The Underserved and Health Information Technology: Issues and Opportunities. Health IT Use Among Providers Treating the Underserved

11/01/2008

There are numerous models by which use of health IT by health care providers either on a community or institutional level can facilitate more effective and efficient delivery of care. Exhibit 2 below outlines some basic objectives of health care providers and demonstrates how health IT functionality can assist in meeting those goals.

Exhibit 2:

Health IT Functionality and Health Center Mission
Provider Objectives   Activities Enabled by Health IT
  • Provide Access to the Uninsured
  • Deliver Evidence-based Care
  • Actively Manage Chronic Illnesses
  • Improve Patient Safety
  • Improve Care Coordination
  • Maximize 3rd Party Reimbursement
  • Report to Funding Agencies
  • Reduce Administrative Costs
Leads to
  • Electronic referral to specialty care
  • Track eligibility for Medicaid
  • Track care delivered and outcomes
  • Generate reminders at point of care
  • Prescribe drugs electronically with built in
    formulary data and interaction warnings
  • Automate patient follow-up
  • Access to patient records online
  • Bill electronically
  • Generate custom reports

It should be noted that existing research on EHR adoption nationally shows relatively low rates of adoption, with estimates ranging from 4 percent for adoption of a fully functional EHR to 17 percent for any form of EHR using consensus based definitions.36 A survey of EHR adoption among federally funded community health centers that treat predominantly low income individuals demonstrates that these providers are less likely than private physicians to have adopted EHRs.37 The study did show, however, that a majority of federally qualified health centers planned on implementing EHRs in the near future.

There are numerous examples of the adoption of health IT among health centers and health center networks and that these providers are committed to using patient registries to support quality improvement programs that are proven to improve processes and outcomes of care for patients with chronic illnesses such as diabetes38. While still in their early stages, health center networks funded under a series of grant programs sponsored by the Health Resources and Services Administration (HRSA) have demonstrated that collaboration and pooling of resources and expertise can lead to broader scale adoption of EHRs among safety net providers and, with it, the potential to improve the quality of care delivered to the underserved39.

Another example of effective use of health IT among providers of the underserved is the Indian Health Services (IHS) which has led the way in addressing the needs of a very complex and underserved population. Because they are mandated by Congress to serve a very specific population with a set of special health risks and needs, for decades the IHS has long used a population health approach to monitor and track the health and health care of their patients through a Resource and Patient Management System (RPMS). In 2007, IHS released a graphical interface designed to work with the RPMS as well as an application called iCare that allows for automated review and tagging of patient level information from RPMS to facilitate timely detection of risk factors and diagnosis of illnesses.40 The interface along with RPMS and iCare represents a robust EHR with clinical decision support. IHS providers note that systems such as iCare that produce automatic alerts and suggest the likelihood that specific diagnoses and treatment approaches may be appropriate based on systematic, automated review of patient data can help maintain a high level of vigilance for opportunities to detect and prevent disease that disproportionately impact American Indian communities such as diabetes, childhood obesity and depression.

Finally, there are examples of community-based implementation of data warehouses and community tracking systems that seek to integrate patient-level data from providers caring for the underserved including information on demographics, clinical experience, health status and eligibility for public insurance programs in a system that is accessible to health care providers, case workers and other social service providers. These systems attempt to facilitate access to a range of social services. Several examples of these systems were initiated under the Healthy Communities Action Program (HCAP) and, while demonstrating some great potential, have proven difficult to sustain over time. Exhibit 3 below illustrates the model for one such program initiated in the state of Kentucky. The original program, known as SKYCAP originally, has subsequently changed its name to the “Kentucky Homeplace Program” after HCAP funding period ended. Kentucky Homeplace is currently funded by the Kentucky Department of Public Health and operates in Western, South Central, Southern, Southeast and Northeast Kentucky.

Exhibit 3: Overview of Kentucky Community Tracking database
Note: solid lines indicate data transfer; dotted lines indicate referral or other case management contact.

block diagram

This graphic illustrates the flow of data in and out of the SKYCAP Central Office and its community data base.  Data come from and go to 1) Public Health Department clinics, 2) safety net ambulatory care providers, 3) emergency departments and 4) social service providers, public housing and shelters.  In addition, family health navigators, who provide case management and care coordination, make referrals to these four types of entities and also provide data to and receive data from the community data base.

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