Community Health Center Information Systems Assessment: Issues and Opportunities. Final Report. Virginia

NORC at the University of Chicago (NORC) is pleased to present this report detailing findings from our recent site visit to Virginia for “Community Health Center Information Systems Assessment: Issues and Opportunities.” NORC conducted this site visit under contract with the Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services (HHS). In coordination with ASPE, the Health Resources and Services Administration (HRSA) and its Bureau of Primary Healthcare (BPHC) provide technical direction for this project.

The current site visit focuses on ongoing efforts in the State of Virginia and, in particular, the Richmond metropolitan area to support enhancements in information systems capacity at BPHC-funded consolidated health centers. We began the site visit with the goal of understanding the information systems capacity at consolidated health centers in Virginia, systems related issues and challenges faced by health centers, and their experience working with two prominent federally funded consortia focused on specific information systems-based projects. Findings presented here will be combined with findings from other site visits and related project activities to help elucidate the current state of health information system use by consolidated health centers, challenges facing health centers in this area, the context of health center information systems activities and models for successful collaboration around health center information systems issues. We organize the site visit report as follows.

• Background and Methods. This section describes key features of the site visit including background on the ambulatory care safety net in the city of Richmond and State of Virginia and details on who we met with as part of the site visit.
• State and Local Initiatives. This section describes the activities and infrastructure of two collaborations investigated as part of this site visit: the Community Care Network of Virginia (CCNV) and the Richmond Enhancing Access to Community Health Care (REACH) consortium. Both of these efforts are funded through grants provided by BPHC.
• Health Center Capacity and Perspectives. Because the project focuses on consolidated health centers and their experiences with use of health information systems, this section presents findings from our interviews with seven ambulatory care safety net providers in Richmond and other parts of Virginia. The majority of these providers are consolidated health centers funded primarily through Section 330 grants administered by BPHC.
• Conclusions. This section presents conclusions and lessons learned from the site visit.

Twenty-seven consolidated health centers currently operate within the State of Virginia and three more will go live in the coming months. The majority of these centers are in rural locations scattered throughout Virginia, with heavier concentrations in the southeast and southwest areas of the state. Four health centers, including two CHCs, support the Richmond population, 21 percent of which is below 100 percent FPL. Statewide, more than one million people — 14.9 percent of the population — are uninsured; the most current estimates for Richmond indicate that 8,265 of the city’s children were uninsured as of February 2003 (there are no estimates for number of uninsured adults).⁸ As of 1998, 689,571 Virginians were enrolled in the state Medicaid program, 61.7 percent of which were covered through a managed care plan.⁹

In addition to receiving core funding through the federal BPHC, consolidated health centers in Virginia interact with and are supported by a number of Government and association entities. In particular, the Virginia Primary Care Association (VPCA) has provided technical assistance and advocacy support for ambulatory care safety net providers in Virginia for several decades. In addition to the VPCA, health centers are supported by the State’s primary care office (PCO) housed in the Virginia Department of Health Office of State Health Planning and Policy. Consolidated health centers in Virginia also interact with various Medicaid payers. Distinct from many States, Virginia’s Medicaid office sits in a separate Department of Medical Assistance, not within the Department of Health with the State’s PCO.

Consolidated health centers also work with each other through various State and community-level consortia. Two of these consortia, REACH and the CCNV, are featured in this report. Our discussions with stakeholders suggest that government and association support for health centers is largely distributed among distinct organizations and that coordination between offices is sporadic, though there is some evidence of increased communication and coordination over the past year.

Methods. The site visit to Virginia involved initial telephone and email contacts followed with in-person interviews with 22 respondents representing 10 institutions involved in the primary health care safety net in the State of Virginia. Because of the concentration of both community health centers and BPHC-funded consortia in Richmond, we focused our site visit around health centers and stakeholders located in this area. To assure that we received a variety of perspectives capturing health center systems resources and experience, we conducted telephone interviews with a number of non-Richmond area health centers following the main site visit. Table 1 below lists all health centers and other stakeholders interviewed as part of the site visit and follow-up telephone calls.

Telephone discussions and in-person interviews with respondents were conducted using open-ended discussion guides that provided some structure to each exchange while allowing sufficient flexibility to capture all relevant information from each respondent. In addition, a table shell was emailed to information systems staff at respondent health centers prior to the site visit to facilitate collection of standard information relating to infrastructure and technical capacity. For each scheduled site visit interview, the NORC team prepared materials that outlined our preliminary knowledge of the respondent and highlighted outstanding questions to address during the interview. Examples of discussion guides, other data gathering tools and preparation materials used in the site visit are included as Appendices A and B. 

As mentioned above, site selection for the current project depends largely on the presence of ongoing activity related to building health information system capacity and infrastructure among consolidated health centers. As such, many of the sites selected are States or local areas where consolidated health centers and other safety net stakeholders are collaborating around community, State or regional approaches to enhancing information system capacity. This site visit focused on two of these collaborations: CCNV, a for profit management services organization providing business and systems support to consolidated health centers and other providers throughout the State, and REACH, a smaller initiative focused on supporting safety net care in the Richmond metropolitan area. This section of the report describes both of these initiatives in greater detail.

In addition to extensive discussions with leadership at CCNV/ComCare, the VPCA, and REACH, core site visit activities included in person or telephone meetings with seven community-based ambulatory care safety net providers in Richmond and other parts of Virginia. Overall, we found that health centers interviewed in Virginia differ substantially in terms of their access to information systems resources. As expected, we found that larger health centers have greater ability to acquire resources using general revenues and are more likely to have dedicated systems staff and ongoing planning around systems issues. We also found that health centers with affiliations to a larger health system such as an academic medical center benefit from increased access to systems resources. For example, we spoke with one center affiliated with the Virginia Commonwealth University health system, which provides all its centers with access to Cerner practice management software, 24-hour IT support, and plans to implement an electronic medical record.

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.