Of the health centers we spoke with, two had implemented EMRs in the last year and were not in a position to discuss broader impact of EMR use beyond the challenges and productivity losses associated with the first year of EMR implementation. The two health centers that have had substantial experience with use of the EMR, Greene County and Steadman-Wade noted that use of the EMR and the data warehouse has enhanced their ability to track care and measure improvement over time.
Greene County indicated that they have been able to achieve sustained improvements in the quality of care provided to chronically ill patients. They cite steady improvements in process measures such as the rate of follow up for diabetic patients in the form of routine testing and clinically recommended examinations (e.g. foot exams). They also indicated improvements in the percentage of patients who regularly receive HbA1c tests as well as the number of diabetic patients whose HbA1c values are “under control.” Greene County has also been able to use the data warehouse to conduct research demonstrating clinical impact and is in the process of publishing findings.
Steadman-Wade health center indicated a slightly less positive picture regarding clinical impact. While the medical director at this center indicated that they were able to observe improvements in key clinical indicators over time, he also noted that these gains were regularly lost because of high turnover among providers and the challenges associated with getting new providers up to speed on effective use of the EMR. This medical director was also among those who noted that a more standardized approach to forms and templates at the network level may help individual centers achieve and measure more consistent improvements in quality over time. The network noted that they have encouraged the medical directors to take the lead, but that health centers have had difficulty finding the time to coordinate on these issues.
Financially, most health center discussants did not believe that they had seen returns or savings equaling their investment in health IT and did not believe that they would. Network discussants emphasized that while there may be savings in some areas, the EMR initiative was largely motivated by quality improvement and not an understanding that costs would be recouped through revenue gains or savings. Health centers noted that use of EMRs would likely represent a “cost of doing business” in their view and that effective use of health IT could improve revenues over time by putting the individual health centers and networks in better position to pursue grants from federal and state government as well as foundations.
Finally, network discussants did not have a clear picture of how they will remain sustainable over time. While CPH did have some members outside their region and, particularly, in rural areas, they were not as aggressive as some networks were in using expansion as a means to achieve sustainability. Network staff did indicate that part of their approach has been to maintain a skeleton staff at the network level to keep labor costs under control. They acknowledge that this approach limits their capacity to serve as a comprehensive resource for health center members particularly as related to providing direct support for QI initiatives, noting that the network serves primarily as an ASP at this point.
They felt that the federal grants meant to support networks did not provide sufficient funds to help achieve their primary goal of improving quality of care and that, in some cases, health centers were not able to contribute resources necessary to support a network-wide QI function. Rather, in their view, these funds provided the resources necessary only to build infrastructure, provide applications and assist with implementation. In the case of CPH, federal funds had been used primarily for software, set-up, implementation and initial training. Membership dues go to pay for support costs, contracting with the vendor and products and services they use outside the basic implementation including additional interfaces, templates or special reports.