This document has presented findings from the first of three main project activities -- a comprehensive environmental scan including review of available printed materials and discussions with a limited group of thought leaders. Because of the unstructured nature of information in this area, we note that environmental scan findings are not intended to identify and definitively characterize all aspects of CHC experience with information systems. Instead, we have attempted to synthesize the background information on the characteristics of CHCs and health information systems as well as the easily available information on the success and challenges with design and implementation of health information systems in community health center settings. We have also characterized the overall vendor environment for clinic based health information systems and particularly those of specific relevance to CHCs. One of the main purposes of this environmental scan was to identify specific themes for further exploration during upcoming telephone interviews with 25 CHC and in-depth site visits with 7 of the 25 centers. We describe topics for additional study below.
Medical Manager/WebMD and vendor relationships generally. While there are a number of companies that CHCs have used for systems issues, the dominant vendor of practice management software to CHCs has been Medical Manger. This seems to be a result of a conscious effort to acquire competitors and develop customizations, such as automatic UDS reporting. Though they have achieved a substantial market share the future for product upgrades and support services for Medical Manager remains unclear. Thought leaders indicate that Medical Manager is not planning on developing a HIPAA compliant upgrade to their existing system for CHCs. There is also speculation that WebMD’s goal is to move CHCs (and other customers) to web-based software platforms - this will likely pose a problem for many current Medical Manager clients with limited access to high-speed Internet connectivity. The CHC experience with Medical Manager may reflect the larger challenges inherent in building relationships with vendors, including the impact of market and vendor volatility and the difficulty involved in procuring and managing vendors in areas where CHC staff traditionally have little expertise. Assisting CHCs in the vendor procurement and relations process has been a priority of HRSA. Our environmental scan findings confirm the importance of expanding CHC capabilities in this area and, in subsequent phases of this study, we will investigate CHC-vendor relationships and produce recommendations to inform current federal policies and programs in this area.
Models for community collaboration on health information management. HHS’ vision for a National Health Information Infrastructure (NHII) requires CHCs to work closely with other community health and social service stakeholders. Use of a common platform for practice management and clinical data systems across providers in a community provides economies of scale and facilitates generation of aggregate data for administrative, public health and public policy purposes. Obstacles to this type of coordination include the challenge of determining how to equitably share management and cost burden of such a system across providers and instituting effective user-training across multiple settings and user types. Although the CAP and SIMIS programs have encouraged the growth of collaborative systems investment and planning, many thought leaders indicate that coordination in developing proposals and securing grant money through these programs, does not always translate into effective collaboration the programs themselves. One notable exception to this trend is the Oregon Community Health Information Network (OCHIN). OCHIN has been able to leverage affiliations with prominent Oregon CHCs and the State’s primary care association to forge a State-wide information management program for community health care delivery, including use of a CAP grant for implementation of a community-wide practice management program and well developed plans to apply for a SIMIS grant to implement a common EMR across the same group of providers. Findings from the environmental scan confirm that OCHIN has been able to establish a unique level of collaboration across community health center stakeholders. Subsequent activities including stakeholder interviews and case studies will assess CHC involvement in community-wide information systems initiatives, strategies used by CHCs to overcome the challenges of community wide or regional collaboration and opportunities to replicate success models for collaboration such as OCHIN in other locations.
Challenges and opportunities related to HIPAA compliance. As described above, CHCs face a substantial challenge related to compliance with HIPAA administrative data standards. Results from the environmental scan indicate that almost all CHCs requested extensions for the compliance deadline. Furthermore, Medical Manager’s CHC practice management software does not accommodate HIPAA requirements and there is no apparent effort underway to upgrade the software for HIPAA compliance. Policy makers at HHS face the difficult task of attempting to encourage and ultimately mandate compliance with HIPAA-related data standards, while supporting the efforts of community-safety net providers to enhance their use of electronic data systems generally. While HIPAA presents a daunting challenge for those CHCs who already use electronic data transfer for billing and reporting purposes, it may serve as an impetus for achieving common (compliant) data format and standards across health care providers. Furthermore, HHS efforts to support the use of HIPAA compliant data exchange models may facilitate the use of electronic data systems among CHCs that still rely on paper-driven processes for administration and billing. Subsequent phases of this project will include detailed investigation of CHCs plans related to HIPAA including strategies for overcoming barriers to compliance and new systems related opportunities that emerge from HIPAA compliance related efforts.
Wide disparities in use of information systems. Findings from the environmental scan confirm that there exist large disparities in the use of information systems for administrative and clinical functions at CHCs. While a main focus of this project will be to identify successful models of CHC systems design and implementation that may be replicable in other settings, the goals of the project also require some investigation of a representative group of CHCs. This group will include those CHCs, that, similar to other providers, demonstrate relatively limited use of electronic systems. Looking at these centers will allow us to describe in detail the basic resource and knowledge constraints facing small- to medium-sized community-based health care providers, including those rural CHCs that are not able to pool resources across a network of providers. In order to provide both a broad picture of CHC experience and opportunities with information systems anda thorough understanding of leading models for integration of systems into the management of CHCs, we plan on using a two-pronged strategy for selecting CHCs for the next stages of the project: we will set aside some (e.g., 8-10) of the interviews to speak with a relatively representative group of CHCs, including those with relatively little access to advanced systems technologies. This will allow appropriate and accurate characterization of the overall CHC experience. With the remaining CHC interviews and subsequent case studies, we will focus on those CHCs, urban and rural, that have some demonstrated successes in information management. This will enable us to characterize various models of CHC IT experience and to compare these models in terms of consistency with the NHII vision, sustainability of progress and replicability in other settings. Furthermore, in looking closely at these CHCs and, in many cases, their networks, we will have the opportunity to assess the impact the various BPHC and privately funded efforts in this area and identify opportunities to enhance these programs over time. A table of potential sites for future study is included as Appendix 3 to this report. Appendix 5 outlines our plans for conducting the CHC interviews and provides information on Community HealthNet and other community providers in Indianapolis, IN the setting identified early in the project as a key target for a site visit.