In the next several paragraphs we outline specific barriers and enablers to health IT adoption articulated by discussants. We note that some factors represent both enablers and barriers to adoption.
Buy-in among regional managers. According to regional and network level discussants, the vast majority of Access staff supported the move to Epic. A number of regional medical directors spoke eloquently about the potential for health IT to help them provide care more efficiently and effectively. Staff members who were less enthusiastic about the new system recognized the importance of the switch to the network generally, with one regional leader saying, “In an organization this size, you need to trust the senior management.” Some regional leaders remained uneasy about the amount spent on information technology generally. Having been exposed to the costs of health IT through an e-prescribing pilot, one regional leader remained unconvinced that the network’s commitment to health IT was worth it. While this opinion was not widely held at the regional level, it does represent a certain level of difficulty in securing buy-in throughout a network of Access’s size.
Clinician buy-in. Despite general support for EMRs across the organization, Access also confronts typical physician buy-in challenges often associated with EMR adoption. Access physicians are generally less computer-literate than other staff. This is a concern for network and regional staff, but one that they hope will be addressed through tiered training and peer-to-peer support. Some physicians remain skeptical of the new system’s potential to increase patient volume. One physician noted that another local health system in the area, Northwestern Memorial, saw a significant decrease in patient volume following their EMR implementation and that reality caused him concern. Others were more optimistic, even suggesting that patient volume could increase after the first week of implementation. Access has established a strict 60-day adoption policy for its providers with financial penalties associated with not using the EMR. Network officials anticipate that this will lead a small number of providers (roughly two out of a total of around 250) to retire within a few years of implementation, although network leaders have taken steps to provide intensive computer and EMR-specific training for willing staff who may feel uncomfortable with the new system. More than anything, network leaders feel that attitude, not age is the most important consideration in building buy-in among providers.
Relationship to Sinai Health System. Access’s relationship with Sinai Health System represents both an opportunity and challenge for the network. Having been formed out of Sinai’s outpatient clinic system, Access relies on Sinai to provide specialty care for many of its patients and many Access providers are affiliated with Sinai. In addition to close operational ties, Access relies on Sinai for technical support and has shared the Meditech information system with them. The transfer of patient clinical information between Access and Sinai represents a significant benefit to Access’s current IT configuration and any changes to it required Access to consider its partnership with this hospital. Network officials asked Sinai leaders about switching to a new system far in advance of the switch, and again more recently. Sinai officials considered moving to a new system, but decided on both occasions to continue to use Meditech. Access values the connection with Sinai and its ability to provide continuous care for patients, but ultimately network officials decided that it needed to adopt an EMR and move away from the Meditech system.
Relationships with other health systems. Although switching to the Epic system may bring some disadvantages with respect to integration with Sinai, Access is hopeful that adoption of an advanced, standards-based EMR will allow them to more effectively share data and coordinate care with other provider systems in the area. They particularly hope to leverage relationships with academic medical centers and ambulatory specialty care providers that are also adopting Epic or similar systems. Network leaders indicated that local academic medical centers and community hospitals have expressed interest in exchanging data with ambulatory care centers such as Access, although no clear precedent for this kind of relationship exists in the Chicago area.
Federal grant support. HRSA’s financial support is an important asset to Access in pursuing HIT. Nearly half of Access’ total projected costs are covered by the HRSA “high impact” grant award. This award amounts to a significant enabler for Access in terms of start-up costs. Without this infusion of capital, Access would have to borrow significantly or postpone implementation until additional capital could be made available.
Staff expertise. Expertise and experience also represent enablers for Access’s implementation efforts. Partly due to its large size, Access has more IT resources than many other health centers. Glass directs a department of roughly five full time equivalents devoted to both health IT and quality improvement. Dedicated staff in these areas amounts to a luxury not available to other networks. Integration of quality improvement and IT has allowed Access to map existing performance metrics to health IT implementation.
Roll out process. Access chose to implement their PM and EMR systems separately, along slightly different timelines. Both systems are set to roll out in phases across Access’ 51 sites, depending on site size. Sites with medium levels of patient volume will implement new systems first, with smaller and larger centers following. According to Access, this will allow the network to learn from the experiences of medium-sized clinics without interference from the idiosyncratic concerns typical of their very small and very large clinics.
Access’s contractor charged with scanning paper records and migrating data to the new system has delayed the contracting process, forcing the involvement of legal representatives. This issue has slowed Access down by about a month and may force future delays. Due to the contracting delay, OCHIN has not been able to move forward with training sessions for the first group of staff super users. this way, external entities and influences can greatly affect any and all aspect of PM and EMR rollouts.
Communication across the network. Partly due to the contracting delays and partly due to internal communication issues, staff members were not clear on the current timeline for implementation. Some expressed doubts that Access would be able to maintain its planned timeline (implementing PM at all sites and EMR at 10 sites by end of FY ’09), although many seemed undeterred by current difficulties, citing trust in senior management to lead this effort. Network leaders conceded that greater attention to internal communication regarding the selection, training and implementation timelines would have also helped the network overcome a certain level of uncertainty and anxiousness among staff members.
Site-level computing. Infrastructure emerged as an issue in some cases but not others. Some clinics reported no problems with their computing. Other regional leaders complained that too many computers were devoted to single uses, such as reporting for specific grants. Having single use computers artificially inflates reports of IT infrastructure and regional leaders noted that these computers can crowd already congested clinics. Many regional leaders expressed concern about the technical support provided through Sinai Health System and others noted that current bandwidth levels would not allow them to efficiently work with web-based clinical tools (e.g. e-prescribing systems). Under Access’s current IT structure and usage, printers play an integral role in center operations. In a particularly extreme case, one regional manager noted that it took two business days for Sinai’s tech support staff to repair a single printer. Network leaders note that these issues will be addressed as the organization moves towards an IT model more independent of Sinai.
Cost of implementation. Interestingly, cost was not mentioned as a significant barrier by Access network officials. Although the network relies on HRSA support for much of the initial investment, Access was not deterred by the usually prohibitive ongoing costs associated with EMRs broadly and Epic in particular. As stated previously, Access made a commitment to invest in information technology at rates in line with industry standards. This commitment to IT, often in the face of financial barriers, has prepared Access both financially and psychologically for the investment required to move toward a robust PM and EMR system. Steven Glass noted that Access had been investing 3-4 percent of operational costs annually in health IT. His estimates suggested that roughly 3-5 percent would be required for any of the systems under serious consideration during the selection process, including Epic. Network leaders also noted that Epic would provide additional services including a new financial and HR system, adding to the value of the network’s investment in Epic.
Training. Access has not yet begun training staff on the Epic system, but network officials hope to begin PM training in the near future. Training will occur in phases, with regional leaders and super users training first and other staff (including operations/front desk staff) following, based on their comfort level and abilities. EMR training will begin with an online demonstration, then there will be on-site training, followed by support during the final “go live.” Network staff anticipate more problems with the EMR training than the PM training because physicians will be involved. They feel that front desk staff are less reticent to change and more familiar with the internet and computers. Access has agreed to contract with OCHIN to conduct trainings on EPIC, specific to FQHC sites. Staff members also mentioned a model exam room that would allow providers to experiment with the new EMR system during the on site training.
Connectivity, workflow and interoperability. In 2007, Access initiated an e-prescribing pilot through PocketScript in a number of sites. Access staff had a number of problems accessing the web-based system and integrating e-prescribing into their daily work. One regional medical director noted that it could take her up to three minutes to fill a single prescription through PocketScript, valuable time in a provider's day. Additionally, the SureScripts pharmacy data intermediary which is an essential partner for eRx with retail pharmacies may not be immediately interoperable with the new Epic system. Network leaders plan to implement a SureScripts interface, but concede that it will take several months to develop and test it.