Findings from the environmental scan informed the second major phase of the study involving in-depth case studies. Site visits supporting each case study were conducted at seven communities or states across the nation from October 2003 through September 2004. Each case study entailed a series of in-person and telephone discussions with leadership and staff members at health centers, health center networks and other stakeholder organizations such as PCAs, public health departments and Medicaid offices. Thought leaders consulted for the environmental scan suggested candidate sites based on the presence of Section 330 health centers that had made progress in their use of IT as part of their local or regional network. ASPE and HRSA made the final site visit selections. Each case study represents a somewhat different functional and organizational model to allow for meaningful comparisons.
Prior to site visits, NORC staff conducted preliminary phone conversations with health center and state government stakeholders to introduce the study and identify appropriate respondents. Site visits lasted one or two days and respondents for structured discussions at each site were identified through a combination of government leads, leads from other respondents, and targeted literature and web searches. Teams consisted of at least one senior staff member and one research assistant primarily responsible for taking notes. One of the case studies, in Kentucky, involved a series of detailed telephone calls with key stakeholders but did not include an on-site component. Overall, we conducted discussions with over 120 respondents from among health center staff and other stakeholders.
Data was collected using instruments tailored to each respondent that allowed us to collect detailed, qualitative data on key topics. Each guide included background information on the respondent and highlighted outstanding questions for the team to address. ASPE and BPHC approved the guides prior to initiation of the site visits. In addition, NORC submitted technology inventory forms to health center respondents prior to each site visit as a supplement to data collected through the discussions. The forms consisted of a short table which took a “snapshot” inventory of the health centers’ networking, data and technology capacity. The data collected revealed the degrees of variation in health IT capacity based on differences in size and health IT sophistication among respondent health centers.
Exhibit 1 below lists respondent groups consulted for each case study including health centers, health center networks and other stakeholders. Network leadership generally included the President, Chief Executive Officer (CEO) or Chief Information Officer (CIO) of the network and other network leaders. Health center respondents included administrators such as the Executive Director (ED) or Chief Financial Officer (CFO) as well as information systems staff. In addition, we spoke with clinicians and other end-users of technology, such as billing clerks.
If key respondents were unavailable during the time of the site visit, the team conducted follow-up discussions with the respondent after the site visit was complete. Additional inputs to the findings from each case study included the review of documentation that respondents made available to the team during the discussions.
We queried individual health centers on their overall approach to health IT, technical capacity and systems, major uses of systems and any challenges they face in adopting technologies. Network directors were asked about the origins and organization of the network, how health IT fits into their goals and mission, and any challenges they faced or currently face in adopting systems. Other stakeholders were asked about their involvement with health center IT initiatives, uses of data produced by shared systems, and their role in future safety net health IT initiatives. Themes covered across respondents are described in further detail below.
- Overall approach to health IT. We asked health center directors to discuss the level of resources dedicated to IT (relative to other areas), the process for planning and decision-making around IT and the health center or network’s approach to compliance with privacy regulations.
- IT infrastructure. We asked health centers to describe their hardware capacity, connectivity and data management capability. In addition, we queried on their level of internal staffing, use of vendors and outsourcing of IT functions.
- Major uses of IT. We asked health centers and networks to list major IT applications (from the MS Office suite to disease registries and EHR) used and their primary functions.
- Enablers and barriers to technology adoption. We asked respondents to describe their motivation for adopting health IT, keys to any success, and what challenges they faced in terms of regulatory, organizational, cultural or financial barriers to adoption.
- Participation in networks and vision for the future. Health centers addressed the benefits and challenges of network participation and steps that the health centers planned to take in the future related to health IT and community partnerships.
- Network governance, organization and services. Network leadership specifically were asked to describe how the network was organized and funded, what types of services they provide to member health centers, and the resulting outcomes of these services.
- Technology tools and community health. We queried network and broader community health leaders on their current and future strategies to coordinate care on a community level using IT and health IT.