Environmental scan activities have revealed substantial activity in the implementation of health center information systems. Advances identified to date in locations such as Oregon, Miami-Dade County, Washington D.C. and other locations reflects both strong vision on the part of community leadership timely, well-focused support by key federal stakeholders such as HRSA and the VA. However, as with other health care providers, CHCs vary dramatically in terms of their approach to health information systems. Thought leaders indicated that many CHCs still rely on long outdated methods for basic administrative tasks and that most CHCs face an uphill struggle with respect to issues such as assuring HIPAA compliance without the use of clearinghouses. We note that this situation is not different from that of most small to medium size primary care health clinics and group practices. Some of the key challenges and barriers related to design and implementation of health information systems in CHCs are described below.
CHC-specific Needs. As community-based safety net providers, CHCs have a special set of data and administrative needs that may be addressed using health center and community based information systems. For example, CHCs are typically required to assess the eligibility of clients for Medicaid, Medicare or other insurance or health care subsidization programs to ensure maximum reimbursement from third party payers. This is particularly challenging when working with a population that frequently falls in and out of eligibility criteria and may seek care only at sporadic intervals and at different locations. Community-wide tracking eligibility systems have been offered as a solution to this need. In addition, CHC administrative systems must accommodate the need for double and triple bookings and sliding fee schedules for determining patient out of pocket costs. Finally, the requirement that CHCs submit data on UDS means that CHCs must have an efficient way to tabulate encounters by diagnosis and procedure and provide additional information such as birth weight and trimester of first prenatal visit for specific types of visits.
Procedural Challenges. Overall, thought leaders indicated that the majority of the IT challenges facing CHCs seem to fall into the area of CHC organization and administrative procedures used in decision-making, design, and implementation activities related to their systems. These challenges include those related to application/system implementation (i.e., project management, skills for proper configuration); vendor performance against contract requirements; user training and issues related to “homegrown” systems solutions. Of these, thought leaders emphasized the concept of poor vendor management and relationship building leading to the inefficiencies and failure to meet important project objectives. Some specific deficiencies cited included the vulnerability of CHCs to unfavorable contracts due to lack of appropriate technical knowledge and also varying levels of assertiveness from leadership. In addition to lacking the appropriate technical knowledge, thought leaders indicated that CHCs face difficulties related to negotiating major vendor contracts generally. Finally, CHCs entering into systems decisions are especially vulnerable, not only because they are more likely to lack appropriate contract and technical expertise, but also because they receive none of the benefits available from group price negotiation. We note that HRSA has acknowledged the importance of vendor relations and provides CHC with substantial guidance on procurement and contract management issues.
Other challenges stem from the lack of knowledge among vendors regarding CHC operations. While there are specific examples of CHCs working with vendors to familiarize themselves with their specific challenges, many of these relationships encounter difficulties because of a lack of understanding of CHCs among vendors. One common refrain is that vendors tend to underestimate the level of support CHC users will require relative to users with their traditional customers.
Organizational Challenges. Environmental scans and thought leader discussions in particular, have elucidated a number of organizational challenges related to issues and opportunities for CHCs in regard to information systems development and implementation. For example, our discussions suggested that strong leadership from a Chief Information Officer (or similar individual) with an accurate sense of organizational mission and culture is an important element to progress on systems issues both for individual CHCs and networks. CHCs and networks that lack strong systems expertise suffer from implementation of systems that are consistent with the expertise and biases of existing staff, rather than those representing the optimal solution given the organization’s mission and constraints. Perhaps most telling is the notion reported by thought leaders that primary care providers including CHCs generally invest too much of their information management resources on specific applications and systems, rather than developing and implementing a strategic plan for procuring and using information technology for their clinic. Again, this is a challenge that HRSA has addressed to some extent by emphasizing the importance of CHC-investments in HIS strategy and dedicated leadership to follow through on HIS objectives.
Finally, there exist challenges related to funding and resources. These include a lack of knowledge or a failure on the part of CHCs to take advantage of all funding sources and other support mechanisms. Conversely, some have expressed concern that the multiple funding sources and programs are too small and seem uncoordinated. Additionally, thought leaders mentioned that individual CHCs that are not in States with strong networks are often ineligible for systems-specific grant funding and that the levels of funding available are not adequate to support necessary improvements even among network CHCs with good management practices. Finally, while CHCs are encouraged to form networks and consortiums to take advantage of funding opportunities or respond to changes in the reimbursement environment, some thought leaders indicated that CHCs are provided relatively little guidance on how to operate successfully as members of a consortium or network.