Providers who disproportionately care for the underserved often face different circumstances and barriers in effectively providing care. Some of these challenges reappear in implementing health IT among providers working with the underserved. For example, community health centers often work with patients who have complex mental and physical health needs.41 The complexity of these needs results in a an integrated services approach to care where medical care, mental health care, dental care and case management may be provided by the same institution. While these providers can help to fully address the needs of the most underserved individuals, the provision of a more holistic set of services can make health IT implementations more difficult. Robert Miller and Christopher West explain: “This complexity increases EHR-related costs for CHCs, because it increases the complexity of CIS changes, staff training, and complementary process changes.” Additionally, chronic resource constraints make the capital investments necessary for health IT a near impossibility.42
While many of the concerns listed above are specific to community health centers and others that disproportionately care for the underserved, many of the barriers to health IT adoption in these settings resemble those faced by providers generally. Issues of workflow redesign, change management and health information exchange appear similarly difficult among those who care for the underserved and other providers. This similarity suggests that wider efforts to address some of the difficulties in health IT adoption may prove effective in underserved environments.
Despite the similarity in barriers, many point to differences in provider adoption rates as a clear sign that progress needs to be made in underserved environments. Some of the key issues and challenges facing safety net providers seeking to implement health IT are elaborated below.
Financing health IT. As might be expected, the most common issue or challenge associated with health IT adoption for providers caring for the underserved is the lack of access to capital to make necessary investments in the start-up and maintenance costs associated with health IT adoption. Because many of these providers are publicly funded, non-profit institutions such as federally qualified health centers or publicly funded hospitals operating on a low or no profit basis, they are not in a position to make significant capital investments that will not result directly in increased revenue through expansion of their patient base or scope of services. Federally qualified health centers also report feeling financially constrained due to limits on their ability to use grant funds meant predominantly to fund direct services to patients to finance health IT adoption that will enhance the overall quality and efficiency of the services they provide.
Vendor selection and customization. Given the diversity among individuals that could be considered among the underserved at any given time, providers seeking adoption of health IT for quality improvement must pay particular attention to the relationship between the health and cultural characteristics of their target populations and the features, functionalities and customization they will require from their health IT applications. For example, providers who treat a predominantly middle age to elderly African American population may want to assure that their EHR system supports diabetes registries and can transfer any registry data from legacy systems into the new application. In addition, providers treating the underserved often are funded from a variety of sources and are required to generate a variety of specified reports to those funders on a regular basis. Many EHRs have rudimentary applications for running custom reports, so it often takes additional resources and attention to assure that appropriate reports can be produced accurately and efficiently.
Finding the right strategy to empower patients. Given the importance of focusing on health IT as a means to the end of improving health and health care for underserved individuals, providers work to set up systems to best support a clinical workflow that provides the greatest opportunity of empowering patients to take an active role in the management of their own care. In the case of some underserved populations, this would require systems to prompt staff to conduct frequent reminders for patients who are due for specific clinical exams, vaccinations or diagnostic tests. How and when this prompting occurs (i.e., by phone, text message or email in the morning or the evening) may depend on circumstances (e.g., work hours, access to computers) of the individual patients as well as the hours of operation of the health center. Health centers that treat specific populations, e.g., homeless persons, day laborers, farm workers or low skilled or low waged employees may need to institute specific prompting strategies that reflect predominant characteristics among their patients. In addition, among some populations it is important that such prompts be directed to family members or surrogates in addition to the patients themselves.
Maintaining cultural competence and trust in a computerized environment. While there is limited information regarding the attitudes of patients generally with respect to health IT use among providers, some anticipate that patients will have concerns both related to the security and privacy of their health information if it is maintained and used in electronic form and in the potential erosion of some aspects of the doctor patient relationship if there is a computer mediating their interactions in the exam room43. There is also some evidence that racial and ethnic minorities, new immigrants and other groups that are disproportionately among the underserved have less trust in the health care system than the general population44. As such, it will be important for community leaders and public health officials to reach out to members of their patient community prior to health IT adoption to explain the benefits of health IT adoption and describe exactly how the care they receive and manner in which their health information is handled will or will not change. Furthermore, the extent to which providers refer to the computer during a clinical exam may be different for populations with limited English proficiency who may require more focused communication with the clinician to exchange critical information.