Creating EHR Networks in the Safety Net C A L I FOR N I A H EALTH C ARE F OU NDATION Introduction The goals of the analysis include: The adoption of electronic health records (EHRs) K Defining the value of an EHR network; has the potential to help medical practitioners raise the quality of their care, increase patient safety, K Understanding how an EHR network differs improve efficiency, and even produce cost savings. from a standard vendor offering; Issue Brief However, despite the increasing evidence for such K Identifying the considerations that safety-net benefits, most community clinics and health providers are likely to take into account when centers have yet to embrace the technology. Studies selecting an EHR network; and indicate that the adoption rate for EHRs among K Evaluating the future of EHR networks. these safety-net providers is less than 10 percent, compared to 52 percent for large medical practices.1,2 In developing this issue brief, Manatt Health Solutions employed a variety of primary and Three major studies have found cost to be the secondary research techniques, including: in-depth number one barrier to EHR adoption.3 However, interviews with three existing EHR networks; it is important to note that any successful interviews with the networks’ clinic members; adoption requires other significant direct and industry research; conversations with industry and indirect investments beyond the price of the software. These typically range from planning and EHR Networks and the HRSA preparation to implementation and optimization. The Health Resources and Services The majority of community clinics and health Administration (HRSA) refers to EHR networks centers are small, independent entities that often as “Health Center Controlled Networks lack the financial and staffing resources available (HCCNs).” Specifically, HRSA defines HCCNs as to larger organizations, such as integrated medical a network of public or private non-profit health centers who come together to form a network to practices and health systems, to fund and sustain plan, develop and implement health IT systems these requirements. (primarily EHRs), among other services that: • Improve access to care; This issue brief explores the network approach to • Increase efficiency, revenue, and productivity; EHRs and its potential to increase EHR adoption and among community clinics and health centers. For • Improve clinical quality and patient health the purposes of the analysis presented here, an status. EHR network is defined as a health information In addition, HCCNs have historically provided a technology partnership focused on community wide range of services within the core areas of administration, finance, information technology, clinics and health centers that provides services clinical and managed care, and are clinician/ to support the adoption of EHRs and other member driven. applications (see sidebar). Source: www.hrsa.gov/healthit/healthcenters.htm M arch 2008 academic experts; and the firm’s own field experience. K Quality improvement. “You can’t improve what you The authors concluded that a network approach can can’t measure” is a popular management adage, and provide California’s community clinics and health centers is a concept that builds the case for EHRs and other with the infrastructure and support that they need to health information technology as an effective vehicle efficiently implement EHR systems, ensuring that they for quality improvement (QI).5 While the EHR will have the tools and knowledge to remain at the forefront provide data to inform measurement, additional of delivering quality care to the safety net. attention to data cleanliness, aggregation, analysis, and application are necessary to improve quality The Challenge: Difficulties with Adoption and access to care. This not only necessitates more of EHRs among Community Clinics and specialized staff, but also often requires integration Health Centers with other technology platforms and vendor software EHR software often requires customization beyond the customizations. vendor’s offering to support health management functions K Hardware and technology operations. From a for particular populations, unique billing requirements, technology standpoint, successful EHR operation and multiple language patient education tools for the requires more consideration than simply loading safety net. These requirements demand additional time, software onto a server. Because an EHR alters technical expertise, safety-net experience and a level virtually every process and workflow, from patient of sophistication not often available or affordable to scheduling to billing, the operation and integration community clinics and health centers.4 of other technology applications are also affected. In addition, all clinical care providers rely on the EHR, Given the complexities of adoption and limited resources, making its availability and reliability essential to avoid it is not uncommon for safety-net providers to overlook an adverse impact on operations. An EHR requires or underestimate demands associated with adoption the existence and continual support of a robust beyond hardware, software, and implementation technology infrastructure, a complex environment components. While these components are certainly that demands dedicated personnel familiar with crucial, they are not sufficient to ensure success. its hardware, software, operating systems, security, backup and recovery, and disaster recovery Successful EHR adoption also requires: components. K Executive and staff commitment. Alignment across departments and key stakeholders is necessary to Many community clinics and health centers individually develop and promote an effective organizational adopt EHRs directly through a vendor without significant strategy for quality improvement. Commitment consideration of alternative approaches. With half of and buy-in across the organization are necessary EHR implementations ending in failure or disappointing for effective implementation and use of health results, one might question whether this is a viable information technology (HIT). strategy for members of the safety-net community.6 In an attempt to improve the odds, the New York City K Care process assessment. Systematic workflow Department of Health and Mental Hygiene is spending evaluation and redesign throughout the organization over $30 million on a group purchasing, quality- are necessary and require the commitment of all staff improvement customization, and service infrastructure and stakeholders for efficient implementation and development strategy. Other community-level providers effective use of an EHR. are taking advantage of recent regulatory changes by 2  |  California HealthCare Foundation adopting EHRs hosted by their local hospital in order Understanding the Value of an EHR to make use of its technical and quality improvement Network experience and infrastructure. For instance, The Just as information technology is a tool to support an Children’s Clinic in Los Angeles is partnering with Long organizational strategy or process, the typical EHR vendor Beach Memorial Hospital to adopt its existing EHR. can be thought of as providing the core components Alternative EHR adoption solutions, such as large-scale necessary to achieve the broader goal. EHR networks group purchasing and hospital-based partnerships, are deliver additional value by providing strategies for primarily a result of two market realities: building capacity and setting expectations that recognize the individual circumstances among community clinics K Few community clinics or health centers have access and health centers. They also offer the operational and to the in-house clinical, quality improvement, technical infrastructure, support services, educational and technical experience needed to navigate the resources, stability and economies of scale that help complexities of EHR adoption. alleviate the burden that small safety-net providers face in K Vendors are in the business of selling technology pursuing EHR adoption alone. products and do not typically provide assistance for EHR use beyond the software itself, the initial Figure 1 illustrates the core approach of the typical EHR implementation, and basic user training. Many vendor encircled in the additional services that an EHR vendors understate additional fees required to network can provide. customize a system to fit the needs of an individual provider. As a result, community clinics and Figure 1. Components for Successful EHR Adoption health centers must turn to external consulting resources or additional in-house staff for support, a time-consuming and expensive strategy that they Process Quality Improvement Change often cannot afford or sustain. and Population Health The consequences of these realities can range from Hardware and Implementation Technology Collaborative Operations Services Assistance long-drawn out implementations that diminish organizational stamina and morale to pulling the plug and EHR Software taking a loss. Software Support Technical and Change Operational Management Support Despite a high degree of discontent with these market Training Services dynamics, continued increase in safety-net demand has catalyzed a growing interest in a more comprehensive Workforce CCHC Development Customizations approach to EHR adoption, specifically an EHR network approach. Although they may sound similar to other multi-clinic consortia or networks in California, these Source: Manatt Health Solutions EHR networks are differentiated by their strong focus on HIT implementation and support services for — and beyond — their geographically defined membership base. Creating EHR Networks in the Safety Net  |  3 While EHR networks may have their own unique Vendor management. As many small health care technology platforms, products, services, approaches providers can attest, vendor management is often and areas of expertise, they have demonstrated that they time-consuming and challenging. From selection, can develop a targeted, more comprehensive solution contracting and issue resolution to system upgrades designed to meet the specific needs of community clinics and maintenance, EHR networks are an alternative and health centers. Common characteristics of an EHR to self-managing vendor relations. In addition, EHR network include: networks have the operational and technical expertise necessary to communicate more efficiently and effectively A focus on safety-net providers. EHR networks provide with vendors, saving precious time and resources for customized templates and workflow designs that are community clinics and health centers. preconfigured to meet the unique processes and staffing models of safety-net providers. Through repeated work Economies of scale. As a multi-entity organization, EHR with community clinics and health centers of varying networks can increase the value of an individual EHR readiness and capacities, EHR networks have built investment by employing bargaining power, minimizing systems tailored to serve particular patient populations, infrastructure redundancy, and drawing upon operational as well as administrative, operational, and integration and technical efficiencies. requirements necessary to implement a particular clinic’s strategy. “ side from the technical support and A knowledge base that an EHR network “ ou need the experience and resources Y offers, costs were a big factor for us. We’re to do a sustainable implementation. If a small clinic and we couldn’t have done I didn’t have anyone to talk to, I would it alone. Through an EHR network, we have felt lost. But as part of an EHR were able to share hardware, licensing, network, I can pick up the phone and customization, and maintenance costs call.” across clinics.” — Margaret Martinez, Chief Executive Officer Community Health Alliance of Pasadena — Will Raj, Chief Technology Officer Howard Brown Health Center Collaborative approach. EHR networks offer a collaborative approach to HIT adoption by creating Quality improvement and population-based services. a community of clinics and health centers. Through EHR networks understand that EHRs alone are not a long-term partnership and periodic interaction with sufficient to achieve quality of care improvement for their members, EHR networks are able to better take patients. Community clinics and health centers need HIT into account the dynamics and capacities unique to each applications that enable necessary data collection, analysis, provider and supply targeted services and guidance. and reporting, as well as support services to interpret and use these data to improve quality of and access to care for the underserved. In addition, safety-net providers 4  |  California HealthCare Foundation are better positioned to move from patient-specific Table 1. omparison of Vendor and EHR Network C Products and Services to population-specific disease management by taking N ecessar y S ervices f o r EHR advantage of EHR networks’ data aggregation services, E H R A d o pti o n V end o r N et w o r k which are essential for advanced analysis and management Executive Commitment of patient populations. Collaborative environment to facilitate ! U peer learning Change management resources ! ~ Training/workforce development. While vendors offer Care Process Improvement product training, it is typically limited to the basics of Readiness and needs assessments ! U EHR use in a generic, unconfigured environment. With Basic user training U U their specific focus on the needs of safety-net providers, Customized workflow training ~ U EHR networks can offer more customized training Workflow re-engineering ~ U and services in both QI and technical components, Workforce development ! U augmenting an organization’s ability to make full use of its Staff training ~ U capabilities. Building capacity among community clinics Operational support ~ U and health centers is a core tenet among EHR networks Quality Improvement because of the potential disruptions that can result from Educational resources ! U turnover among trained staff. EHR networks are more QI Expertise ~ U likely to develop creative training programs and capacity Population-based services ! U building models that avoid continuous onsite training. Hardware and Technology Operations Data center ! U Support services. In addition, EHR networks can Software configuration ~ U provide ancillary services such as 24-hour help desk Software maintenance U U support, claims management, accounting services, Installation U U disaster preparedness, integration support, and reporting Integration with existing system ~ ~ functions, all staffed by specialists with a safety-net focus. Integration support ~ ~ Technical expertise U U Table 1 provides a more detailed comparison of products Vendor management ! U and services typically provided by vendors and EHR Help-desk support ~ U networks. Disaster recovery ~ U Since vendors usually provide only a portion of the overall legend: U Typically provided in a basic service ~ May require additional cost services (and in some cases, functionality) necessary for ! Typically not provided in a basic service successful EHR adoption, a vendor may be able to offer Source: Manatt Health Solutions a lower up-front cost than an EHR network. However, the EHR network is able to offer a higher level of services and support customized to the safety net, as well as a long-term commitment to the successful adoption of an EHR system. Consequently, some community clinics and health centers have considered the EHR network more of a long-term investment partnership rather than a one-time technology purchase. Creating EHR Networks in the Safety Net  |  5 “ hen pursuing an EHR through either a W not-for-profit business model, allowing them to reinvest funds to reduce member costs or add necessary services. network approach or a vendor approach... the issue is not just which services are As a result, community clinics and health centers that provided, but their quality... A network use an EHR network may be better positioned to has the opportunity to provide more and allocate a significantly higher percentage of expenses to the installation, training, long-term support, and other better quality services because it can afford elements that are crucial to the successful adoption of an to hire and train specialized staff that can EHR system, including quality improvement, population- learn from each implementation, apply based services, care process redesign, and workforce those lessons to other community health development. This also implies that a greater amount of investment may be available for further infrastructure centers, and generally get better and better development to achieve quality-related strategies through at providing EHR services to members. EHR adoption. (With a vendor approach), individual community health centers must depend The current state of the vendor market — notably its lack of focus on the safety net and limited service on vendors that often provide insufficient offerings — has driven community clinics and health services and on staff or consultants that centers to procure and organize their own resources. are not as specialized...” Recognizing the value an intermediary organization can — Robert Miller, Professor of Health Economics bring to this problem, several vendors have partnered University of California, San Francisco (UCSF) Figure 2. HR Adoption Costs Incurred for Vendor versus E EHR Network Figure 2 shows the average initial and operating costs for six community clinics and health centers from Hardware $26,588 and maintenance $9,622 2004-2005, using the results of a study published in Health Affairs that compared high-level EHR adoption Software $20,888 and maintenance costs.6 The study highlights the difference in EHR $14,342 Vendor adoption cost allocations between a vendor and an EHR Installation $9,215 Network network approach, or “what” and “how much” these and training $17,568 safety-net providers typically incurred for specific EHR $10,840 Support adoption services. The results reveal that those that and training $12,111 pursued EHR adoption through a vendor approach spent $5,145 a higher percentage of their expenses on hardware and Productivity loss $5,000 software purchases. This difference reflects the economies $5,697 of scale, volume discounts, and shared data centers that Other $8,380 allow EHR networks to offer lower marginal prices for hardware and software. In addition, EHR networks Source: Miller, R.H. and C. West. “The Value of Electronic Health Records in Community Health Centers: Implications for Policy” Health Affairs Jan/Feb 2007 26(1):206 – 214. are member-driven organizations that operate under a 6  |  California HealthCare Foundation with EHR networks and other value-added resellers to operational, and technical resources to the EHR assist them in customizing their product and promoting implementation; adoption within the safety net. For example, EPIC, K Those with an interest in working with and learning an EHR vendor that typically works only with large from other clinics or health centers that have already organizations, has partnered with the Our Community adopted an EHR system; and Health Information Network (OCHIN) to provide a more tailored product by drawing upon an EHR K Organizations that want to implement disease network’s safety-net expertise and implementation management and QI programs predicated upon an knowledge. Similarly, in addition to its VAR relationships, EHR system. GE Centricity has a partnership with Alliance of Chicago Community Health Services that provides On the other hand, there are several types of safety-net a robust QI-focused EHR with data and workflow providers for which an EHR network approach may not services designed to advance care improvement. Another be the best option. These include: prominent player in the EHR market, eClinical Works K Organizations that already have robust technology (more commonly known as eCW), is a key partner and QI expertise, maturity, and infrastructure; of both the New York City Department of Health and Mental Hygiene initiative and the Health Choice K Those with customized requirements that may differ Network, a Florida-based EHR network. These three from the average community clinic or health center; examples are but a sampling of such partnerships, and K Providers with sufficient financial and/or staff it is likely that other EHR network opportunities will resources and consulting relationships to assist in all continue to develop around the country. phases of EHR adoption; and Is an EHR Network the Right Approach? K Organizations which have implemented sophisticated Before purchasing an EHR, community clinics and disease and QI applications that would require health centers should have a strategic plan, a full extensive custom development before they could be assessment of their requirements, and a clear sense of integrated with an EHR system. their capabilities. This plan should take into consideration important factors such as available financial resources and These considerations provide a starting point for operational and technical capacity in order to determine determining if an EHR network may be the best option. whether an EHR network is a sound approach. Community clinics and health centers should also consider the financial impact of adopting an EHR system. For those who fit one or more of the following high-level With limited financial resources, the temptation to select characteristics, an EHR network may be more suitable: an EHR with the lowest price tag is strong. However, considering the full breadth of components necessary for K Organizations seeking products and services successful adoption, it is vital to analyze the total cost tailored to the safety net without need for extensive to help identify the best solution. What resources are customization; required for success and at what additional cost? What is K Small or mid-sized organizations without a strong the impact on productivity and staff? Potential purchasers technical or quality improvement infrastructure; should perform due diligence to understand what services are included and available both during and after K Community clinics or health centers that cannot implementation to limit the risk of unforeseen expenses. divert a substantial amount of time from clinical, Creating EHR Networks in the Safety Net  |  7 “ ou have to think about both your direct Y does not have dedicated development resources familiar with the code used by the vendor. Community clinics and indirect costs. Our costs right now and health centers can reduce this risk through an EHR are about 6 percent, but as we grow, we’ll network. While most of the clinics and centers will not probably bring it down to 4 percent of have access to the necessary development resources, an operating costs. This may seem high to EHR network likely will. In such cases, or in the event of a vendor acquisition, EHR networks are better positioned some people only spending 1 percent or and motivated to help these providers make the transition 2 percent for their IT. But the question to a new platform, rather than figure out how to continue is, what are you getting for that 1 or to support an abandoned platform from a defunct vendor. 2 percent? How often is the system down? Federal and state governments and funding organizations How much data are you getting? Are you are giving substantial attention to supporting a getting on-going training for your staff? collaborative EHR network approach. At the Federal Do you have a robust disaster recovery level, the Health Resources and Services Administration plan? Do you get the support you need? If allocated $27M to “support implementation of EHRs at health centers and in networks that link multiple health we’re serious about our mission, then we center grantees.”8 A total of 25 grants were given to build should be willing to spend what it takes. or augment EHR networks to create market alternatives IT is a part of that.” for community clinics and health centers across the country, signaling their confidence in more established — Richard Taaffe, Executive Director EHR networks such as OCHIN, Health Choice West Hawaii Community Health Center Network, and Alliance of Chicago — three of the several EHR networks operating in the country. Looking Forward: The Future of EHR In 2005, the California EHR network for EHR Adoption Networks (CNEA), co-funded by Community Clinics Initiative, a The health care landscape is an increasingly complex joint program of Tides and The California Endowment, and competitive field. With growing pressure to control the California HealthCare Foundation, and the Blue costs, increase market share, improve profit margins, and Shield of California Foundation, began to explore provide high-quality and customized services, there is collaborative approaches to facilitating the access and use persisting concern that not all vendors will meet these of EHRs for the safety net. Recently, CNEA provided challenges, leaving many community clinics and health significant funding to support the development of a centers to fend for themselves. new EHR network in California, and continues to seek ways to support California community clinics and health How are EHR networks, most of which are directly centers working to successfully adopt EHRs. Although linked with vendors, prepared for this scenario? In cases non-recurring capital infusions do not ensure stability, where a vendors has gone out of business, many have significant federal and regional alignment provides a contractually agreed to make their source code available promising foundation to assist EHR networks in helping in escrow to their customers. However, source code clinics and health centers in the safety net achieve their access will have little to no use for any organization that mission together. 8  |  California HealthCare Foundation Case Studies Advice to Others (from executive director Richard Taaffe) Community clinics and health centers across the nation • “It shouldn’t be about individual egos, but about the have partnered with EHR networks in adopting EHRs as organization and services for patients. Get someone well as other HIT systems. Here is a summary of their else who knows what they’re doing and has a vested experiences: interest in your organization.” • “Remember that many clinics are going to have Community Health Alliance of Pasadena (CHAP) is a turnover. You need to have continuity for the single-site primary care clinic offering medical and dental organization and support. Being part of an EHR network services to children and adults. It has four physicians, one is the best way of doing that” nurse practitioner, and two physician assistants and has • “In an EHR network, you can bring your concerns and been a member of Our Community Health Information know that they’ll listen. It’s about their members; it's Network (OCHIN) since 2005. CHAP went live with a about us. You can’t do that with a vendor and that’s practice management system in 2005 and completed its something to consider.” rollout of an EHR system in November 2007. Benefits of an EHR Network St. Anthony’s Free Clinic in San Francisco is a single- • An application service provider (ASP) model; site clinic that provides primary and urgent care services to children and adults who have no health insurance or • A well-developed, detailed implementation plan limited access to care. It has nine providers who offer including role-based descriptions customized to safety- clinical services part time from 20 to 36 hours per week net providers and their training process; and see approximately 3,500 patients a year. St. Anthony’s • Robust support and help-desk services; and Free Clinic recently joined the Alliance of Chicago network • An ability to respond to clinic needs such as providing and expects to implement an EHR in March 2008. CHAP with a portable system to aid in CHAP’s field work as well expanding functionality of the EHR Benefits of an EHR Network system to meet specific clinic needs and reporting • A focus on quality improvement, including integration of requirements. guidelines and clinical expertise; • An EHR product and services developed and Advice to Others customized for clinics; • “Understand that productivity hits can occur before • Robust technical and operational support; and implementation.” • An organization created for safety-net providers in • “Don’t underestimate the support that you will need. support of their mission. Don’t do it alone.” Advice to Others (from medical director Ana Valdés) West Hawaii Community Health Center (WHCHC) is a • “If you have a lot of IT support and limitless amount of single site rural health center in Kailua, Kona. It has two money, a vendor may be a better option. But for us, a family practice physicians, one nurse practitioner, several network provided the support and expertise we needed. psychologists who saw approximately 4,250 patients in There are not a lot of clinics using an EHR, so there was 2007. WHCHC has been a member of the Health Choice a lot of hesitation. When you think about all the things Network since 2006. that you need to think about, it can be very daunting. Benefits of an EHR Network I feel like we’ve come a long way with the help of a network.” • Support services; • “In my experience, EHR networks are much easier to • Sustainability and dependability; work with and are there to support your organization. • Responsiveness to clinic concerns; When you send them an email, they get back to you • Member leverage with EHR network versus a vendor; and are very responsive to your needs. With vendors, and we just didn’t get that kind of service — and when • Access to training to meet concerns about staff you’re server is down, you need someone who will be turnover. there.” Creating EHR Networks in the Safety Net  |  9 Authors Endnotes Julie V. Murchinson, M.B.A., Joseph D. Ray, and Christine E. 1. Dutton, M., and P. Epp, “Supporting Health-Center IT Sison, M.S., of Manatt Health Solutions. Investments Through Medicare And Medicaid” Health Affairs Blog December 5, 2007. (healthaffairs.org/ blog/2007/12/05/health-it-supporting-health-center-it- A c k n ow l e d g m e n t s investments-through-medicare-and-medicaid) The authors would like to acknowledge contributions by Laura D. Jantos of ECG Management Consultants and 2. Simon, S., et al. “Correlates of Electronic Health Record Cheryl Austein-Casnoff of Health Resources and Services Adoption in Office Practices: A Statewide Survey.” Administration. Journal of the American Medical Informatics Association October 26, 2006. (www.jamia.org/cgi/content/ abstract/14/1/110) About the F o u n d at i o n 3. California HealthCare Foundation, The State of Health The California HealthCare Foundation, based in Oakland, Information Technology in California, 2008. January, is an independent philanthropy committed to improving 2008. (www.chcf.org/topics/chronicdisease/index. California’s health care delivery and financing systems. cfm?itemID=133552) Formed in 1996, our goal is to ensure that all Californians 4. www.nhpf.org/pdfs_bp/BP_HealthCenterIT_07-23-07.pdf have access to affordable, quality health care. For more information about the foundation, visit us online at 5. Morris Cohen, “‘You Can’t Manage What You Can’t www.chcf.org. Measure:’ Maximizing Supply Chain Value.” Knowledge@ Wharton, December 6, 2006. (knowledge.wharton.upenn. edu/articlepdf/1546.pdf?CFID=963296&CFTOKEN=923 87275&jsessionid=a830d3617f20734f401a) 6. David Brailer, M.D., Ph.D. speech to America’s Health Insurance Plans audience, January 5, 2005, Washington, D.C. 7. Miller, R.H. and C. West. “The Value of Electronic Health Records in Community Health Centers: Implications for Policy” Health Affairs January/February 2007 26(1):206 – 214. 8. U.S. Health Resources and Services Administration press release, August, 2007. (newsroom.hrsa.gov/releases/2007/ HITgrantsAugust.htm) 10  |  California HealthCare Foundation