Health centers consulted for this study demonstrated substantial progress in the use of health IT to meet important financial, administrative and clinical goals. Although challenges persist, our findings validated initial observations by some thought leaders that health centers represent fertile ground for health IT adoption among ambulatory providers.
The experience captured in this report represents important lessons learned for future investments in health IT among health centers, health center networks and other ambulatory care providers. We attempt to synthesize these lessons learned focusing 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 health IT in the safety net. Health center networks successfully acquired systems and innovatively harnessed them for the improvement of operations, both administrative and clinical.
- Access to funding. Individual health centers most often cited cost as the main barrier to purchasing IT. Network formation allows health centers access to grant money above their Section 330 grant. We found that networks often were able to secure a number of Federal grant programs simultaneously, often by having different member organizations take the lead role on different grants. In two cases, networks benefited from private donations that would not have necessarily been made to individual health centers.
- Leveraging resources and expertise. We found substantial evidence that health center networks take advantage of economies of scale to provide resources that health centers could not afford to procure individually. These benefits apply to basic purchases such as software licenses or service time from vendors as well as structural issues such as the ability to attract skilled technical staff. Individual health centers often reported that they found it challenging to find IT staff that had adequate training for complex systems issues. The ability of networks to afford IT staff with the necessary expertise (e.g., on building interfaces, mining practice management and EHR data, building databases, and customizing systems) was critical to individual health center satisfaction with their technology.
- Vendor selection and management. We found that health centers benefited greatly from having access to network executives who were skilled at the vendor evaluation, management and procurement processes. Aided in part by economies of scale, respondents mentioned that network executives were often in a much better position than individual health center Executive Directors to characterize their requirements in an RFP, negotiate favorable terms and hold vendors to a high standard for technical assistance, customizations and other services.
- Collaboration and coordination with other health centers. We found that funding specific to coordination and collaboration across health centers was important to improvements in their use of IT. Several health centers noted that networks offer important forums to share best practices, allowing centers to troubleshoot specific functionalities and share new knowledge relevant to technical, administrative and clinical challenges. Networks brought together providers with similar needs and common goals. In some cases, networks have been able to build an infrastructure for sharing data through community tracking applications and data warehouses. While networks that seek to integrate functionality across centers meet with varying levels of success, it is clear that without funding to promote collaboration and coordination among health centers network development would not be possible.
In addition to these important benefits, we found that health centers faced a number of difficult challenges in fulfilling their mission.
- Meeting diverse requirements of health centers. Because health centers differ substantially operationally and culturally, networks often face the challenge of addressing a diverse set of needs through a single operational model. Network leadership recounted the difficulty in identifying systems and governance structures that met the needs of both larger, more sophisticated centers and smaller centers. More decentralized networks that were unable to build a strong collaborative framework tended to be less successful, as health centers were not fully bought-in and did not share a common vision. These networks were often unable to overcome health centers’ tendency to compete with each other or the fear that their interests would not be addressed in a network structure.
- Building and using community based applications. We noted that networks which focused on building applications to collect, store and maintain data from individual health center applications in a single community faced difficult challenges. The process of building interfaces to allow data exchange across two non-interoperable systems was both time-consuming and costly. Networks reported that vendors were often resistant to release code to interface developers and even when they had access to the right information, turnover in the system of any individual health center meant significant setbacks to these data integration projects.
We found that health center participation in community data warehouses was contingent on some promise of benefit to the individual health center. For example, health centers that felt they could already access and analyze data effectively through their practice management system were unlikely to contribute proprietary data to a warehouse that would only offer slight improvements in ease of reporting.
- Setting up networks in rural areas. Rural health centers and networks faced special challenges in building and accessing community-based applications. Rural centers often have limited budgets for IT, less sophisticated IT expertise than urban centers and difficulty in purchasing off-the-shelf systems due to highly specific requirements. In terms of technical challenges, rural initiatives are often unable to access high-speed Internet connectivity needed to use networked applications because of low availability in rural settings. Urban-based networks will likely rely on the improvement of infrastructure in rural areas in order to incorporate rural centers into their network. Progress was being made to this end during the course of the study; for example, SKYCAP’s goal of sharing client tracking data among its community-wide partners recently improved with the spread of high-speed Internet connectivity in that region. In addition, OCHIN leveraged improvements in access to high speed connectivity in rural parts of Oregon to expand its membership.
- Achieving vertically-integrated data sharing model. Most networks in our study were horizontal collaborations among geographically linked ambulatory primary care providers. Only Boston HealthNet formed a true vertical collaboration, revealing both real and perceived barriers to achieving a model shown to be fairly successful for early IT adoption. In order to form a successful vertical relationship among the city’s major safety net hospital and health centers, Boston HealthNet was fortunate to already have an established relationship among these institutions, as the health centers supplied a large portion of the hospital’s patient base. Despite this fortune, the network still had to overcome the barriers of finding interoperable software that met the needs of both the large inpatient institution and ambulatory health centers in addition to mitigating the reluctance on the part of both the health centers and the hospital to share data due to perceived concerns of a breach of privacy and a resulting loss in market competitiveness. Even with its success, Boston HealthNet and other networks attempting to forge a vertical collaboration face the ongoing challenge of prioritizing resources and meeting the technical needs of a very diverse clientele.
- Population health functionality remains a future goal. Health center information sharing initiatives with hospitals, public health agencies and Medicaid are slow in evolving, although most networks felt that building those connections would be an important part of future activities. Networks that had fairly strong ties with public health stakeholders in their region, such as OCHIN, were able to build a collaborative vision for using IT to improve the population’s health and were beginning to work toward a population-wide data warehouse for the safety net population, however formal linkages with Medicaid or state public health information systems had not yet been achieved in any of the networks.
- Achieving sustainability. Network leadership across each case study noted that financial self-sufficiency is not a near-term possibility for their organization. Even in cases where one-time private donations facilitated the purchase of software licenses, networks required a sustained level of public funding for the training, initial implementation and ongoing support necessary to realize benefits from the software.
Critical Factors for Success
While case studies demonstrated that there is more than one model for successful implementation, we did find several factors closely associated with successful adoption of IT among health centers.
- Understanding the relationship between clinical and administrative applications. Depending on the immediate need articulated by health centers, networks took different approaches towards prioritizing between practice management and EHR. Overall, we found that having a robust practice management application was a necessary first component to implementing an EHR, as the full benefit from both applications comes with the ability to seamlessly exchange information between the two. Even in networks where EHRs were pursued in the absence of networked practice management system, each participating health center did have a successful practice management implementation that they were able to then interface with the EHR.
- Structure of the network impacts function and success. Across the seven sites, we observed a link between the operational model of the network and their success in implementing clinical technologies. We found that more integrated networks where there was strong buy-in for shared systems generally managed a smoother implementation of the technology. Health centers in less integrated networks sometimes could not agree on shared systems, focusing resources instead on systems such as data warehouses and external client tracking systems which have proven very difficult to implement. We illustrate the relationship between network and function and relative success in Exhibit 5 below.
Exhibit 5: Level of Integration and Function
- Building trust through strong leadership. We found that strong, skillful leadership played an indispensable role in building trust and successfully implementing IT on the network level. For example, highly skilled and charismatic network leadership in Boston, New Hampshire and Florida were able to garner trust and buy-in not only for membership into the network but to pool resources for the purchase of common, centrally-housed practice management and EHR systems through which data could be exchanged. These leaders demonstrated not only a strong skill for fostering collaboration but also expertise in key areas such as selecting vendors and building sustainable business models for health center IT investments. Strong leadership was also the keystone to building a vision for systems adoption that facilitated the evolution towards a unified goal of quality improvement for the safety net population both at the network and health center level. In addition to strong leadership, consortia also benefited from a high level of collaboration among consortia partners and public health stakeholders. CHAN, for example, credited a large part of its success to the health centers’ consistent desire to exchange data, overcoming challenges other networks faced in building members’ buy-in and trust.