In this section we briefly summarize key conclusions following from this report with an emphasis on areas relevant for federal funding and policy making. Additional conclusions related to the replicability of the OCHIN model, challenges facing Oregon consolidated health centers and OCHIN moving forward will be discussed at more length after subsequent site visits and other project activities have shed more light on these issues.
Overall IS infrastructure among consolidated health centers in Oregon. The consolidated health centers visited as part of this case study all demonstrated substantial use of IS and systems for key functions. All those included had ample access to desktop hardware and basic software used in most professional settings. There were substantial differences in terms of connectivity, access to networks and data maintenance capabilities across consolidated health centers. Beyond the obvious factors such as total patient served, number of sites and annual revenue, we found that a few key factors can affect the type of infrastructure at a health center and their ability to make use of what they have.
As described above, affiliation with a county health department allows some health centers to more efficiently access some level of technical infrastructure and networking, though the level of function provided by counties, particularly in rural areas, may fall short of the consolidated health centers needs. Furthermore, health centers that staff or have some access to even one dedicated IS employee report far fewer problems with use of networked applications such as Epic compared to those who rely on outside vendors or ASP-providers (e.g., OCHIN) to trouble-shoot and handle connectivity or applications related problems from a distance. In particular, we found that technology solutions for safety-net providers in Oregon often relied on the idea of collaboration and leveraging technical resources and expertise across providers. Aside from OCHIN, we see this with CHNO and the efforts of the Coalition of Community Clinics described above.
Vision and acceptance of OCHIN from relevant stakeholders. One of the striking features of the materials provided by OCHIN (mostly applications for HHS grants) and generally validated through discussions with health centers and other safety net stakeholders in the State was the network’s strong vision around which all stakeholders could take part and organize. All respondents agreed with OCHIN’s approach of addressing systems needs of health centers while simultaneously addressing information needs of public health stakeholders. This agreement around vision has led to good, active collaboration from both the health center and public health community. Although some respondents questioned specific aspects of the network’s decision making processes and pricing policies, all agreed on the importance of a comprehensive, collaborative vision for improving using health IS to improve the health and health care of vulnerable populations.
Satisfaction with existing products and services. Although, overall IPM partners indicated satisfaction with their organization’s participation in OCHIN, particularly from the perspective of enhanced opportunities for collaboration and the prospect of a centrally administered EMR, the preceding section’s discussion clearly demonstrates some lack of satisfaction with specific aspects of the practice management software and services provided by OCHIN. One common theme was that operations staff at health centers felt that OCHIN needs to do a better job of understanding existing workflows and requirements at IPM partner health centers and, particularly, how the needs of smaller, stand-alone or rural health centers differ from the needs of larger, county-based health centers such as Multnomah County. These issues may be indicative of the early stages of a complex implementation. One positive sign, according to OCHIN respondents, was the lack of connectivity problems during the start-up of their newest IPM partner health center in recent weeks.
Integration with Medicaid or public health systems. Although OCHIN has spent considerable effort reaching out to State Medicaid and public health officials and complies with accepted transfer standards (e.g., HL7), as of yet, there has not been a successful initiative to link the 400,000 MPI with Medicaid or state public health systems. This is in part due to the fact that they currently collect only administrative data, with very limited and incomplete information on procedures and diagnoses. In addition, there is some evidence that Medicaid systems in Oregon, and other States, are outdated and significant upgrading will be necessary before data can be integrated in a useful way with outside databases. Still, this is an issue that is of importance both to OCHIN and State officials with whom we spoke, particularly as OCHIN moves toward rolling out a data warehouse and EMR application.
Sustainability. The issue of OCHIN’s long to medium term sustainability remains open. To date, they have been largely financed through HHS grant programs designed to provide start-up costs for community-based consortia to improve quality and efficiency of health care delivery, with the idea that over time the activities of the consortia will be self-sustaining. Although OCHIN has shown strong motivation in leveraging start-up financing from a number of federal grant programs (often by having different IPM partners take the lead role on different grants), achieving longer term financial viability through expansion of partnerships exclusively among safety-net primary health care providers is clearly a more difficult challenge.
Importantly, OCHIN has and continues to make important strategic decisions that will influence their ability to meet this challenge. For example, by selecting a higher end vendor they have effectively priced out some of the smaller and rural safety net providers in the State. OCHIN acknowledges this and has considered development of an “Epic-lite” package that could be offered to these health centers at lower cost. Additionally, because OCHIN has made the decision not to accept partnerships from private group practices, they will need to continue to effectively build partnerships with out of State health centers. Aside from the challenges of inter-state collaboration described earlier in this report is the issue that OCHIN will not be able to count on the automatic buy-in and support from non-provider safety net stakeholders in other States unless they actively pursue this end.
Replicability. OCHIN’s success in dealing with challenges associated with building a broad-based coalition of disparate health centers and stakeholders around a comprehensive safety net health information system is encouraging with respect to replicability of this model in other settings. It is important to note, however, that Oregon was somewhat ideally positioned for a network of this type because of the state’s long history of partnership across the safety net and between the safety net and state/local health departments. The best example of this was the establishment of CareOregon in the 1990s to help consolidated health centers continue to serve vulnerable populations that were moved to Medicaid managed care. In addition, the time was ripe for a solution such as Epic in Oregon given that there were a number of consolidated health centers concurrently looking to replace an existing system or establish a robust practice management system.
A fair amount of resource investment from the local safety net community itself (e.g., Multnomah County, CareOregon and OPCA) was necessary before the network could secure start-up funding from the federal government and OCHIN benefited by finding an early organizational home within CareOregon. Finally, all respondents complimented OCHIN’s early leadership and attribute much of the network’s success to the efforts of individuals to see the project through. In particular, respondents felt that OCHIN is aided by its staff’s ability to find “next best” or good solutions when the optimal route is ruled out for one reason or another. As the network moves forward, it will be important to assess the extent to which early service and functionality problems reported by out-of-state or rural partners are resolved in the near future, as this will inform the federal government’s understand of the feasibility of implementing this type of network across a demographically diverse group of providers.