Although all networks investigated shared similar goals and basic governance models, we observed important variations in the path chosen to achieve network goals. In particular, networks differed widely in terms of their financial and operational model (level of integration, level of financial contribution from health centers) as well as their approach to partnerships. We found that, in many cases, these variations drove the types of functions and services provided by health center networks or the way in which different functions were prioritized.
In order to illustrate important differences among network models and demonstrate the relationship of these differences to actual network function, we divided the seven health center networks investigated as part of this study into three groups described in greater detail in the bullets below. Health center characteristics relevant to each of these models are presented in Exhibit 4 on the following page.
- Incremental adopters refers to the strategy taken by the health center networks in Oregon, Virginia and Florida to incrementally adopt IT systems based on prioritized objectives, beginning with practice management for the purpose of stabilizing health center operations, finances and administrative reporting and then graduating to roll-out of EHR and data warehousing applications on a network level to support quality of care and community health objectives. Key to the success (or non-success) of these networks is their ability to forge some basic consensus among health centers on decisions such as which practice management vendor to select or what type of customizations are appropriate for implementation across health centers. Because these networks provide networked applications, there is some basic level of integrated decision making that health centers must buy into. Finally, in addition to support through grant programs, these networks are funded, in large part, through membership dues and user fees collected from health centers or other providers receiving their services.
Exhibit 4: Dimensions of Network Variation
- Early EHR adopters. We characterize the Boston and New Hampshire networks as early EHR adopters because they rolled out a networked EHR without first establishing a networked practice management system. Reasons for moving directly to EHR were twofold, first that health center members were generally comfortable with the practice management systems they were using and second that the networks both received an infusion of private sector monies tagged for clinical system purchase and rollout. In general, roll-out of EHR occurred successfully for both of these networks that are now moving forward with developing additional reporting and data management functionality to maximize returns from EHR. In the case of CHAN, poor integration between the legacy practice management system and the newly implemented EHR in part prompted the health centers to adopt a new common practice management system that was interoperable with clinical systems. As with the incremental adopters, networks that offer networked EHR are funded, in part, through fees paid by individual health centers and must work to achieve integrated decision making on technology and support issues.
- Decentralized networks. Networks in Southeastern Kentucky and Philadelphia focused mainly on building systems to collect data on the safety net population and integrate data across individual health center systems in data warehouses. Of the networks visited, these were the most decentralized, with each health center maintaining their own systems and no use of network wide applications for internal functions. Although there have been some important successes in these cases, for the most part respondents indicated that the promise of community-based applications has not yet materialized because of technical difficulty in building interfaces and difficulties with incorporating community based applications into the workflow of individual provider institutions under a loosely connected network.