The following paragraphs highlight challenges identified for OCHIN and health centers from the discussion above. In addition to operational challenges we describe those challenges related to their perception by the larger safety net and public health policy community in Oregon.
Supplementing and enhancing existing application functionality. While most the Oregon health centers indicated that the Epic application provides them with the important functionalities required for compliance with federal rules and efficient administrative management, many report that important enhancements to existing functionalities are required. In particular, health centers with no dedicated IS staff reported an interest in seeing a more user-friendly reporting and billing systems, that would allow non-technical health center staff to more independently create specialized reports and billing formats as necessary. In addition, almost all health centers indicated being ready and willing to move forward with EMR and clinical decision support applications, stating that clinicians for the most part were eager to begin using these types of systems.
Capacity of data storage and WAN infrastructure. OCHIN has made substantial investments in server and network technology to secure data storage and transfer capacity that exceeds current requirements. However, expansions to additional IPM partners and addition of applications may, at any time, lead to steep increases in capacity requirements. This is a particular challenge because, to date, OCHIN has successfully acquired adequate technology and communications services at discounted pricing because of active planning on their part and their ability to “sell” vendors on the importance of their mission. There is no guarantee that these types of arrangements will be available moving forward.
Collaboration under the ASP model. As mentioned above, the ASP model offers both substantial benefits and some potential problems for collaborations like OCHIN. The two primary pitfalls are processes surrounding customization and release strategies. ASPs work best when all of their customers’ needs are identical; this keeps custom application development to a minimum. When customers require customizations, as the health centers have, one of two approaches can be taken. The ASP can either build customizations on a per-customer basis, or the ASP can require that all customers agree to the customizations (in essence, treating all customers’ needs as identical).
OCHIN has elected to work with the latter approach requiring “free” customizations to be agreed upon by all IPM partners. In the event that one IPM partner requires specialized customizations that are not relevant to a broader group of stakeholders, they must fund the customization on their own. This is particularly difficult for smaller health centers that have needs distinct from larger centers, limited internal systems resources to implement reporting customizations on their own, and fewer resources to draw on to fund special customizations.
Cost of OCHIN to health centers. Most health centers that decided not to become IPM partners in OCHIN cited cost as the largest barrier to joining. Both the start-up cost and the per-encounter cost required by OCHIN were especially burdensome for smaller health centers. The start-up costs include Epic’s fees, licensing costs and any necessary hardware upgrades, which can cost centers anywhere from $50,000 to $100,000 depending on how many licenses are needed and how many upgrades need to be performed. The centers also have to pay a $1.04 per patient encounter fee. This per encounter cost can increase during periods when OCHIN is expanding to another health center.
Some, such as La Clinica del Valle, a consolidated health center in Medford, OR, stated that their concerns about joining OCHIN were partially related to the per-encounter costs, which created a disincentive for their goals of expansion. While this is a typical pricing scheme for ASP models such as OCHIN, it is one that health centers are unfamiliar with and which can become a barrier to participation. Even larger-size health centers that had more resources, such as Northwest Primary Care in Salem, OR, had reservations about participating in OCHIN because they believed there was no way to ensure that costs would stay below a certain threshold. In other words, being a part of the collaborative forced them to lose total control over their cost structure and they would be unable to control overall costs individually.
Future expansion and solvency.OCHIN’s structure necessitates that the program expand substantially to maintain financial viability and achieve independence over time. Ideally for OCHIN, the total patient population served by their IPM partners (existing and new) would at least double its current numbers. This expansion will require working with health centers both outside of the state and potentially outside of the entire Northwest region. However, this expansion is not guaranteed: OCHIN has accrued a substantial and early market share, but Oregon’s second largest consolidated health center has declined to participate in the network. Furthermore, as the experience from Seattle demonstrates, out of State providers pose special challenges to OCHIN because of differences in Medicaid billing requirements by State as well as problems with establishing a healthy collaborative atmosphere when IPM partners are too geographically distant for regular, in person meetings. Some health centers felt that the current model for achieving financial solvency through expansion is not realistic and leaves the network financially exposed in the medium to long term.
Service delivery (e.g., training).Although feedback about OCHIN from participating health centers was generally positive, several raised concerns about the organization’s record of providing program support and training to center staff. This was particularly an issue among smaller health centers, which tend to have little internal systems expertise and depend heavily on OCHIN’s IS staff. Reports indicated that key services, such as training, are of mixed quality and in need of improvement. At the same time, OCHIN will need to expand their business in the future to provide EMR to the IPM partners and collaborators, putting stress on their in-house systems personnel and financial resources.
Support from non-provider safety net stakeholders. Although by and large complimentary, stakeholders from government, payer organizations and associations were acutely aware of challenges facing OCHIN related to expansion to smaller health centers and maintaining a balance between a robust system and a costly system. They acknowledge a tension within OCHIN in terms of how best to simultaneously achieve a stable financial model, robustly meet the disparate operational needs of safety net providers in the State and support public health policy. One respondent expressed the sentiment that OCHIN’s longer term success depends on its ability to hold and consolidate gains as they are made in addition to looking ahead towards their next project.