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.

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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 cross-

organizational 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 41 (33)

2-4 36 (29)

5-9 30 (24)

10 or more 19 (15)

Role of Respondents N (%)

Administrative 51 (48)

Clinical 9 (8)

Technical 44 (40)

Financial 4 (4)

Other 2 (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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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.

96% 95% 100%

4% 5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overall Urban Corporations Rural Corporations

Percent

Clinic Corporation Type

Not certified

for MU

Certified for

MU

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Table 2: Internal and External Data Exchange

Overall

N (%)

Urban

N (%)

Rural

N (%)

Share patient electronic data internally 45 (67) 32 (67) 12 (67)

Mean number of internal exchange locations 1.97 1.97 1.67

Share patient electronic data externally 34 (52) 23 (48) 11 (65)

Mean number of external exchange locations 2.11 2.09 2.17

Access to external data:

View it via a website or portal 11 (32) 6 (27) 5 (42)

Receive it into the EHR 9 (27) 7 (32) 2 (17)

Both portal and into EHR 14 (41) 9 (41) 5 (42)

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

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.

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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 N (%)

Nextgen 12 (22)

eClinical Works 11 (15)

Mirth 10 (13)

AT&T 7 (9)

Microsoft 5 (7)

Homegrown System 5 (7)

Epic 3 (4)

GE Healthcare 3 (4)

Medicity 3 (4)

Oracle 2 (3)

Verizon 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.

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Figure 2. Electronic data exchange partners

43%

32% 32%

64%

16%

34%

14%

43%

2%

0%

10%

20%

30%

40%

50%

60%

70%

Percent

Exchange Partner

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.

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.

0

10

20

30

40

50

60

70

80

Percent

Data Types

internal exchange

external exchange

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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.

49%51%

20% 20%

9%

21%

9%

47%

51%

20%

25%

16%

20%

8%

0%

10%

20%

30%

40%

50%

60%

PDF, TIFF HL7 V2 CCR, CCD Word, Excel Plain text Non-standard Direct

Percent

Data Format or Standard

Send

Receive

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Figure 5. Outsourced HIE Services

15%

30%

8%

43%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Hospital or health

system

Community clinic

consortium

HCCN Other HIT provider

Percent

HIE Technology Provider

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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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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

Number (%)

HIE decreases cost 12 (11)

HIE increases cost 61 (68)

No change to cost 32 (29)

HIE decreases revenue 14 (12)

HIE increases revenue 28 (25)

No change to revenue 71 (63)

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.

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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).

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.

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.”

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Table 5: Importance of HIE in relation to other priorities, scale of 1 (not important) to 7

(extremely important)

Overall Urban Rural

Priority compared to other initiatives 4.40 4.45 4.22

Importance to daily operations 4.70 5.69 4.73

Importance to quality of care 5.28 5.25 5.39

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).

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.

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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 Urban Rural

Overall Challenge 5.16 5.15 5.22

Adequacy of internet connection 5.39 5.40 5.35

Availability of HIO in area 5.61 5.59 5.68

Availability of technical assistance 5.65 5.69 5.45

Technical expertise 5.75 5.81 5.55

Privacy 5.88 5.83 6.09

Security 5.90 5.83 6.17

Data Standards 5.99 6.03 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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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)

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.

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.

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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)

Overall Urban Rural

Clinic leadership understanding of HIE 5.35 5.43 5.05

Knowledge about HIE 5.38 5.43 5.17

Level of interest of clinic leadership in HIE 5.41 5.48 5.17

Level of interest in HIE among clinicians 5.55 5.51 5.73

Clinician understanding of HIE 5.64 5.67 5.50

Individual HIE leader in the community 5.67 5.75 5.35

Willingness of local health organizations to collaborate 5.95 5.97 5.86

Willingness of partners to share data electronically 6.01 6.06 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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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 Urban

Corporations

Rural

Corporations

Capital expense 5.48 5.58 5.09

Availability of funds 6.18 6.26 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.)

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.”

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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.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Grant to the clinic Clinic general funds Sponsored by

Professional

Association

None

Percent

Source of Funding for HIE

Overall

Urban

Rural

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Figure 7. Budget for Health Information Technology Overall and By Geographic Setting

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Overall Urban corporations Rural corporations

Percent

Percent of Budget Allocated to Health Information Technology

0-4%

4-9%

10-14%

15% or more

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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.

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.”

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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. National Alliance for Health Information Technology. Defining Key Health

Information Technology Terms. 2008;

http://www.nacua.org/documents/HealthInfoTechTerms.pdf. Accessed May

1, 2008.

2. 111th Congress of the United State of America. American Recovery and

Reinvestment Act of 20092009.

3. Vest JR, Gamm LD. Health information exchange: persistent challenges and

new strategies. Journal of the American Medical Informatics Association.

2010;17(3):288-294.

4. eHealthInitiative. 2012 Report on Health Information Exchange: Supporting

Healthcare Reform. 2012; http://www.ehidc.org/resource-

center/surveys/view_document/43-survey-2012-annual-hie-survey-results-

report-on-health-information-exchange-supporting-healthcare-reform-data-

exchange. Accessed October 21, 2013.

5. 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.

6. Fiscella K, Geiger HJ. Health information technology and quality

improvement for community health centers. Health Affairs. 2006;25(2):405-

412.

7. Sicotte C, Paré G. Success in health information exchange projects: Solving

the implementation puzzle. Social Science & Medicine. 2010;70(8):1159-

1165.

8. 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. 10-0047-

EF). 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.