Community Health Center Information Systems Assessment: Issues and Opportunities. Final Report. Support for CHC Information Systems


In recent years, the federal government have directed additional funding towards advancing CHC information management goals. In addition to programs focused exclusively on specific information management issues, CHCs have made use of more general grants to make important advances in IT. The main focus of these programs, described below, has been to encourage community-wide collaborations on systems issues. This type of collaboration helps pool costs to accommodate the substantial fixed costs of operating and maintaining systems and helps facilitate the important goal of seamless exchange of data across all relevant health care stakeholders.

Integrated Services Development Initiative (ISDI). The Integrated Services Development Initiative (ISDI) is a CHC focused grant that funds two major activities: (1) implementation joint practice management systems and EMR systems across centers in a single area and (2) to work with (or establish) managed care networks to maintain CHC share of clients eligible for Medicaid coverage. Since its initiation in 1994, the ISDI program has awarded approximately 70 grants (ranging from $250,000 to $400,000) for up to four years.

Shared Integrated Management Information Systems (SIMIS). The Shared Integrated Management Information Systems (SIMIS) grant administered by BPHC supports inter-center collaboration on systems issues. Funded grantees typically design and implement common platform and tools for centralized billing, utilization review and quality assurance. Another goal of the program is to encourage integration of administrative and clinical information management functions within and across centers. In addition to joint purchasing of HIS resources, the SIMIS program requires health centers to implement strategic model for community-wide systems decision-making including: fulfilling IT staffing needs, conducting employee trainings, optimizing use of software licenses and support contracts, planning for regulatory compliance and mapping out future systems-related investments.

Community Access Program (CAP). The Community Access Program (CAP) funds models for enhancing integration of safety net services provided in any community. Unlike the SIMIS program, CAP is not designed to exclusively support systems initiatives. Examples of activities funded under CAP include development of client eligibility tracking databases to be used by a range of community social service providers and establishment of a shared electronic medical records (EMR) system public health plans and safety net providers in a community. Although, not restricted to systems-specific initiatives, nearly all recent CAP grants include substantial allocation of funds for information systems issues. The Oregon Health Information Network’s (OCHIN) use of CAP to establish a common, state-wide system for practice management including safety-net health care providers and health plans represents a leading case of the use of a CAP grant for an information system enhancement and integration. CAP grants are currently found in 158 communities around the U.S. in urban, rural, and tribal areas.  

HIPAA-related support from HRSA.  A major regulatory compliance issue facing CHCs and other primary health care centers involved in electronic transfer of health care related information is adherence to Health Insurance Portability and Accountability Act (HIPAA) requirements for Standard Transactions and Code Sets, Privacy and Security. In an effort to assist CHCs in moving with the development and implementation of HIPAA compliant electronic data systems, HRSA has contracted with MGMA to conduct a series of technical assistance audio conferences. As an initial phase, MGMA conducted a focus group with CHC grantees to determine HIPAA implementation status and common problems. Focus group participants revealed that many vendors were not planning on developing HIPAA compliant software, instead directing clients to use data clearinghouses at extra cost. Based on this feedback, HRSA incorporated management and negotiation with vendors as an important aspect of the audio conference curriculum. To date, three audio conferences have been presented. The first audio conference on Standard Transactions and Code Sets drew 420 registrants and 1,500 listeners. Subsequent audio conferences focused on the privacy rule and drew over 1,000 listeners. Future audio conferences are being planned to cover the security rule as well as additional information on later stages of standard transactions and code set implementation, including testing systems with payers. Although thought leaders knowledgeable on CHC issues related to HIPAA compliance expressed support for the technical assistance effort, some expressed concern regarding CHC access to technical resources to implement recommendations provided as part of this effort.

Electronic Medical Records Resources Project. BPHC is currently working on an initiative to assist CHCs in developing effective Electronic Medical Records (EMR) and Disease Management (DM) systems to enhance the quality of care.  This effort hopes to identify the functional role that EMR and DM systems would ideally play for CHCs and help determine how CHCs can reach this ideal with their systems.  The project includes: in-depth research of EMRs history, goals, current status, and future direction; identifying current EMR vendors; interviewing health care providers as well as Health Information Management professionals to assess their Medical Record needs in addition to their opinion of currently available systems; and creating a set of functional specifications to establish a standard for ambulatory care EMR. BPHC is currently funding an EMR pilot program involving three California CHCs and provides extensive guidance on its website for CHCs interested in using EMR technology in their clinic. The project’s website also includes information on basic functional requirements for EMR vendors appropriate for community-based health centers, vendor assessments and guidance related to planning EMR projects.

Veterans Health Information Systems and Technology Architecture (VISTA). VISTA is a federally-run, publicly-owned health information software system administered by the Department of Veterans Affairs that has become available for use by some community-based providers.  First implemented in 1996, VISTA is a comprehensive system supporting all sizes of health care providers ranging from small community-based clinics to community hospitals to tertiary facilities, covering virtually all aspects of care.  Currently, VISTA is undergoing a number of modifications to enhance and improve its capabilities with the aim of forming both a next-generation VISTA system for the VA, Healthe-Vet VISTA, as well as a public version, Healthe- People VISTA, which will be made available to such entities as state departments of health, medical schools and physician group and solo practices and individual practices.  Currently VISTA automates patient records and provides VA clinicians with patient level information during encounters using a graphical user interface (GUI). The VISTA system has been incorporated by community health providers in Washington, DC, who received a grant from the Department of Commerce to fund the purchase and implementation of the software.  In addition, a new project will look at using VISTA in a number of community health settings in West Virginia, possibly hosted by one of the state’s universities or major hospitals in the area. We note that while many observers consider VISTA a strong model for health center information management, others note the challenge of adopting VISTA for non-VA use. Important requirements include development of clinical modules not relevant to the VA population such as pediatric care as well as recording and coding encounter data for billing purposes.  

Indian Health Service. Finally, the Indian Health Service also implements a computer-based health system known as Resource and Patient Management System (RPMS) to meet their health center management needs. Because IHS clinics are largely, rural and modestly staffed, the IHS currently does not use a GUI front end for data entry and clinical information dissemination (though IHS is in the process of developing a GUI). Instead, clinic staff enter data from a specifically designed encounter form into the RPMS system. This data entry includes comprehensive therapeutic and diagnostic information including CPT codes for billing. Specific information entered varies by diagnostic module. In addition to allowing for automated billing based on the encounter specific data entered into the system, for subsequent patient visits the encounter form can be printed out to include information on prior visits and serves as a clinical tool. Notably, a number of IHS tribal clinics, particularly those in Alaska and California are also designated as FQHCs eligible for Section 330 funding and so some FQHCs currently use the RPMS system.

Tides Foundation. In addition to public sector funders, some community providers receive support for technical infrastructure from charitable foundations. Most notably in partnership with the California Endowment, The Tides Foundation has granted approximately $30 million to help develop basic health infrastructure (i.e. automated accounting, practice management) for community-based safety net providers in California since 1999. Tides reports that 80% of funding has gone to individual primary care clinics with the remaining amount going to regional provider networks in California. The program targets funds towards centers that lack basic electronic resources such as Internet access or any form of automated information system. According to Tides much of the funding under this initiative goes toward planning and training health center staff. Specific grants have also gone toward implementation of practice management and EMR systems in community based health settings.

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