Overall, our site visit to BHN revealed the operation of a complex, but largely coordinated, set of initiatives to improve quality of care and efficiency that focused significantly on the promise of enhanced information systems and technical resources. Although they have made significant strides over the past several years, all respondents in Boston candidly discussed limitations of their current activities and their enthusiasm for building on these projects moving forward. In particular, the experiences described in this report inform policy and planning related to community-level EMR implementation among a set of diverse, mostly independent urban health centers. We end the report with the following set of analytic conclusions highlighting aspects of site visit findings.
BMC leadership. Although the hospital merger that created BMC is now nearly 10 years old, respondents made it clear that the success of the initiatives discussed largely leveraged the early momentum from this event and BMC’s leadership. Respondents cited several specific reasons why their model of vertical collaboration, with a safety net hospital at the head, contributed to their ability to acquire sophisticated health information systems. First, BMC (BHN) proved to be an effective platform for applying for federal grants and attracting private donations to support IS initiatives. In addition, BMC’s experience with large scale systems implementations and resource management, led to very effective planning and project implementation processes with an appropriate emphasis on standardization and adherence to deadlines. Finally, the BMC’s participation, allowed health centers to benefit from grand economies of scale for hugely expensive, core activities such as housing and maintaining servers and securing back-up technical support. Because BMC’s own operations require large scale systems administration and support resources, they were able to contribute to health center-focused initiatives at little additional cost.
Vertical collaboration among heterogeneous institutions. The success of IS initiatives in Boston is particularly surprising considering the number and diversity of independent health centers in collaboration. For the most part, BHN health centers are entrenched institutions with long histories and close ties to their community. In addition, prior to the BMC merger, each health center worked relatively independently to fund, develop and implement IS projects. Bringing health centers together in this environment required the BMC and BHN leadership to walk a fine line between building systems to meet the unique needs of individual health centers and maintaining a basic level of standardization necessary for efficient centralized maintenance and administration. While some health centers did note typical criticisms, e.g., larger health centers having greater leverage to influence group decision making, overall all, health centers reported positive experiences working with the central BHN/BMC programs. Respondents acknowledge that institutional incentives also helped shape the collaboration. BHN health center referrals represent the majority of BMC admissions and health centers benefited greatly from the extraordinary levels of uncompensated care that BMC provides to their patients.
Clinician buy-in for EMR. As with new EMR implementation, the CHART and HCAP groups in Boston had to contend with the difficult process of securing clinician buy-in for using an EMR. Although, this process was aided somewhat due to the relatively sophisticated health care environment in Boston relative to other parts of the country, many respondents still noted clinician buy-in as a significant challenge. Respondents noted two major strategies for securing buy-in. First, they made sure to include clinical representation in the earliest work group discussions related to design and implementation of the EMR. This allowed clinical interests to weigh-in on issues such as template design, application set up and functionality. In addition, the HCAP program in particular, has focused on quickly leveraging the EMR to support difficult aspects of clinical care, such as management of chronic illness, streamlining referral and follow-up and designing an appropriate level of clinical decision support (e.g., automated reminders that are useful not burdensome). The guiding philosophy has been that once clinicians see improvements in care and outcomes as a result of EMR use, their buy-in is permanently secured. Another key aspect of achieving and maintaining clinical buy-in is buy making sure the system works to enhance clinician access to key data by allowing them to electronically query lab results and inpatient records.
Need for substantial initial and ongoing investments. The experience in Boston demonstrates the need for two significant types of investment to implement and sustain a community-wide EMR. Clearly the $6 million in seed money that was privately donated was the critical, initial investment required to get the project off the ground. More than just allowing access to the software and licenses, the seed money supported costly hardware purchases, implementation assistance from the vendor and technical staffing that were as important as the application itself. While the large bolus was necessary to get the system up and running, continuous and ongoing investments provided through the HCAP grant were critical to helping health centers transition smoothly and leverage the new functionality to quickly achieve improvements in care delivery and outcomes. Without this ongoing centralized investment in reporting, customization and clinical enhancement, enthusiasm for the technology would have likely waned leading to only piece-meal improvements in service delivery. Finally, obstacles to the success of the EMR and data warehouse remain. For example, as health centers replace core applications such as practice management or accounting systems, they will need to find resources and time to plan and develop new interfaces. Again, there will be risk that buy-in and collaboration will falter because of these new costs. As such, respondents emphasize that ongoing investment in using EMR and data warehouse resources to assess and improve care will be critical to the ongoing success of the initiative.
Community cost savings and return on investment. Several respondents indicated that use of EMR has led to a series of cost savings. One health center reported that Logician has enhanced revenue capture by facilitating more accurate, comprehensive recording and coding of procedures. Another center immediately noticed cost savings in terms of the reduced medical records staff time and the restructuring of their work to remove some of the burden off of the front line nursing staff. Users also noticed that the time delay that was present with faxing and locating paper records is eliminated with the EMR since information may be accessed immediately from any BHN provider site.
Still, respondents acknowledge that they could never have justified the required initial and ongoing investments described above without the upfront gift and ongoing support through BHN and federal grants. As with other cases, we found that measurable cost savings to individual institutions did not meet the costs associated with purchasing and maintaining an EMR. However, community-level, vertical collaborations such as BHN represent strong model for understanding the system-wide benefits of using EMR to improve quality and efficiency of care. For example, the network has already prioritized efforts to measure savings due to reductions in inappropriate ED admissions for ambulatory care sensitive conditions that affect BMC. In addition, by providing patient-level data to state health care financing and public health officials, through the data warehouse, BHN, and specifically the HCAP project is making an important stride toward turning the EMR initiative into a true patient electronic health record as envisioned by the National Health Information Infrastructure.