Acknowledging health center arguments that “one size does not fit all” in the case of practice management as well as the understandable reluctance on the part of health centers with an established practice management system to change to a different community-wide application, the HFP decided to focus community-level information systems efforts around developing a data warehouse which pulls data from individual health center systems into a common format to facilitate assessment of health care experience on a community or health center level. While some health centers eagerly await the enhanced data access and reported functionalities promised by the data warehouse project, some remain skeptical of the merits of the project.
Multiple hurdles to interfacing practice management systems. The experience in Philadelphia highlights the substantial challenges associated with developing and using data tools that pull data from disparate systems into a single database. First, the design of the database structure and the knowledge embedded in the structure may be considered the intellectual property of, not the health center. As such, obtaining specifications necessary to implement interfaces across practice management systems requires extensive negotiation with each vendor. In some cases, vendors simply refuse to provide access to these specifications regardless of the proposed application. In addition, health centers often use their practice management systems idiosyncratically. Under these circumstances, developing standard data requirements and developing extracts to pull consistent data across systems requires significant investment to investigate and reconcile each health centers data management practices.
Changing vendor landscape. Fluidity in the products and services available to health centers from information systems vendors also contributes to the challenge of implementing community-wide data projects. Rapid consolidation among practice management vendors has led to discontinuation of support for many practice management products causing unpredictable changes in the software a health center will use from one year to the next. Programs designed to extract data from one health center practice management system will not be useful in subsequent years if the health center switches systems or if the existing product is modified in such a way in which the database design changes.
Data access and reporting issues are key. Despite the delays in fully implementing the data warehouse, the four participating health centers we spoke with indicated that they were very excited at the warehouse’s potential. Although none of these centers have used the system to generate reports to date, they have been able to identify errors and missing elements in their records and in some cases correct the problems. The drill-down capabilities of the software are extensive and will allow the centers to locate bad data as well as to perform detailed manipulations. In addition, respondents anticipated the ability to share information and best practices across individual sites as well as health centers. This enthusiasm reflects a common complaint regarding poor access to data and reporting flexibility using commonly available practice management products.
Health center organizational orientation and approach differs. Interestingly, larger consolidated health centers interviewed in Philadelphia took different positions with respect to their willingness to share their practice management data on a community level. Some health centers participating in the data warehouse indicated going through a process where at first they were worried about the implications of sharing data that could be used to compare health centers on quality of care issues, but slowly bought into the idea because of the promise of having access to data that they could readily use to support robust continuous quality improvement efforts. These health centers generally warmed up to the idea that the data warehouse would provide them with a valuable opportunity to learn from others. Other health centers candidly expressed that there was some degree of competition within the city among consolidated health center providers and that they didn’t understand the benefit to their health center in participating in the data warehouse.
Defining the role for public health. In some ways the ultimate success of the data warehouse project in Philadelphia may hinge on the successful integration from the single largest ambulatory care safety net provider in the area, the Department of Health’s AHS clinics. Integration of the AHS clinics’ would not only substantially expand the data available for analysis within the data warehouse, it might signal the potential public health applications of the data warehouse. Experience has shown that appeals to collaborate based on the project providing necessary services to individual health centers does not always work in situations where health centers feel comfortable with their in house capacity and expertise. Instead, endorsement from the public health department and their clinics may establish a feeling that participation in the data warehouse is the “right thing to do” from a public health perspective regardless of gains for individual centers. To do this, HFP would have to continue working with AHS, not only to integrate data from the AHS clinics, but also establish an analytic program where data warehouse output could meaningfully inform local and regional public health policy on an ongoing basis.