In synthesizing lessons learned from the case studies, we focus on key issues relevant to the current policy debate, including support for health center networks and EHR adoption. We also describe areas for future research and analysis.
Network Benefits and Challenges. Overall, findings confirm that health center networks can be successful vehicles for the adoption of IT in the safety net. Networks help health centers to finance costly technologies by accessing grant money over and above the Section 330 grants. In addition, we found substantial evidence that health center networks provide human and technology resources through economies of scale that health centers could not afford on their own. Networks offer health centers access to executives skilled at the vendor evaluation, management and procurement processes and are able to leverage market share to hold vendors to a high standard. Finally, networks serve as important forums for sharing best practices among health center members. For communities working to share data through community applications and data warehouses, the network model was particularly suitable to gather buy-in and build infrastructure for such a system. We found that network formation would not be possible without funding specific to encouraging collaboration among health centers.
In addition to these important benefits, networks face a number of difficult challenges in fulfilling their mission. Networks often struggle to meet the diverse requirements of their member health centers in terms of financial resources, IT capacity, infrastructure and vision. Successful networks featured a centralized, collaborative framework that was central to establishing a common vision and strong buy-in among its partners. Networks that focused on building applications to collect store and centrally maintain data from individual health centers faced difficult technical, financial and legal challenges. They were pressed to prove clear benefit to individual health centers in order to ensure participation and realize the goal of data exchange at the network level and beyond.
Rural networks faced especially difficult challenges in building and accessing community-based applications because of resource and infrastructure constraints. Overall, realizing robust, measurable public health and financial benefits from EHR and health data exchange remain opportunities for the future among those health centers consulted. Formal data sharing relationships among hospitals, public health agencies and Medicaid are slow in evolving and networks still require a sustained level of public funding for the training, initial implementation and ongoing support necessary to realize benefits from their software.
EHR-specific Lessons Learned. Successful early adopters of clinical technology offered several lessons for future funders and implementers of EHR. Case studies demonstrated the importance of having not only buy-in, but significant involvement from clinicians at all phases of an EHR implementation to ensure the technology’s smooth integration with clinical work processes thereby allowing clinicians to realize clear benefits from using the system. In order to support the purchase and implementation of such systems, the network required three levels of substantial funds: seed money for start-up, money to build infrastructure and transition workflow, and funds for the ongoing maintenance of technologies. The networks we studied all relied on outside funding to support ongoing maintenance and future systems purchases.
Some health centers that implemented EHR were able to quickly translate resulting improvements in patient outcomes, although the ability to accurately quantify a return on investment on the institutional level is still underdeveloped. Future safety net providers looking to adopt health IT systems may benefit from a riper environment for adoption given its recent emphasis in the policy arena. Adoption efforts would be especially enhanced by the development of data standards, more “usable” software and more available funding to consortia of community providers. However, advances will be balanced by sustained challenges of developing a collaborative and functional network model and overcoming fears of data sharing.
Critical Factors for Success. Despite the many organizational and cultural models employed by these early adopting networks, we did find several factors closely associated with successful adoption of IT among health centers. Networks that understood the relationship between clinical and administrative applications, particularly implementing a robust practice management system as a backbone to implementing an EHR, were more successful in achieving a seamless exchange of information between the two systems.
We found that more integrated networks where there was strong buy-in for shared systems generally managed a smoother implementation of the technology. More decentralized networks sometimes could not achieve consensus necessary to procure shared institution-level applications, focusing instead on combined systems such as data warehouses and external client tracking systems which have proven difficult to implement. Another important aspect determining the networks’ success was the need to build trust through strong leadership. Only those network leaders experienced in large scale IT design and roll out and highly skilled at customer service were able to implement common practice management and EHR applications across centers.
Key Issues for Future Study. This study has elucidated important lessons learned for adoption of IT, including health IT, among health centers and health center networks. A number of areas that merit further investigation to assist policy development include studying the feasibility and sustainability of promoting a network model, analyzing coordination and overlap among health center networks and attempting to quantify the value of health IT systems relative to their costs. In addition, it will be important to follow examples of successful networks as they work to wean themselves from large amounts of outside funding to support ongoing operations.