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Community Health Center Perspective

January 19, 2011
by Jennifer Prestigiacomo
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Insight into the special challenges of EHR implementation

Last week’s HIT Standards Committee Implementation Workgroup hearing “Real World Experiences Working with Meaningful Use,” sponsored by the Office of the National Coordinator for Health Information Technology (ONC) culled together voices from around the country to share what’s really going on with the meaningful use of electronic health records (EHRs). Lisa Levine, M.P.H., vice president-operations, Family Health Center of Worcester, Mass. shared her thoughts on her panel “Implementation Support – Regional Extension Centers,” as well as some insight into the special path that community health centers must tread toward meaningful use.

Healthcare Informatics: What did you find most interesting about the Implementation Workgroup hearing?

Lisa Levine, M.P.H.: What was nice to hear is that there were lots of other people that were nervous about meaningful use Stages 2 and 3 as I was. What I found most interesting was how different each state experience was. Each of us had a different experience and view of the REC [regional extension center] and the whole implementation strategy. When you’re coming at it from the point-of-care, you know the broader framework of the HITECH [The Health Information Technology for Economic and Clinical Health] Act and meaningful use, but your actual experience is built on the REC in your state. So, I had this assumption that they all operated the same way. And what I found was there was a lot of individuality. There is a whole difference in charges for enrollment. Our REC [the Boston-based Massachusetts eHealth Institute, a division of the Massachusetts Technology Collaborative] charges $800 for specialists and $600 for primary care providers. The physician that was sitting next to me from Arizona [Dan Nelson, Desert Ridge Family Practice, Phoenix, Ariz.] said the Arizona REC charges nothing for primary care providers. And the enrollment charge for the RECs appeared to be part of their long-term sustainability strategy.

The other thing I found interesting is there seemed to be different vetting processes. There was some discussion about if you could have a preferred vendor list and the implementation optimization organizations, and again, there didn’t seem to be a huge agreement or consistency state to state. And there was discussion around if it made sense to have as many vendors as you could fit on a list, or do you try to narrow it a little? I believe the gentleman from the ONC [Mat Kendall, Director, Office of Provider Adoption Support, Office of the National Coordinator] said there was a feeling in the ONC there should be vendor agnosticity [sic] in the way RECs were choosing [vendors].

HCI: What kind of workforce initiatives would you want to see coming out of your REC and implementation optimization organization to help out with the HIT professional shortage?

Levine: I’d like to see some of the RECs develop some kind of a job training program, somehow working with the community colleges and universities. People don’t necessarily think of community health centers when they think of job opportunities, especially in information technology. Sometimes if you train at a place, it can make you realize that they are really good places to work. For the health centers it becomes a nice recruitment stream. Especially in Massachusetts, it’s very hard for us to compete on a salary level when we’re competing with some systems in our state with some very deep pockets.

HCI: Can you talk a little bit about the hindsight of your EHR implementation? You spoke in your testimony about wishing you had had a full-time, on-site dedicated project manager and a faster implementation strategy.

Levine: We have a project manager, who is also the director of medical records. We basically gave him a full-time job on top of his full-time job. It’s a huge undertaking. When you’re not an IT professional, you don’t realize that from a project management standpoint it really is pretty-much a full-time job because there is so much you have to coordinate. If you can do it as a dedicated job then things run much smoother, and you tend to be able to tie up loose ends really quickly. We created committee structures, a steering committee and an implementation committee [to implement the NextGen (based in Horsham, Pa) EHR]. Sometimes that process can work really well, when the person leading the process is a [full-time project manager]. But when you have people who are coming together, who are all working on their regular day jobs and doing this, sometimes you can get bogged down in the process because it’s hard to have that one person whose responsibility is to move this forward. So, that’s why I think having a dedicated person really would have made sense.

I wasn’t at the health center when they decided to do a phased-in approach. It’s kind of like ripping a Band-Aid off your skin, you can do it in little bits and pieces, or that quick yank to get over the pain of implementation. In some ways it would have been better to do it all at once, and everyone could have suffered at the same time. I think part of the reason we didn’t do that is we didn’t have a lot of IT resources in-house; we have a very small department.

HCI: How do you think that RECs can accommodate the uniqueness of community health centers?

Levine: Community health centers are mission driven organizations because community health centers were developed to serve the medically underserved and take care of people with no insurance. I think it’s two-fold: one is to understand that most community health centers don’t have deep pockets, so when you charge an enrollment fee, it’s an expense that we don’t have built into our budgets. And the fact that we employ our providers, it would have been good if there to either not charge us at all or charging a per health center rate, instead of a per provider rate. Even though we’re large organizations—we have over 300 employees at my health center—we don’t necessarily have large telecommunications or information technology departments. A lot of places don’t even have chief information officer positions, maybe they have a director of IS. I think from an IT perspective for a lot of health centers, some of us still feel like we’re mom and pop organizations, not as sophisticated on the IT side. So for RECs to understand the kind of support you might need and the knowledge curve that you’ve got in order to understand all the implications moving toward meaningful use can be helpful.

HCI: What other types of challenges did you hear from the other testimonials? Were they similar to yours?

Levine: The physician from Arizona, it seemed like there was a lot of support in his practice for moving ahead with this and they were pretty advanced. The person from Oregon [Clayton Gillett, executive director, O-HITEC, Oregon’s Regional Extension Center] told me that 60 percent of providers in Oregon were already on an EMR. I found that interesting because there was a real acceptance for moving toward an electronic health record. There was another person who said there was a whole host of physicians who didn’t know anything about this and were taking a ‘wait and see’ [approach]. My experience was that if we weren’t talking to our physician group about what was going on in the state and the country with the HITECH Act, my guess is there would be a large majority of our providers who wouldn’t be thinking too much about this either.

I think there is a lot of disparity across the country. All the RECs are implementing this in different ways. And you get a different degree of comfort and interest around the country. I almost get the sense that the federal government is moving ahead with this, and doing a fine job moving it forward, but the rest of us are just racing to keep up with them. But we haven’t caught up.

I think the people that carry the largest burden in moving this forward is the providers. It really is a whole other style of practice. It’s pointing and clicking, instead of writing it down. It’s talking while you’re typing. It’s a whole other method they haven’t been trained in. I don’t’ think we’ve acknowledged enough the burden we’ve placed on the caregiver. My one curiosity, as someone who has worked in medical schools, is how are we training the next generation of doctors? Right now the burden of training is on institutions where they work. And how do we go down the road where this training takes place during their education and not during their work experience?


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