Findings from Virginia illustrate important opportunities and challenges facing consortia that work with health centers to maximize benefits from administrative and clinical information systems. Many of the conclusions presented here highlight challenges owed to the rapidly changing context for safety net activities in Virginia and elsewhere.
Network participants have diverse needs which are not always met. While the health centers generally applauded CCNV’s efforts to address the need to support a basic platform for practice management, many centers indicated that they continue to face important unmet needs. For example, most health centers we spoke with lacked confidence that they were gaining the full benefits from their use of the MegaWest system due to lack of in-house IT expertise. On the other extreme, health centers that enjoyed ample resources for hiring senior information systems staff have been opting out of participation in CCNV for practice management, citing greater flexibility and efficiency from setting up individual relationships with practice management vendors.
This situation highlights the importance of and the challenges associated with meeting the broad spectrum of needs facing health centers of all sizes and levels of access. Less sophisticated health centers expressed the desire for services such as basic technical support (e.g., network connectivity), training, user support (e.g., helpdesk) and application services (e.g., a hosted application), but larger health centers with an existing systems infrastructure believed they would benefit more from interfaces linking their existing tools to community or State-wide systems. In all cases, the ability to customize services to meet diverse health center needs was seen as an important capability.
A changing environment poses special challenges. As in other areas, the ambulatory safety net provider landscape in Virginia has changed rapidly over the last four years. Health center and consortia are at risk for losses resulting from prior infrastructure investments that leave them with limited ability to adapt to these changes. As such, the ability to anticipate these changes and actively assist health centers avoid this potential danger is crucial. For example, some consortia have established efficient exit procedures allowing health centers to opt out of specific aspects of collaborative activities, recognizing that the needs and resources of health centers are likely to evolve. Furthermore, several centers mentioned that they would like to conduct regular vendor evaluation and re-assessment, but did not have the resources to do so themselves and therefore saw CCNV as a potential agent for this kind of activity. Having exit procedures and ongoing vendor assessment emphasize the flexibility of the consortium and its focus on meeting health centers’ evolving needs.
The need for ongoing vendor re-evaluation is particularly critical in light of the perception that MegaWest is not a priority product for Companion. CCNV regards MegaWest and Companion as a viable solution at this time, but if it is truly the case that the MegaWest application is not a priority for Companion, then it is likely that its viability as a solution will degrade over time and CCNV would find itself in the position of needing to migrate to another solution in order to provide current levels of service. This is not an unusual situation in that all software products and services solutions have known lifecycles which include migration to new products and technologies. However, it highlights the need to build in flexibility to any model for procuring and managing vendors.
Consortia can leverage sophistication of high end health centers. In trying to assure that the needs of all health centers are accommodated, the larger, more sophisticated health centers can provide an invaluable source of leadership and direction. Gains from systematic thinking on the part of those health centers with more resources to hire management staff with technical backgrounds can be spread to all consortium members through regular and open communication regarding system performance, unmet needs and strategies that can be implemented on health center or consortium-wide level. For example, several smaller health centers in Virginia appreciated the casual communication between themselves and larger, more sophisticated partners, but thought that a more extensive collaboration process would be of benefit to both parties. Existing solutions should be open to review and reconsideration.
Financial constraints contribute to the unequal status and lesser potential of smaller centers. While large, well-established safety net providers have the financial viability and resources to implement solutions independently if need be, smaller centers rarely have this option and must rely on consortium activities or outside funding to address their needs. This situation can result in two “tiers” of network partners, with the potential to adversely affect potential for collaboration. The specific challenge for policy makers and consortia leadership is to develop mechanisms that allow smaller health centers to benefit from the sophistication of those health centers with greater access to resources, while giving the larger centers a strong incentive to provide that assistance.
Coordination of support activities between regional health stakeholders is vital. One important frustration voiced by health centers in Virginia and elsewhere focuses around less than appropriate coordination and communication around ongoing grants, administrative, and support activities between the key players. For example, while stakeholders suggested collaboration, we found limited evidence of interaction on health systems issues between key organizations such as CCNV, the VPCA, REACH, the DOH Office of Primary Care, and the State Medicaid office. In addition to missing out on some opportunities to capitalize on collaboration, the distributed support atmosphere puts additional burden on health center leadership looking for involvement and support from each of these separate entities.