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The American Journal of Managed Care December 2015
Interest in Mental Health Care Among Patients Making eVisits
Steven M. Albert, PhD; Yll Agimi, PhD; and G. Daniel Martich, MD
The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality
Ilana Graetz, PhD; Jie Huang, PhD; Richard Brand, PhD; Stephen M. Shortell, PhD, MPH, MBA; Thomas G. Rundall, PhD; Jim Bellows, PhD; John Hsu, MD, MBA, MSCE; Marc Jaffe, MD; and Mary E. Reed, DrPH
Health IT-Assisted Population-Based Preventive Cancer Screening: A Cost Analysis
Douglas E. Levy, PhD; Vidit N. Munshi, MA; Jeffrey M. Ashburner, PhD, MPH; Adrian H. Zai, MD, PhD, MPH; Richard W. Grant, MD, MPH; and Steven J. Atlas, MD, MPH
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Dennis P. Scanlon, PhD, Associate Editor, The American Journal of Managed Care
An Introduction to the Health IT Issue
Jeffrey S. McCullough, PhD, Assistant Professor, University of Minnesota School of Public Health; Guest Editor-in-Chief for the health IT issue of The American Journal of Managed Care
Preventing Patient Absenteeism: Validation of a Predictive Overbooking Model
Mark Reid, PhD; Samuel Cohen, MD; Hank Wang, MD, MSHS; Aung Kaung, MD; Anish Patel, MD; Vartan Tashjian, BS; Demetrius L. Williams, Jr, MPA; Bibiana Martinez, MPH; and Brennan M.R. Spiegel, MD, MSHS
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Currently Reading
Health Information Technology Adoption in California Community Health Centers
Katherine K. Kim, PhD, MPH, MBA; Robert S. Rudin, PhD; and Machelle D. Wilson, PhD
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Health Information Technology Adoption in California Community Health Centers

Katherine K. Kim, PhD, MPH, MBA; Robert S. Rudin, PhD; and Machelle D. Wilson, PhD
This study examined the adoption of health information technology-electronic health records, health information exchange, and patient engagement-by California state community health centers.

Objectives: National and state initiatives to spur adoption of electronic health records (EHRs) and health information exchange (HIE) among providers in rural and underserved communities have been in place for 15 years. Our goal was to systematically assess the impact of these initiatives by quantifying the level of adoption and key factors associated with adoption among community health centers in California.

Study Design: Cross-sectional statewide survey.

Methods: We conducted a telephone survey of all California primary care community health centers (CHCs) from August to September 2013. Multiple logistic regressions were fit to test for associations between various practice characteristics and adoption of EHRs, meaningful use–certified EHRs, and HIE. For the multivariable model, we included those variables which were significant at the P = .10 level in the univariate tests.

Results: We received responses from 194 CHCs (73.5% response rate). Adoption of any EHRs (80.3%) and meaningful use–certified EHRs (94.6% of those with an EHR) was very high. Adoption of HIE is substantial (48.7%) and took place within a few years (mean = 2.61 years; SD = 2.01). More than half (54.7%) of CHCs are able to receive data into the EHR indicating some level of interoperability. Patient engagement capacity is moderate, with 21.6% offering a PHR, and 55.2% electronic visit summaries. Rural location and belonging to a multi-site clinic organization both increase the odds of adoption of EHRs, HIE, and electronic visit summary, with the odds ratio ranging from 0.63 to 3.28 (all P values <.05).

Conclusions: Greater adoption of health information technology (IT) in rural areas may be the result of both federal and state investments. As CHCs lack access to capital for investments, continued support of technology infrastructure may be needed for them to further leverage health IT to improve healthcare.

Am J Manag Care. 2015;21(12):e677-e685
Take-Away Points
National and state initiatives to spur adoption of electronic health record (EHR) use and health information exchange (HIE) among providers in rural and underserved communities have been in place for 15 years. Yet there has been little systematic effort to assess the adoption among community health centers (CHCs). California is a leader in its focus on health information technology for CHCs. Specific findings for CHCs in California: 
  • Adoption of any EHRs (80.3% of CHCs) and meaningful-use–certified EHRs (94.6% of those with an EHR system) is very high. 
  • Adoption of HIE is substantial (48.7% of CHCs) and recent (mean of 2.61 years). 
  • 54.7% of CHCs receive electronic data into the EHRs. 
  • Factors increasing the odds of adoption include rural location and belonging to a multi-site clinic organization. 
  • Public funding and support for technology infrastructure in CHCs appears to be effective in promoting adoption, and more support is likely needed for further improvements.
California has an unusually active health information technology (IT) environment. In addition to the national investment in electronic health records (EHRs) and health information exchange (HIE) through the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), over the last 15 years, private and state initiatives have aimed to improve digital infrastructure for the safety net through community health centers (CHCs). However, there has been little systematic effort to assess the impact of these policy and funding drivers on the general adoption of health IT among CHCs. The purpose of this study was to: 1) examine the level of adoption of EHRs and HIE among CHCs in California, and 2) assess the relationship among health IT adoption and key practice characteristics. To this end, we conducted the first statewide survey of health IT adoption in CHCs in California after HITECH. Results will contribute to the understanding of health IT issues faced by CHCs and may interest policy makers who wish to improve adoption and effective use in the safety net.

Health IT, including EHRs and HIE, is a core component of the US government’s strategy to improve quality and reduce costs of care.1,2 EHRs replace the paper charts used by providers to record a patient’s information, and HIE is the electronic sharing of clinical data among unaffiliated providers, who may be using EHR products from different vendors, caring for the same patient.3,4 Through HITECH and other programs, federal and state governments have invested substantial sums to promote health IT adoption among hospitals and eligible professionals, and have provided direct funding to CHCs.5 CHCs, which include federally qualified health centers (FQHCs), other primary care clinics, and free clinics, are a vital part of the safety net for the underserved, uninsured, and indigent. HITECH funding for CHCs was offered in the form of “Meaningful Use” (MU) incentives to eligible professionals working at CHCs, as well as regional extension centers to assist with adoption, and grants to states to promote HIE.6

Two recent national studies found that more than 90% of FQHCs had adopted EHR use, a substantial increase since the passage of HITECH.7,8 One of those studies found that 50% had adopted a basic EHR system (defined as having 7 computerized capabilities, such as maintaining patient problem and medication lists, incorporating laboratory results into the EHR, and entering prescription orders electronically), and one-third were capable of meeting MU Stage 1 requirements.8

Of the articles found in a recent systematic review of publications about HIE,9 only 4 studies collected data related to attitudes and barriers of CHCs, and none focused solely on this type of provider.10-13 One of these studies, by Yamin et al, highlighted unique challenges, including a shortage of staff and IT resources to implement HIE. Yamin and colleagues also pointed out that “the needs of the safety net population and its providers were not explicitly addressed, and some CHCs believed they were overlooked as important data providers.” CHCs may be at risk of falling behind in adoption of HIE, thus impacting quality of care and creating a digital divide in healthcare services.14

While previous studies have focused on health IT adoption among FQHCs, we did not find any that addressed all types of CHCs; hence, the focus of this paper is health IT adoption in CHCs in California. California represents a particularly active health IT landscape, with 16 communities organizing HIE among unaffiliated health organizations and 14 enterprises conducting HIE within an integrated delivery network.15 In addition, a number of state-level programs have focused on health IT adoption in CHCs since the 1990s. One such program was the Tides Foundation’s Community Clinics Initiative, which supported EHR implementation and expansion.16 Another program, The California Telehealth Network’s Broadband Technology Opportunity Program, provided connectivity, equipment, technical assistance, and education to rural communities to promote adoption of broadband-enabled telemedicine and telehealth.

Blue Shield of California Foundation was an early funder of EHR and HIE readiness, planning, and implementation for CHCs; and UnitedHealthcare also offered grants for health IT innovation in rural and underserved communities. Finally, the HITECH-funded, state-designated HIE in California collaborated with regional quality improvement organizations to offer assistance to rural communities with EHR adoption and provided several rounds of rural HIE grants and technical assistance. Thus, California is likely a leading state for health IT resources for CHCs. Understanding progress here may offer insights to inform other state and national strategies.

The purpose of this paper is to assess the level of adoption, and related factors, of EHRs and HIE among CHCs to inform future policy efforts to promote the use of health IT in California and nationwide.

Sample and Administration

A publicly available database of CHC sites and administrative contacts was obtained from the Office of Statewide Health Planning and Development (OSHPD), which licenses CHCs. The OSHPD database includes safety net clinics, including primary care clinics and free clinics—some of which may also be federally qualified health centers (FQHCs)—but does not include physician-owned clinics or those covered solely by a hospital license. A starting set of 1059 CHCs was obtained. Specialist and single-issue centers (eg, oncology, dialysis) and headquarters or administration-only locations of a multi-site CHC were excluded. To ensure a site met inclusion criteria, an Internet search was conducted and, if needed, a phone call was placed to ascertain the scope of care services. CHCs were grouped according to parent organization, if applicable, and only 1 survey per parent group (randomly selected from among locations) was attempted until the entire sample was attempted twice; this allowed for the greatest reach of opinions from different organizations. Screening resulted in 264 eligible sites. Respondents targeted were clinic site managers or administrators who had oversight of day-to-day delivery of services and would therefore have insight into how health IT was used in the clinic. An external survey firm collected the data through a computer-assisted telephone interviewing (CATI) software application used by 8 interviewers in a central location in San Francisco. Data collection occurred during August and September 2013. The study was approved by the San Francisco State University committee for human subject protection.

Survey Instrument

The questions analyzed for this paper were part of a larger telephone survey of 44 items (original survey available by contacting the corresponding author). The items included for analysis in this report were newly constructed based on investigator experience and literature review.

EHR Adoption

Two measures of EHR adoption were determined based on “yes” responses to: “Does your clinic have an electronic health record system, also known as an EHR?” and “Is your organization currently using an EHR certified for meaningful use?” MU was described as: “In 2011, Medicare and Medi-Cal began offering financial incentives for physicians to adopt, implement, or upgrade computerized medical records systems (also known as electronic health records or electronic medical records) and use them meaningfully in practice. A certified EHR is one that is approved by the federal government to allow providers to obtain meaningful use incentive payments.” Based on the timing of the survey, the question refers only to MU Stage 1.

HIE Adoption

HIE adoption was determined by a “yes” response to: “Does your clinic currently send or receive any electronic patient health information, not including claims or billing, externally, that is with other locations that are not under the same parent organizations? In other words, external locations are separate legal entities or unaffiliated organizations.” We also asked about the length of time the organization had conducted HIE, how they accessed incoming electronic data (ie, view it in a website or portal, receive it into the EHR, or both), the external organizations with which they exchanged data (hospitals, physician offices, pharmacies, laboratories, other clinics, radiology/imaging centers, patients’ personal health record systems, public health agencies, and other), and the types of data they exchanged (eg, lab orders, lab test results, radiology orders, radiology results, patient summary care records, inpatient clinical notes, inpatient medication lists, inpatient problem lists, discharge summaries, ambulatory clinical notes, ambulatory medication lists, ambulatory problem lists, referrals, and clinical summaries). Two items explored the importance of HIE: “How much of a priority is implementing electronic health information exchange, compared with the other initiatives you currently have going on in your clinic, on a scale of 1 to 7 with 1 being the lowest priority and 7 being the highest priority?” and “How important is health information exchange, which is the electronic sharing of patient health information, to your clinic’s mission, on a scale of 1 to 7 with 1 being not at all important and 7 being extremely important?”

Patient Engagement

Patient engagement was assessed with dichotomous responses to: “Do you offer an online personal health record (PHR) to your patients?” and “Do you provide visit summaries electronically to your patients?”

Practice Characteristics

All CHCs were located in California and were defined as urban or rural based on the Rural-Urban Commuting Area–mapped zip code of the local site. The sites were categorized according to size based on the number of full-time equivalent (FTE) billing providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives (small, ≤1 FTE; medium, 2 to 5 FTEs; large, >5 FTEs). Other characteristics included being part of a multi-site clinic organization, recognition as a patient-centered medical home (PCMH), and the level of such recognition.


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