We queried health center leadership on how their center made decisions regarding IT and the level of priority afforded to IT in the organization overall. We also asked specifically about trends in IT spending and recent changes in their staffing and organizational approach to IT. Overall, we found that health centers’ approach to IT is evolving along with changes in reimbursement for health care delivery and regulation related to maintaining and exchanging health data. In addition, we found that health centers have increased their focus on disease management and quality improvement leading to increased demand for health IT.
IT Planning and Decision Making. Case study findings indicate that there is substantial variation in the extent to which individual health centers develop strategic plans around IT investment. While nearly all center leadership recognized the need for such processes and noted that a having a strategic vision around these investments was desirable, many smaller or mid-sized providers cited a lack of the resources (both financial and personnel) necessary for such planning. These smaller centers indicated that IT decisions were generally made on an ad-hoc basis, often when they were “forced” to make a change because the vendor discontinued support for the application they were using.
Larger centers were more likely to have developed formal strategic planning and investment initiatives. For example, one large Virginia health center’s Board of Directors had formulated — on the recommendation of the center’s CIO — a strategic plan that prioritized re-allocating budget allotments to permit systems upgrading, staff training in IT, and pursuing investment in EHR. A Philadelphia health center reported going through a lengthy RFP process for selecting a practice management vendor and indicated that IT represented the top budget priority for their center moving forward. Overall, however, we found that this level of planning represented the exception rather than the rule for health centers.
For nearly all the health centers visited, the Board of Directors made the final decisions on IT investments. In health centers with a dedicated CIO or manager-level IT staff (only nine of the 38), recommendations for investment generally came from these staff members and were developed out of some type of systematic planning process. In other centers, recommendations for IT investments were made by committees comprised of the health centers’ administrative, financial and clinical leadership. Increasingly, health centers reported relying on networks to make (or help them make) major IT decisions.
Budget for IT. Health center IT budgets vary substantially. For example, some health centers indicated that IT was the most rapidly growing segment of their annual budgets, while one rural health center in Kentucky reported having no funds to spend on IT and relying on a completely paper-based office. While it was not feasible to systematically collect financial data from each health center, on average, health centers reported spending between two to five percent of their budgets on IT. Respondents frequently indicated that during periods of early ramping-up in information systems investment, IT budgets dramatically increased for a short time.
Funding Sources. We found that health centers fund IT investments from multiple sources. Basic expenditures such as hardware, office software and connectivity come out of the centers’ institutional Section 330 grant, but nearly all of the health centers we spoke with had access to IT-related Federal or state grant money through their regional network. As described in the background section, the Federal government maintains several grant programs aimed at supporting specific aspects of health center information technology service provision, management, and infrastructure and most health centers (33 of 38) consulted took advantage of one or more of these programs. Importantly, in two of the seven case studies, Boston and New Hampshire, private donations have been targeted towards the purchase of software licenses, which was a critical driver for EHR adoption.
Support Staff Resources. Health centers reported that recent investments in IT have largely gone toward improving staffing. Only seven centers reported having no in-house IT expertise. Smaller centers employed only one IT staff person, frequently part-time, to manage technical issues. Nineteen health centers employed between one and three IT staff, while two centers employed 10 or more IT staff.
Three health centers outsourced some or all of their IT support services to local companies, instead of employing internal staff. Some of these centers had long-term relationships with such consultants, who were involved from the beginning of the center’s IT implementations and had worked with the center to develop customizations to its practice management system. Smaller centers generally reported experiencing more problems with systems implementation and ongoing support. IT issues that would have been minor problems for a large center with on-site technical support staff could easily become major stumbling blocks for centers lacking such expertise.
As would be expected given our approach to selecting cases, we found that many health centers counted on networks to supplement their in-house IT expertise. In general, larger centers with their own dedicated IT staff tended to report having better technical support and fewer implementation and maintenance issues with health IT systems, irrespective of whether they also received support from a network.
Chief Information Officers (CIOs). Of the 38 health centers we spoke with, four had an in-house, full-time, dedicated staff member described as a CIO. Dedicated health center CIOs provided vision for prioritizing systems investment, expertise for selecting and managing IT vendors, and managerial experience for the implementation process. Five other centers had senior IT staff with titles such as “IS Coordinator” or “IT Director,” whose duties included managing the two to four support or programming staff and providing some systems investment direction. While these individuals managed other staff they often did not share decision making responsibility on the same level as health center executives. Several of the remaining centers had access to CIOs through their network affiliation.