We observed a clear link between network characteristics, described above, and their functionality, with less centralized networks performing fewer services and exhibiting less likelihood of adopting shared systems. For example, less integrated models observed in HFP and SKYCAP faced both financial barriers and lack of buy-in for integration from health centers. These networks served largely as a forum for health centers to convene and communicate with one another. The following paragraphs highlight the many functions that the studied health center networks served, identifying the operational models more or less conducive to specific functions.
Coordinating and convening. As mentioned earlier, many health centers entered into networked relationships to garner better market power for the health center community. Therefore, one of networks’ main functions is to convene leadership across health centers to identify priorities and common needs around IT. Respondents across all sites praised their network’s ability to convene health centers to share best practices in application implementation and use.
Networks also served to represent the needs of their health consortium to negotiate with vendors, to leverage funding opportunities and to lobby resources for health centers in relation to other safety net providers. This is especially applicable in networks which included a large inpatient institution, such as Boston HealthNet, where the network was able to lobby for resources from the safety net hospital using the health centers’ combined leverage. However, we also saw the HFP network take on that function, representing health centers at city-wide coalitions and acting as an advocate for health centers with Federal, state and local governments.
Vendor evaluation and group purchasing. Once networks identified a common need and technology solution, network staff usually initiated the vendor selection and evaluation process. In some cases, such as OCHIN and CCNV, the network determined system requirements and wrote a formal request for proposals, evaluated responses and selected vendor finalists to demonstrate their product. While this process involved input from stand-alone health centers, network staff spearheaded the task using pooled resources. In other cases, the vendor selection process was more informal. For example, staff at SKYCAP worked directly with a local vendor to develop a customized electronic client tracking software.
Network staff often took on negotiations with vendors to secure an affordable and reliable system for their members. Through this method, networks were often able to acquire certain customizations (e.g., interfaces) that member health centers would need due to disparate IT capacity or configurations. In addition, some networks secured training and system maintenance add-ons from vendors based on their size and skill in negotiation. After our visit, OCHIN successfully acquired a state-of-the-art EHR at a price markedly lower than an individual health center could have negotiated.
Centralized IT implementation. Relatively centralized networks initiating shared systems provide a high level of support to health centers during initial startup and in maintaining remote access to network applications. Networks rolling out these systems expressed a great desire to ensure that the systems were implemented successfully. Boston HealthNet and CHAN, for example, deployed their EHRs following large-scale private donations earmarked for the purchase of EHR software licenses. With license costs subsidized, the network targeted its resources towards procuring network staff to manage the implementation of the technology in member health centers, and providing additional staff, training and IT expertise to facilitate a minimally disruptive implementation. Other networks, such as OCHIN, provided some support to their health center members during implementation by sharing network staff among health centers.
Training and user support. Networks provided critical IT support for those centers who did not have their own dedicated IT staff or whose staff were not adequately trained to support some network applications. In two of the networks visited, the vendor agreed to provide support to member health centers by making available their system experts when troubleshooting was necessary. Several networks provided a HelpDesk function to centralize the daily IT support that centers need during and after implementation of a major information system. In two cases, networks purchased staff time from the vendor for a certain period during and after implementation to assist and train health center staff in using the applications.
Hosting networked applications. Often, individual health centers are unable to provide the space and expertise required to store and maintain servers and to host applications. Networks take on this role in a variety of ways. CCNV, for example, relies on a vendor data center while OCHIN and HCN host and maintain their own data servers. This allows the health centers to access vital applications through a desktop PC, with an internet browser and connection, without physically maintaining the servers. The network assumes the burden of ensuring proper maintenance of the central servers. Costs can therefore be spread among multiple parties.
Data management. As mentioned earlier, one of the main goals of all the networks was to facilitate reporting on grant activities as well as to facilitate the production of customized reports on other areas of interest. Networks sought to enhance health centers’ access to their own vital, administrative and clinical data. Networks that administered shared applications made data from these applications available to health centers centrally. In addition, some networks regularly generated standard health center-level and network-level administrative reports and provided these to the centers. To support development of other reports, some networks helped health centers to collect, clean, and transform data housed in disparate applications to develop a common data warehouse. Many of the networks that created data warehouses described this set of activities as among their most complex and time-consuming.
Centralized administrative functions. As mentioned earlier, the networks visited primarily help health centers achieve administrative benefits through the enhanced use of IT. Networks providing centralized practice management applications often expanded their scope of services to include functions such as centralized claims processing. Most networks offer a liaison service to a claims clearinghouse capable of handling electronic claims submissions in a HIPAA-compliant manner. The use of clearinghouses aims to reduce the administrative cost of submitting paper claims and decreases the turnaround time on processing. Of networks investigated in this study, HCN provides the best example of centralized administrative functions, where a network-level executive serves as the centers’ Chief Financial Officer. The Community Care Network of Virginia (CCNV) also provides some centralized administration through a central billing office that several member health centers use.