Health Information Exchange in California Community Clinics:
Adoption, Priority, Facilitators and Barriers
Part 2. Community Clinic Corporation Survey
January 30, 2014
Katherine K. Kim
Danielle Gordon
Holly C. Logan
San Francisco State University, Health Equity Institute
Prepared for California Health eQuality
University of California Davis
Institute for Population Health Improvement
http://www.ucdmc.ucdavis.edu/iphi/programs/cheq/
Copyright © 2013 The California Health and Human Services Agency (CHHS). All rights reserved.
This publication/product was made possible by Award Number 90HT0029 from Office of the
National Coordinator for Health Information Technology (ONC), U.S. Department of Health and
Human Services. Its contents are solely the responsibility of the authors and do not necessarily
represent the official views of ONC or the State of California.
Health Information Exchange in California Community Clinics:
Adoption, Priority, Facilitators and Barriers
Part 2. Community Clinic Corporation Survey
Contents
Background and Introduction ................................................................................................................................2
Results ................................................................................................................................................................................4
Electronic Health Record Adoption ................................................................................................................4
Health Information Exchange Adoption .......................................................................................................5
Types of Data Being Exchanged ........................................................................................................................9
HIE Services and Management ....................................................................................................................... 10
Impacts of Health Information Exchange.................................................................................................. 13
Priority of Health Information Exchange .................................................................................................. 14
Facilitators and Barriers.................................................................................................................................... 15
Financial Issues ...................................................................................................................................................... 19
Conclusions ................................................................................................................................................................... 22
About the Partners .................................................................................................................................................... 25
Appendix: Methods .................................................................................................................................................... 27
Survey Methods ..................................................................................................................................................... 27
Focus Group Methods ......................................................................................................................................... 27
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Health Information Exchange in California Community Clinics:
Adoption, Priority, Facilitators and Barriers
Part 2: Community Clinic Corporation Survey
Background and Introduction
New healthcare delivery models such as learning healthcare systems, accountable care
organizations (ACO) and patient-centered medical homes (PCMH) have evolved to
address the imperative triple aims of patient experience (quality and satisfaction),
population health, and cost
(http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx). These models
necessitate a new technical infrastructure for data collection, data normalization,
making sense of data, and communication across disparate organizations and users.
Health information exchange (HIE), the electronic movement of health-related
information among organizations according to recognized standards 1, is a critical
component of this new technical infrastructure.
HIE has gained prominence in part due to one of the largest federal investments in
health information technology, Title XIII of the American Recovery & Reinvestment Act
of 2009, also called Health Information Technology for Economic and Clinical Health
(HITECH)2. HITECH provided funding to improve healthcare quality and accessibility
through interoperable health information technology through two key provisions. First,
HITECH funded states directly to develop HIE. Second, it spurred adoption of electronic
health records (EHR) among providers by authorizing $27 billion in Medicare and
Medicaid incentives for achievement of certain clinical or “meaningful use” objectives
with EHR data while promising future penalties for failure to adopt. HIE is an underlying
requirement of the meaningful use of EHRs as it enables ePrescribing, lab result
reporting, online access to health information for patients, exchange of summary of
care documents between EHRs, and transmission of data for syndromic surveillance,
cancer and other registries. HIE has been identified as a solution to healthcare
coordination problems which include patient safety and quality issues, recalls of drugs,
healthcare pandemics and chronic care coordination for patients who may be seen in
different locations.3
Community health information organizations (HIOs), those who organize and govern HIE
for unaffiliated organizations, are considered a neutral party for enabling this crossorganizational data sharing. There are 161 HIOs nationally and 109 of them are
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supporting ACO or PCMH 4. As of October 2013 there were eight operational—defined
as transmitting data—community HIOs in California and eight others in some stage of
formation or implementation but not yet operational
(http://www.ucdmc.ucdavis.edu/iphi/Programs/cheq/hieactivity.html). Many
community HIOs have a local or regional geographic boundary within which they
operate which reflects the referral relationships, patterns of care, and flow of patients
among the participating organizations.
There are several reasons that community clinics as providers of care for underserved
and vulnerable populations may be particularly interested in HIE. First, they cooperate
intensively with hospitals, specialists, retail pharmacies, and other community services
in order to provide needed care. Second, they depend on federal and state programs to
fund core infrastructure development and technology. Finally, they must leverage scant
resources across communities to fulfill their mission.
However, there is little published on the status of HIE among community clinics or their
participation in HIOs. One area that has been reported is facilitators and barriers to HIE
for community clinics in small, qualitative studies. Facilitators include financial
incentives, including those for e-prescribing and pay-for-performance, potential cost
savings, workflow efficiencies and improved patient quality and safety.5 Barriers to HIE
included lack of interoperability, privacy and security5, high costs of both initial
implementation and ongoing sustainability6, inadequate buy-in, lack of trust, lack of
leadership and technical/workflow issues7,8. Lack of consistent connectivity and
difficulty finding expert IT staff to assist are barriers that affect rural and underserved
communities in particular.8
In order to better understand whether and how California’s community clinics are
participating in HIE and HIOs, California Health eQuality program (CHeQ), a program of
the Institute for Population Health Improvement at UC Davis, engaged San Francisco
State University to conduct a statewide survey in 2013. In addition, the California
Primary Care Association (CPCA) partnered with CHeQ to develop the survey and
helped recruit respondents.
Recognizing that the level of participation, knowledge, technical resources, and strategy
development may differ substantially between potential clinic site respondents and
corporate office respondents, we conducted two separate surveys. Results of each
survey were reviewed with a subset of respondents who volunteered to participate in a
webinar focus group.
This report covers the survey results and feedback from the focus groups. Following the
report on outcomes of the survey, there is a section covering the methodology used for
this study. The report on this study is divided into 2 parts: Part 1 reports on the clinic
site survey and Part 2 reports on the clinic corporation survey.
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Results
A total of 126 clinic corporations, defined as the corporate headquarters of a
community clinic, responded to the on-line survey, representing a response rate of 56%.
78% were located in urban areas, as determined by the zip code of the headquarters
office, and 21% were rural. One third of clinic corporations had just one clinic site, and
15% had at least 10 sites. (See Table 1.) The survey was completed primarily by
administrators (48%) and technical staff (40%) of the clinic corporations. However
clinical (8%) and financial staff (4%) also responded to the survey.
Table 1: Clinic Demographics
Number of clinic sites
N (%)
1
2-4
5-9
10 or more
41
36
30
19
(33)
(29)
(24)
(15)
Role of Respondents
Administrative
Clinical
Technical
Financial
Other
N
51
9
44
4
2
(%)
(48)
(8)
(40)
(4)
(2)
Electronic Health Record Adoption
Clinic corporations have a high level of adoption of electronic health records (EHR).
Overall, 86% of clinic organizations reported having an EHR: 100% of rural clinics and
82% of urban clinics. Of the clinic corporations not currently utilizing an EHR at the time
of the survey, 77% reported that they plan to implement an EHR within the next 12
months.
In order to meet the requirements and receive meaningful use incentive payments from
the Centers for Medicare and Medicaid Services, providers must use an EHR certified for
this purpose. Among those clinic organizations with an EHR, overall, 96% are using a
certified EHR. (See Figure 1.) Rural corporations have complete adoption of a certified
EHR.
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100%
4%
5%
96%
95%
90%
80%
70%
60%
Percent 50%
100%
40%
Not certified
for MU
30%
Certified for
MU
20%
10%
0%
Overall
Urban Corporations Rural Corporations
Clinic Corporation Type
Figure 1. Electronic Health Record Adoption
Health Information Exchange Adoption
56% of clinic corporations reported that they are engaged in sending or receiving
electronic data of any type. A greater percentage of rural clinic corporations (79%) than
urban (48%) are participating in HIE.
Of those organizations exchanging data, 67% are sharing data with other locations that
are part of the same parent organization; 52% are sharing with external entities. (See
Table 2.) On average, they share with approximately two internal and two external
locations.
Among all organizations with access to externally provided electronic data, 41% are able
to access it both through a portal as well as receiving data directly into their EHRs.
Somewhat fewer organizations (32%) access data exclusively through a website or
portal.
Thirty percent of all organizations reported having an online personal health record
(PHR) available to their patients. Of those, 75% reported that less than 5% of their
patients are accessing the PHR.
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Table 2: Internal and External Data Exchange
Share patient electronic data internally
Mean number of internal exchange locations
Overall
N (%)
45 (67)
1.97
Urban
N (%)
32 (67)
1.97
Rural
N (%)
12 (67)
1.67
Share patient electronic data externally
Mean number of external exchange locations
34 (52)
2.11
23 (48)
2.09
11 (65)
2.17
Access to external data:
View it via a website or portal
Receive it into the EHR
Both portal and into EHR
11 (32)
9 (27)
14 (41)
6 (27)
7 (32)
9 (41)
5 (42)
2 (17)
5 (42)
Focus Group Findings Box 1: Online Personal Health Records
Participants stated that patients have not pushed for PHRs. Possible reasons for this low
level of interest were that low income patients may not know about PHRs, concerns
about having personal information online, and lack of interest in keeping personal health
information. One participant stated that some patients don’t want to receive the visit
summaries that are generated at each medical visit and ask for the clinic to shred them.
For patients to become more engaged in using a PHR, patients need to be educated
about the benefits of PHRs and also how to utilize these tools especially when they are
juggling many other priorities in their lives:
“For the vast majority of patients they are not educated and to tell you the truth the
providers are not educated about nor do they want to spend time educating patients on
the benefits…”
One participant who had previously held a small focus group with patients to inform the
PHR rollout at their clinic did receive good feedback from patients. They found the most
popular feature was access to lab results and being able to print out a medication list.
Another reported that patients liked being able to make corrections to their health
information and found the PHR generates more discussion between patient and provider.
Clinic corporations reported a wide array of HIE technologies in use. (See Table 3.) Most
frequently identified HIE technologies cited included two electronic health record
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systems, Nextgen and eClinical Works, and one open-source technology, Mirth. A
number of other technologies are being used in smaller numbers. Finally, there were a
number of technologies being used by just one organization each. These included:
Caradigm, Cerner, Certify Datasystem, DBmotion, MEdplus, Orion Health, Assa,
Netsmart Careconnect, Beacon, SIDR, MobileMD, Lifetime Clinical Records, Axesson,
Gnosis, eMedapps Seva exchange, and RPMS/escrib. Nine organizations (12%) reported
they did not know which technologies are being used in their organization.
Table 3. HIE Systems
Name
Nextgen
eClinical Works
Mirth
AT&T
Microsoft
Homegrown System
Epic
GE Healthcare
Medicity
Oracle
Verizon
N (%)
12 (22)
11 (15)
10 (13)
7 (9)
5 (7)
5 (7)
3 (4)
3 (4)
3 (4)
2 (3)
2 (3)
Clinic corporations are exchanging data with a variety of external exchange partners.
Organizations have the highest frequency of exchange with laboratories (64% of
exchanging clinic organizations). 43% of respondents are exchanging with Public Health
agencies or Hospitals; 34% are exchanging with radiology/imaging; 32% are exchanging
with physician offices or pharmacies; 16% with other clinics, and 14% with patient
health record systems.
7|Page
70%
64%
60%
50%
40%
Percent
30%
43%
43%
32%
34%
32%
16%
20%
10%
14%
2%
0%
Exchange Partner
Figure 2. Electronic data exchange partners
Focus Group Findings Box 2: Difference in rural and urban clinics’ participation in HIE
Some participants were surprised at first that a greater percentage of rural clinic
corporations were engaging in HIE than urban. They wondered if one reason might be
that HIEs are more often in rural areas and some funders were targeting rural sites.
Another reason raised was easier collaboration in rural communities:
“…Whereas in rural organizations you have small groups that usually band together,
they set up a technology stack and they work together as a small group to basically
allow… and you know the technology so that everybody can share.”
Others suggested that urban clinics are less likely to be involved until a business case
was identified:
“And the people who might be exchanging information don’t necessarily see a business
value in it. They may recognize that it is good for patients, it is a good overall idea but
are hesitant to invest funding in it without any realized benefit to themselves…”
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Types of Data Being Exchanged
Figure 2 shows the range of data types being exchanged between clinic corporations in
both internal locations (belonging to the same corporation) and external locations.
For most data types, with the exception of radiology and imaging data, exchange is
occurring more frequently between internal locations than external.
Laboratory result data were the most frequently exchanged data type, both internally
(74% of clinic corporations) and externally (68%). The least frequently exchanged data
were inpatient care data. Inpatient notes are exchanged externally by 14%, inpatient
medication lists and problem lists are both exchanged externally by 9%. The greatest
differential between internal and external exchange was seen in ambulatory care data.
Sixty-five percent of organizations report they exchange referral data internally, vs. 46%
externally.
80
70
60
50
Percent 40
30
20
10
0
Data Types
internal exchange
external exchange
Figure 3. Types of data being exchanged
Among all organizations exchanging electronic data, about half are using HL7 interfaces
to send or receive electronic data and non-computable PDF or TIFF documents. (See
Figure 2.) Few are utilizing Clinical Care Record/Clinical Care Document format or Direct.
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60%
50%
49%
47%
51%51%
Send
Receive
40%
Percent 30%
25%
20%20%
21%20%
20%
20%
16%
9%
10%
9% 8%
0%
PDF, TIFF
HL7 V2
CCR, CCD
Word, Excel
Plain text
Non-standard
Direct
Data Format or Standard
Figure 4. Standards used to send and receive data
HIE Services and Management
Clinic corporations are utilizing a variety of strategies to manage their HIE systems. Of
organizations engaged in HIE, 53% reported they manage the technology internally, and
do not rely on outside assistance. The other 47% leverage a range of resources to
maintain their HIE technologies. (See Figure 4.) Among the organizations utilizing
outside IT support services, 43% contract with an IT vendor, 30% receive their service
through their local clinic consortium, 15% work with a local hospital or health system,
and 8% receive IT services through a health center controlled network (HCCN).
In addition, 12% of clinic corporations belong to a health information organization (HIO).
8% of urban clinic corporations and 27% of rural are participants in an HIO.
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50%
43%
45%
40%
35%
30%
30%
Percent 25%
20%
15%
15%
8%
10%
5%
0%
Hospital or health
system
Community clinic
consortium
HCCN
Other HIT provider
HIE Technology Provider
Figure 5. Outsourced HIE Services
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Focus Group Findings Box 3: Tradeoffs in Internally Managed and Outsourced HIE
Services
There were mixed experiences with managing HIE services. Some clinics manage the
technology themselves but supplement with vendors for specific situations such as
network connectivity or service issues with specific applications.
A question was raised regarding how a clinic can manage HIE when it requires
bidirectional exchange:
“I still think it would be interesting to know how they’re managing it themselves and if
it’s really true exchange, you know between outside organizations and stuff like that. I’d
like to just have more clarity.”
The participants discussed several challenges faced in managing HIE:
1. Technical: Using outside vendors is helpful but when there are glitches in the
system, it can cause large delays and big issues when the vendors aren’t
knowledgeable:
“…the consultant basically crashed the interface for about two weeks and you
can imagine how many personnel hours were put into retrieving all the data and
getting it inputted and stuff.”
2. Resources: Difficulty in recruiting and keeping experienced IT resources in
house.
3. Financial: Costs for outsourcing to a vendor and can be higher than having an
internal resource.
In reference to the importance of good management of HIE services:
“It’s not pretty, it’s like the plumbing underneath your house, the pipes in your wall you
don’t see it but it makes everything go where it needs to go.”
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Focus Group Findings Box 4: HIO Membership
The participants who had previously participated in an HIO spoke about a vision of
having a hub that allows HIE and keeps the cost of implementing interfaces to all of the
partners low:
“The key is to partner with a viable health information exchange or HIO that builds all
the interfaces. They’re paid for once usually and they maintain them and you basically
connect to that HIE and you get your results and your CCDs and everything from there.”
One of the participants was no longer in the HIO because it shut down.
Another participant is in the process of developing a community HIO. The participant
described previous attempts to start an HIO which had not come to fruition due to lack
of interest and commitment from stakeholders. Currently, the effort had come along
much farther with high interest among hospitals and private clinicians in the
community and a vendor had already been selected.
Impacts of Health Information Exchange
Although the majority of clinic corporations believe HIE increases cost (68%), substantial
segments believe it decreases cost (11%), or has no change on cost (29%). In terms of
revenue, the majority (63%) believe HIE has no impact on revenue, and 25% believe HIE
increases revenue. (See Table 4).
Table 4: Perceptions of HIE impact on cost and revenue
HIE decreases cost
HIE increases cost
No change to cost
HIE decreases revenue
HIE increases revenue
No change to revenue
Number (%)
12 (11)
61 (68)
32 (29)
14 (12)
28 (25)
71 (63)
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Focus Group Findings Box 5: Cost
Ways in which participants think HIE might decrease cost include:
• Manual processes and manual workflows are diminished; shredding is
diminished, which can reduce staff costs
• Timeliness of getting data and getting results to provider are cost savers
• Readmission rates might go down because of HIE which will reduce cost
One participant noted that their e-consult program had achieved cost savings by
reducing unnecessary visits to specialists.
Participants think HIE might increase cost due to capital and ongoing expense of
maintaining technology or fees to an HIO.
Participants also predicted that it could potentially be a wash for clinics. There was
agreement that there had not been enough experience with HIE to assess cost savings.
“If you had asked me that question two different ways and say you know does HIE affect
costs in the short run, of course the slam dunk answer is of course, yes, but long term I
think it’ll decrease it by virtue of reduction and duplication of efforts.”
Focus Group Findings Box 6: Revenue
There was little confidence expressed that HIE would impact revenue. One participant
thought that HIE could improve revenue through quality and performance incentive
programs, e.g. reducing hospital admissions/specialist use. Others discussed the
possibility that HIE could reduce revenue for hospitals and labs by reducing the number
of lab tests.
Priority of Health Information Exchange
In examining the importance of HIE implementation among organization priorities, it
was reported that HIE was considered somewhat important, but not a top priority (table
5). Clinic organizations rated HIE more important to quality of care than to daily
operations (mean 5.28 vs. 4.70 on a scale of 1, not important, to 7, extremely
important).
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Table 5: Importance of HIE in relation to other priorities, scale of 1 (not important) to 7
(extremely important)
Priority compared to other initiatives
Importance to daily operations
Importance to quality of care
Overall
4.40
4.70
5.28
Urban
4.45
5.69
5.25
Rural
4.22
4.73
5.39
Focus Group Findings Box 7: Strategic Priorities
Participants were asked to speak about where HIE fits into their clinics’ strategic
priorities. The group agreed the survey findings were not surprising and that the
ultimate goal, to improve quality of care, was reflected in the survey responses. They
also agreed that while HIE is an important, it can sometimes be pushed down to a lower
priority, due to competing initiatives:
“Most healthcare operations/organizations these days are besieged on all sides by so
many different initiatives everything from meaningfully use and patient centered
medical home, trying to manage healthcare reform, expansion of MediCal
coverage…priority scoring lower is a byproduct of all the balls that are in the air right
now with no time to juggle.”
One participant spoke about their clinic opening up a new clinic and another spoke
about revamping their care models to support health care reform in addition to
upgrades to the EHR and agreed that their time and resources are limited. ICD-10 was
also mentioned as an immediate priority.
“…it is not like imminent at this moment when other things maybe are.”
“HIE has always been kind of a big gorilla that sits in the corner of a room that
everybody talks about but really it just really hasn’t been done sufficiently…” The
participant went on to say that they think for HIE to be done efficiently, the politics;
resources and time constraints need to be solved first.
Facilitators and Barriers
We asked clinic organizations about the importance of a variety of factors to their ability
to implement HIE. Table 6 presents the mean scores given to each factor of importance,
again on a scale of 1 (not important) to 7 (extremely important). In this table we also
see how organizations rated the overall degree of challenge experienced (mean 5.16).
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In this group of factors, the adequacy of internet connection received the lowest overall
importance score (5.39), and Data Standards received the highest overall importance
score (5.99) out of a possible high score of 7. In this group of factors, there was some
variability between urban and rural organizations. Availability of technical assistance
scored lower among rural organizations than urban organizations (5.45 vs. 5.69);
similarly the rural organizations also scored technical expertise lower than the urban
organizations (5.55 vs. 5.81).
Table 6: Importance of technical factors in ability to implement HIE, scale of 1 (not
important) to 7 (extremely important)
Overall Challenge
Adequacy of internet connection
Availability of HIO in area
Availability of technical assistance
Technical expertise
Privacy
Security
Data Standards
Overall
5.16
5.39
5.61
5.65
5.75
5.88
5.90
5.99
Urban
5.15
5.40
5.59
5.69
5.81
5.83
5.83
6.03
Rural
5.22
5.35
5.68
5.45
5.55
6.09
6.17
5.83
Focus Group Findings Box 8: Privacy and Security
Participants discussed privacy and security and had some concerns about ensuring that
it was being handled to the highest standard. One participant worried that the
technology was being implemented too quickly and that we haven’t addressed security
adequately:
"We can have confidence in our systems’ ability to be secure but once we release those
data and they go over to the other sites we’ve basically lost control of that. Well yeah I
mean even if you think about a secure email for example. Okay say you have a patient
portal and you have a secured email and you send an email back to the patient securely
and then they have somebody come along at their home computer and forward that
message to someone you know not securely. Although anything like that can happen
and you know I just think you know we’re in such a hurry to go forward with this
technology I’m a bit concerned about the foundations of security and privacy that we’re
laying."
Others noted that privacy is a particular concern in small rural clinics:
"Because everybody is related to everyone and you don't you know we should treat
every patient like this but it's particularly acute in these kinds of environments [small
rural clinics in Indian county]…the trust of the patient is pretty important."
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Focus Group Findings Box 9: Patient Consent
Participants agreed that consent for HIE has both technical and policy aspects that are
not clearly developed yet. There are a lot of options such as opt-in, opt-out, consent
for all exchange partners or limited to some. One clinic who is participating in an HIO
has an opt-out model but they still ask all patients sign a form to document that they
opted-in because they are concerned about liability if data is breached.
Focus Group Findings Box 10: Resources
Participants suggested additional resources would be helpful to supplement the
resources they currently use.
A forum that brings together people who are ready to start working on HIE:
“I would certainly follow someone or participate in something and arrange and be ready
to say yes and just to allocate resources to something so we could begin. I don’t think
the impetus is going to happen in the next six months here, next year even. It’s not
going to come from internally but from the community to take real action.”
A guide from an HIE that has been in place (e.g. Santa Cruz HIE) that highlights what
happened, pitfalls you might run into, experiences, etc:
“I don’t know the extent to which those experiences have been (a) catalogued or (b)
shared but I think as the rest of us start on this journey that you know as an
organization they obviously have a lot to give and a lot to offer in terms of guidance and
pitfalls to avoid.”
Inexpensive solution to exchanging data such as a central hub where only one interface
is needed to interact with other regions or states:
“I think coming up with just the standard, the definition of what people need to develop
in order to have this exchange I think that’s the biggest key that we’re missing right
now.”
Finally, the need for a sustainability plan for HIE was highlighted.
Leadership factors were also rated at a high level overall, with all being above a 5 on a
scale of 1 to 7. (See Table 7.) Of this group of factors, clinic leadership’s understanding
of HIE was rated lowest (mean 5.35), and the willingness of partners to share data got
the highest importance score (mean 6.01)
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Table 7. Importance of leadership factors in the ability to implement HIE, scale of 1 (not
important) to 7 (extremely important)
Clinic leadership understanding of HIE
Knowledge about HIE
Level of interest of clinic leadership in HIE
Level of interest in HIE among clinicians
Clinician understanding of HIE
Individual HIE leader in the community
Willingness of local health organizations to collaborate
Willingness of partners to share data electronically
Overall
5.35
5.38
5.41
5.55
5.64
5.67
5.95
6.01
Urban
5.43
5.43
5.48
5.51
5.67
5.75
5.97
6.06
Rural
5.05
5.17
5.17
5.73
5.50
5.35
5.86
5.82
Focus Group Findings Box 11: Willingness of partners to exchange information
Participants spoke about the challenge of making sure external organizations are ready
to exchange data with them.
“There’s you know kind of a nervousness by some of the players about how this is going
to work and ownership of the data and all of that….I don’t know how we’re going to do
it and maybe HIE can help but we need to go from need to know to need to share if this
is going to work because everybody being hyper-protectionist and what not because the
stakes are so high I mean I totally get it but maybe when the benefits of HIE start to
come around, we can revisit some of this stuff.”
By saying “Need to share,” the participant was referring to being able to get all patient
data if their information is stored somewhere in the HIE and the clinic not be penalized
for having access to patient data if the patient never opted out.
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Focus Group Findings Box 12: Understanding and Knowledge of HIE
All participants agreed on the importance of having clinic leadership and clinicians
understand HIE and champion the effort to accomplish it. Clinic leadership may be
knowledgeable and think that HIE is important, however clinicians do not have any
familiarity with HIE yet:
“I think they’ll (clinicians) be pleased you know pleased as punch when it comes but you
know right now it’s something that’s outside of their control. I think they see it as an IT
project and they’ll benefit from it when it comes but until then why spend a whole lot of
time thinking about it.
“You know I just don’t see the HIE coming up in those conversations. Now it’s the big
gorilla in the room you know everybody knows it has to be there but really nobody really
understands or has the level of knowledge that it takes.”
Financial Issues
Because implementation of HIE represents a significant financial commitment for a clinic
organization, we explored the question of financial impact from several angles.
In terms of the relative importance of financial factors to a corporation’s ability to
implement HIE, organizations responded that both capital expense and the availability
of funds are extremely important. The availability of funds was rated highest, among
both urban and rural corporations.
Table 8. Importance of financial factors in ability to implement HIE, scale of 1 (not
important) to 7 (extremely important)
Overall
Capital expense
Availability of funds
5.48
6.18
Urban
Corporations
5.58
6.26
Rural
Corporations
5.09
5.86
Most clinic corporations are not including HIE costs in their yearly budget planning.
Only 36% of respondents reported having HIE included in their budgets for the next 12
months. The most common sources of funds for HIE are the clinic’s operating funds and
grants. About one third of organizations reported that they use general operating funds
(37%) or grants made to the clinic (33%) to cover their HIE costs. (See Figure 5.)
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45%
40%
35%
30%
Percent
25%
Overall
20%
Urban
15%
Rural
10%
5%
0%
Grant to the clinic Clinic general funds
Sponsored by
Professional
Association
None
Source of Funding for HIE
Figure 6. Sources of funding for HIE services
Clinic corporations’ budgets allocated to all Health Information Technology (HIT),
including HIE costs are quite variable. Most common is spending of less than 4% on HIT,
followed by 5-9%. Thirteen percent of clinic corporations allocate 15% or more of their
budgets HIT. A third of rural corporations spend 10-14% on HIT, a much higher
proportion than urban.
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0.5
0.45
0.4
0.35
0.3
Percent0.25
0-4%
0.2
4-9%
10-14%
0.15
15% or more
0.1
0.05
0
Overall
Urban corporations Rural corporations
Percent of Budget Allocated to Health Information Technology
Figure 7. Budget for Health Information Technology Overall and By Geographic Setting
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Focus Group Findings Box 13: Funding HIE
The primary concern expressed regarding HIE funding was the need for a sustainability
plan:
“I would say the key word is sustainable because I don’t know of something in the future
that is a sustainable model and the only thing I’ve kind of heard about is joining an
accountable care organization and that would sort of facilitate something like that and
[be] worth the investment.”
“For us just about every clinic is going to have to purchase something from their vendor
to play in the sandbox whether it’s a bundled series of interfaces to pass the data and
catch it or what have you. And there’s upfront costs for it and then there’s an annual
maintenance cost and unless you have some economy of scale the cost can get, they can
get pretty high and you’d hate to have people be put in a position where the cost is
something that they can’t handle year to year or it comes out of costs that they have to
cut other services within their organization of something terrible like that.”
Conclusions
Overall, EHR adoption among community clinic corporations is proceeding rapidly.
More than 85% of all clinic corporations surveyed reported that they are currently
utilizing an EHR and among those not yet transitioned to electronic records, three
quarters intend to make that change within a year. There are small differences in rates
of adoption in general and for meaningful-use certified EHRs: rural clinics exceed urban
clinics in both areas. 100% of the rural organizations in our sample are already using an
EHR certified for Meaningful Use. In contrast, 96% of the urban organizations sampled
are currently using a certified EHR.
More than half of clinic corporations are participating in HIE and with a diverse array of
partners including labs, pharmacies, hospitals, physician offices, clinics, imaging centers,
public health, and personal health records. On average, they share data with two
internal locations and two external locations. Rural clinics have higher rates of HIE
adoption than urban.
30% of clinic corporations offer a PHR but there is minimal uptake by patients. The clinic
corporations suggest that additional outreach to patients is needed to let them know of
the availability of PHRs and the benefits of use.
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There are many types of clinical data being exchanged. Lab orders and results are the
most frequently exchanged type of data followed by referrals. The least exchanged data
types are inpatient notes, inpatient medication lists, and problem lists. There are also
differences in the rates of exchange of different data types internally vs. externally.
Although HL7 v2 is used by about half the clinic corporations, most of the exchange is in
formats such as pdf and office documents, limiting its contribution to interoperability.
Clinic corporations are challenged with the management of HIE systems, whether they
manage them internally or outsource them to vendors. They have difficulty finding
experienced resources for internal management. But, the costs are high for outsourcing
and in some cases the vendors’ staffs are not experts either. While HIOs are potential
solution providers, only a small number of clinic corporations are participating, in part
due to lack of operational HIOs, issues with delivery of interfaces or reaching promised
milestones, or capacity constraints.
The majority of clinic corporations think HIE increases cost and has no impact on
revenue. But, focus groups expressed that there had not been enough experience with
HIE to know for sure what the impact might be. While costs might increase due to the
investment and ongoing expense of technology, longer term savings could potentially
remediate some of those expenditures.
HIE is important to clinic corporations, especially to the quality of care. However, HIE is
in competition with numerous other priorities which may have more urgency such as
Affordable Care Act implementation, Medi-Cal expansion, and ICD-10 implementation.
The most important factors in clinics’ ability to implement HIE were data standards,
privacy and security issues, and willingness of partners to share data. A key concept
that was raised was a cultural change to move the industry from “need to know” to
“need to share,” reflecting the importance of access to data.
The lack of funds designated for HIE in clinic corporations’ budgets reflects the priority
of HIE. HIE is budgeted in approximately one-third of clinic corporations’ current year
budgets. Clinic corporations are quite concerned about sustainability of HIE.
The benefit of HIE increases as the size of the network increases. With over half of clinic
corporations exchanging data, the state is on its way towards seeing effective use of HIE
to better serve patients seen in community clinics. There is still work to be done to
identify the needs of those clinic corporations who have not adopted HIE. It appears
that urban clinic corporations are lagging behind their counterparts and resources could
be applied to support them. There is interest in participating or starting HIOs, and
additional work should be done to extract tools, templates and lessons learned from
those that are successful to disseminate throughout the state.
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Finally, attention must be paid to the prioritization of HIE given the competing initiatives
and mandates facing clinic corporations. While HIE alone might not seem like a priority,
it is a necessary component in many of the other strategic initiatives. This value
proposition for HIE should be clearly and compellingly stated so that funders, regulators,
and clinicians will champion the resources to help clinic corporations adopt it “For the
good of the patient, the care of the patients and the providers so they don’t go insane
trying to get the information when, where and how they need it.”
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About the Partners
About California Health eQuality (CHeQ)
California Health eQuality (CHeQ) is a program of the UC Davis Institute for Population
Health Improvement that administers statewide health information exchange (HIE)
projects for California. Funded by the California Health and Human Services Agency,
under the auspices of the Office of the National Coordinator for Health IT State HIE
Cooperative Agreement, CHeQ is promoting coordinated and integrated care through
health information exchange. Programs including a trusted exchange environment,
improved public health capacity for electronic reporting, HIE acceleration funding
opportunities, and the monitoring of HIE adoption lay a foundation for improved quality
of care for all Californians. Please visit CHeQ at
http://www.ucdmc.ucdavis.edu/iphi/programs/cheq/.
About Institute for Population Health Improvement (IPHI)
The UC Davis Institute for Population Health Improvement (IPHI) is working to align the
many determinants of health to promote and sustain the well-being of both individuals
and their communities. Established in 2011, the institute is leading an array of
initiatives, from improving health-care quality and health information exchange to
advancing surveillance and prevention programs for heart disease and cancer.
About California Primary Care Association
The California Primary Care Association (CPCA) represents the interests of California
community clinics and health centers and their patients. CPCA represents more than
1,000 not-for-profit Community Clinics and Health Centers (CCHCs) and Regional Clinic
Associations who provide comprehensive, quality health care services, particularly for
low-income, uninsured and underserved Californians, who might otherwise not have
access to health care.
About Health Equity Institute at San Francisco State University
The Health Equity Institute at San Francisco State University (SFSU) seeks to foster
innovation and community engagement towards a vision of a truly healthy society. The
mission of the Health Equity Institute (HEI) is to create an intellectual environment that
encourages diversity of perspectives, challenges conventional approaches, and produces
innovative action-oriented research in the biomedical and behavioral sciences in order
to improve health, eliminate health disparities, and establish equity in health. SFSU is a
public university affiliated with the California State University system. Located in San
Francisco, it offers 118 different Bachelor's degrees, 94 Master's degrees, and 5 Doctoral
degrees.
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References
1.
2.
3.
4.
5.
6.
7.
8.
National Alliance for Health Information Technology. Defining Key Health
Information Technology Terms. 2008;
http://www.nacua.org/documents/HealthInfoTechTerms.pdf. Accessed May
1, 2008.
111th Congress of the United State of America. American Recovery and
Reinvestment Act of 20092009.
Vest JR, Gamm LD. Health information exchange: persistent challenges and
new strategies. Journal of the American Medical Informatics Association.
2010;17(3):288-294.
eHealthInitiative. 2012 Report on Health Information Exchange: Supporting
Healthcare Reform. 2012; http://www.ehidc.org/resourcecenter/surveys/view_document/43-survey-2012-annual-hie-survey-resultsreport-on-health-information-exchange-supporting-healthcare-reform-dataexchange. Accessed October 21, 2013.
Fontaine P, Zink T, Boyle RG, Kralewski J. Health information exchange:
participation by Minnesota primary care practices. Archives of Internal
Medicine. 2010;170(7):622.
Fiscella K, Geiger HJ. Health information technology and quality
improvement for community health centers. Health Affairs. 2006;25(2):405412.
Sicotte C, Paré G. Success in health information exchange projects: Solving
the implementation puzzle. Social Science & Medicine. 2010;70(8):11591165.
Hook J, Grant E, Samarth A. Health Information Technology and Health
Information Exchange Implementation in Rural and Underserved Areas:
Findings from the AHRQ Health IT Portfolio (AHRQ Publication No. 10-0047EF). Rockville, MD: Agency for Healthcare Research and Quality. 2010.
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Appendix: Methods
Survey Methods
A survey instrument was built to explore progress toward adoption of EHRs and
implementation of HIE across California from the perspective of the parent
organizations of community clinics. Constructs were selected to capture both objective
measures of implementation, as well as subjective beliefs about the challenges and
facilitators of HIE implementation. The self-administered survey was built using the
QualtricsTM software, and was accessible to the participant via an internet link sent by
email.
Eligibility criteria were established to capture those community clinic corporations
responsible for the provision of safety-net services. A publicly available list of clinic
organizations (2012 reporting year) was obtained from the Office of Statewide Health
Planning and Development (OSHPD) website and reviewed. An internet search was
conducted for each organization that was not clearly eligible and if necessary, a phone
call was placed to ascertain the scope of care services provided at that organization or
contacts for the IT manager. The California Primary Care Association (CPCA) also
partnered in the survey distribution, and sent an introductory email and survey link
directly or through local clinic consortia to their members. Eligible clinic organizations
not belonging to CPCA were sent the same email by the SFSU research team.
The survey materials and study protocol received IRB exemption from the SFSU
committee for human subjects protection. An introductory email was developed to
both present the survey, and to identify the individual best suited to respond. The goal
was to administer the survey to an individual whose role included oversight of clinic IT,
including management of systems and strategic decision making.
Follow-ups with non-responders occurred at timed intervals via email and direct phone
calls over five weeks to encourage participation. The dataset was downloaded from
Qualtrics, and was processed at SFSU for analysis. These initial results were then
presented to interested survey responders in a series of two focus group webinars held
in December, 2013.
Focus Group Methods
Two focus groups were conducted via webinar and conference call. Each of the focus
groups lasted 90 minutes. Participants who had indicated interest in a follow-up focus
group on the survey were sent an invitation via email from researchers at SFSU. Those
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who responded to participate were sent a consent form to sign and return to the
researchers before the group took place. 80 participants indicated they were interested
in participating in the focus group. They were contacted a total of four times before they
were marked as no longer interested. A total of 12 participants signed the consent form
and participated in the two focus groups.
One researcher led the focus groups. The focus group slides contained findings from the
survey and were divided by the different sections of the survey. Participants were asked
their thoughts about the findings and were then asked brief follow-up questions after
each set of findings were shown. The presentation included seven sections and
questions were asked after each set of findings were shown. The sections included:
1. Online Personal Health Records and patient use
2. Data exchange
3. HIE technology management
4. HIO membership
5. Financial Ramifications of HIE (Cost and Revenue)
6. HIE and strategic priorities
7. Factors that are important to clinics implementing HIE (e.g. technical expertise,
privacy and security, availability of an HIO, resources, etc.)
The focus groups were audiotaped and transcribed by a professional transcriptionist.
One researcher analyzed the focus groups transcripts for common themes among the
groups.
A copy of the survey instrument can be obtained by contacting Katherine Kim at
kathykim@sfsu.edu or kathykim@ucdavis.edu.
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