can be used to lower the annual fees paid by the four core FQHCs or create additional funding for other Alliance-sponsored activities.
Expertise and experience. The staff discussed several different factors related to staff expertise, which they felt were crucial to success in their implementation. The Alliance has carefully used outside consultants for a range of tasks, including development of a long-term business plan, an interim Chief Technology Officer who was able to design a cost-effective technical architecture for the overall GE solution, informatics IT consulting on an as-needed basis and the long-term "rental" of a part time CIO for one of the FQHCs from a health IT consulting firm. The Alliance staff also noted that the network model allowed health centers to retain staff that would otherwise move on to different opportunities by giving them an opportunity to expand their skills by working at the network level. The Alliance created an Implementation Specialist role that has proven to be very successful in their experience. This position serves a range of IT lifecycle roles in the planning, training, rollout and ongoing support of all of the health centers. Finally, the Alliance is able to access deep product skills by establishing a close and collaborative relationship with the EMR vendor, which improves the ability to obtain timely product support and has a strong say in providing guidance on future product enhancements.
Deployment success factors. In developing the IT implementation process outlined above, the Alliance made a number of decisions regarding how to work best with the each health center. During the interviews several key success factors were identified in the rollout strategy. One of the key decisions was about which existing patient data should be moved forward from their "legacy" formats into the new system prior to the system going live. This, in essence, is the data that the providers would see for the patients the very first time (and every subsequent time) that they entered the patient's electronic chart. Two specific types of data were mentioned in the interviews, the patients' paper charts and the results of the patients' prior laboratory tests.
While the Alliance and its FQHCs had initially planned to scan at least a subset of their paper records, eventually a decision was made not to scan these charts. Instead, each site focused during the pre-implementation phase on developing a robust "minimum data set" for each patient on a paper "cover sheet." This information was validated with patients in a pre-deployment clinic visit and was then preloaded into the system by non-clinical staff before the system was first launched. In retrospect all involved felt that loading the old paper records would have been a distraction from the electronic system and would not have been useful based on how rarely the paper records were reviewed for reference post-launch.
Historical laboratory data results were felt to be much more useful in the EMR context. This data was already considered to be of consistently higher quality than the paper charts, since it was already electronic and structured (i.e., specific values in specific fields) as opposed to unstructured (i.e., handwritten free text on pages of essentially blank paper).
The Alliance and the FQHCs made the decision to import existing laboratory results data into each patient's record and make these data look essentially no different than if they had been ordered directly through the EMR. These data, unlike the paper charts, are frequently referenced by clinicians. Another key element of the success of the deployment was the strong focus that the Alliance and the FQHCs placed on developing super users and extensive "grass roots" expertise at the site and FQHC level. Additionally, the network had super users handle all interactions with the Implementation Specialist staff at the Alliance.
Role of workflow assessments. The usefulness of the workflow analysis was also cited as a key success factor in the implementation. Every site invested extensive effort to document and understand the current workflows and then to map these workflows to the EMR system (even when the staff found it to be an arduous process). As noted above, some sites used this as an opportunity to redesign some workflows and ended up substantially redesigning their operations, including allowing non-clinical staff to play a greater role in non-technical aspects of managing a patient visit. Some health centers also found the workflow assessment to be valuable as a check of the appropriateness of their processes. For example, one site noted that their process for intake often took place in the hallways of their facility, which could have resulted in a series of problems with respect to regulatory compliance and was not consistent with best practices or their organizational policy. Other health centers did not attempt workflow redesign at the same time as the initial documentation. In both cases the staff felt that the due diligence involved in this step was a key enabler to a successful implementation.
Impact of EMR. While Alliance health centers are still in early stages of EMR use, some have reported rates of provision of preventive services such as vaccinations and the number of patients who are developing and reporting self management goals. It was clear from the discussions that Medical Directors are just now getting familiar with the quality reports that are being generated on a regular basis and looking at the quality and change in quality at the provider and center level. Many of the Medical Directors noted that they were anticipating important benefits in the ability to track manage and improve the quality of their services. In particular, Medical Directors noted that they would be interested in using provider specific data to set incentives and set performance goals for each of their providers.
Medical Directors also felt that EHRs would allow them to compete more effectively for clinical talent by attracting and retaining residents and doctors who had been trained to practice medicine with only electronic records or who had already switched from paper to electronic environments in past positions. Finally, a few discussants noted the basic public relations value of having electronic-only sites in that the EHR would contribute to a perception of a high quality of care among patients, the general public and potential local funders.