Prepared for the Tides Foundation San Francisco, California. Prepared by Kendall Guthrie, Ph.D. and Adelaide Nalley Blueprint Research and Design

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1 Blueprint Research & Design, Inc. 247 Fourth Street, Suite 105 Oakland, CA T: F: E: Moving from Data Collection to Health Promotion: Lessons on the information management capacity of California s community clinics and health centers drawn from the first year of the Community Clinics Initiative Prepared for the Tides Foundation San Francisco, California Prepared by Kendall Guthrie, Ph.D. and Adelaide Nalley Blueprint Research and Design with assistance from Bobbie Wunsch Pacific Health Consulting Group May 2001

2 Page 2 of 9 Executive Summary The Tides Foundation, in partnership with The California Endowment, has developed a major grant program to strengthen information management capacity for community clinics and health centers throughout California. By advancing local clinics and regional clinic consortia in their use of technology, the program seeks to increase their efficiency and competitiveness in providing quality health care services. In its first 18 months, the Community Clinic Initiative has awarded $18.7 million to 130 clinic corporations and regional consortia. The grant program expects to distribute another $8 million over the next 18 months. New and existing information technologies can expand and enhance the quality of care, efficiency, external marketing efforts, alliance-building, infrastructure and financial viability of safety net services. However, community heath centers need resources to take advantage of these technologies. Like other nonprofit organizations, clinics are often slower to adopt new technologies than their commercial counterparts, in great part due to a lack of both financial and skilled human resources. This report documents the state of information management capacity of California s community clinics and health centers when the grant program started in 2000 and highlights key areas for improvement. It also identifies some of the key management factors that can help clinics expand their information management capacity. The most significant findings presented in this report include: Clinics information management capacity varies greatly across the state. While a few clinics are experimenting with advanced medical records systems, about a quarter of the clinics have not yet automated some of the most basic administrative functions, such as appointment scheduling and accounting. Most clinics are automating their financial management systems; very few have automated their clinical management systems. Current clinic practice management software is significantly underutilized; lack of training has been identified as a key barrier to full utilization. Clinics management information reports focus on financial and patient demographic data. A significant portion of clinics would like to use their clinic management and patient tracking data to guide management decisions, but they do not know how to extract this data from their information systems. The management factors critical to successful Information Management system implementation are: o A management team with a comprehensive vision of how information systems can support clinical operations. o A Medical Director with a good conceptual knowledge of information management issues and active involvement in the clinic s information management planning process.

3 Page 3 of 9 I. Introduction The Tides Foundation, in partnership with The California Endowment, has developed a major grant program to strengthen information management capacity for community clinics and health centers throughout California. By advancing local clinics and regional clinic consortia in their use of technology, the program seeks to increase their efficiency and competitiveness in providing quality health care services. In its first 18 months, the Strengthening Clinics Information Systems program has awarded $18.7 million to 130 clinic corporations and regional consortia. The grant program expects to distribute another $8 million over the next 18 months. California s community clinics and health centers provide a wide range of health services to nearly 2.3 million Californians annually. In many California counties, community clinics and health centers are responsible for providing a significant portion of comprehensive primary care services to those who are publicly subsidized or uninsured. This continually shifting environment has presented clinics with their greatest challenge: operating on the margin, calling upon diminishing resources to provide increasingly costly care to growing numbers of un- and under-insured. New and existing information technologies can expand and enhance the quality of care, efficiency, external marketing efforts, infrastructure and financial viability of safety net services. However, community heath centers need resources to take advantage of these technologies. Like other nonprofit organizations, clinics are often slower to adopt new technologies than their commercial counterparts, largely due to a lack of both financial and skilled human resources. However, the changing economics and outcomeorientation of the health care marketplace make the efficiency and effectiveness gains of embracing technology even more important. This reports describes the state of information management capacity at California s community clinics and health centers when the grant program started in June 2000 and highlights key areas for improvement. The findings are based on data that Blueprint Research and Design collected as part of the ongoing evaluation of the Community Clinics Initiative. The report also identifies some of the key management factors that support clinics to expand their information management capacity. 1 1 A note about methodology In June and December 2000, Blueprint Research and Design surveyed the community clinics and consortia participating in the Community Clinic Initiative to help the Tides Foundation obtain a comprehensive picture of the technology capacity of community health clinics throughout California. The survey included questions about the administrative and clinical functions clinics have automated, the types of data they regularly collect, the reports the management team regularly consults, the organizations with which they exchange information and the capabilities of their current computer software and hardware. Quantitative data was supplemented with in depth case studies of six clinics, selected to represent organizations at different stages of their information management development and strategy. The case studies were designed to provide a deeper understanding of how clinics went about expanding their information management capacity. They also explored how this strengthened capacity influences business operations and the quality of patient services. Daylong site visits were conducted at each case study clinic.

4 Page 4 of 9 II. The Current State of Clinic Information Systems A. Clinic Technology Infrastructure Clinics across the state show a huge range in information management capacity. About 15 percent of California s community health centers have sophisticated information systems that include managed care and clinical management features. Several are implementing state-of-the-art electronic medical records systems. However, as of June of 2000, about a quarter of the clinics had not yet automated some of the most basic administrative functions, such as appointment scheduling and accounting. Proportion of Community Clinic Initiative Grantees Billing/Claims Table 1: Clinics have focused on automating business functions; they are not using their software's capabilities to automate clinical functions Accounts Receivable Registration Accounts Payable Apt/Scheduling Payroll Patient Tracking/Recall Eligibility Utilization Review Case Management Managed Care Features Referrals Basic Medical Records Functionality available but not implemented Automated Results of Ancillary Services Other Full Medical Records The physical infrastructure of hardware and software is old. Almost half the computers used in community clinics in June of 2000 were more than 18 months old. Moreover, about half of the clinics reported that they had an information system that was more than two years old. A quarter had information systems 5 years or older. Most clinics have significant gaps in their internal data communications systems. More than a third of the clinics had significant numbers of computers not connected to their local area network. Two-thirds of clinics with remote sites had one or more remote site that could not access the practice management system. While nearly all clinics now have some type of access to the Internet, it is generally limited to one or two computers. Electronic mail is primarily a vehicle for senior staff to conduct external communications.

5 Page 5 of 9 Generally, it is not used for internal staff communications, even when clinics have a number of remote sites. Clinics are most likely to automate their financial management systems; very few have automated clinical management systems. About 70 percent have automated functions such as billing and claims, accounts receivable and registration. Only one third of the clinics have automated clinical management functions, such as utilization review, case management and patient tracking/recall, despite the fact that these issues are the major driving forces in current health care. Current clinic practice management software is significantly underutilized. Nearly a quarter of the clinics are not using some of the most basic automation capabilities built into their current practice management systems, such as appointment scheduling, patient tracking/recall and eligibility. Less than a third of the clinics use their practice management system to track basic patient health status such as acute and chronic diseases, immunizations and wellness reminders. However, one third of the clinics have practice management systems capable of tracking this information but have not implemented this functionality. 70% Table 2: Clinic practice management systems have the capability to support population health management; however, clinics need training and additional software modules Functionality available but not implemented Proportion of Community Clinic InitiativeGrantees 60% 50% 40% 30% 20% 10% 29% 33% Tracking capability currenly used 32% 27% 24% 23% 0% Immunizations Wellness Reminders Acute/Chronic Diseases The two primary reasons reported for under-utilization are lack of training and lack of money to buy additional software modules. Moreover, many Medical Directors don t know that their practice management systems even have the capability to support patient tracking and health promotion because they generally aren t involved in information management planning.

6 Page 6 of 9 The sophistication of a clinic s information management system is not highly correlated with the age of the system or size/configuration of the staff. Clinics with newer and more complex/powerful information technology hardware or larger staffs do not necessarily have more sophisticated systems or effective procedures for producing useful management reports. Whether IT staff members are clinic employees or outside consultants also did not appear to be correlated with the clinic s ability to effectively design and utilize their information management system. The key to effective information management lies in top management vision, trained staff and maximization of software, not in large staffs and fancy hardware. B. Clinic Reporting and Health Data Analysis Capability Clinics most commonly produce and review financial and patient demographic reports. More than half the clinics report that someone on their management team reviews some type of report on patient registration, aged accounts receivable and payable, unpaid claims and rejected claims tracking, budget variance reports, administrative cost/overhead, primary and secondary payor sources and provider productivity reports on at least a quarterly basis and usually a monthly basis. Only one third of all clinics regularly reviewed any kind of report on clinical management issues such as utilization, patient flow or ancillary services by provider or user Table 3: Clinics tend to produce business operations reports; they want to review clinical administration and patient care reports but don't know how to produce them Produced and Reviewed Desired Business Operations Reports Clinical Administrative Reports Individual Patient Care Reports Proportion of Community Clinic Initiative Grantees Aged accounts receivable/payable (Q) Personnel tracking(q) Budget variance reports (Q) Unpaid / rejected claims (M) Cost report for FQHC(A) Administrative cost/overhead (Q) Cost per encounter ancillary service(a) Inventory (Q) Patient registration (A) Provider productivity reports (A) Utilization reports (Q) Patient flow efficiency (Q) Provider incentive performance profile (A) Presenting diagnoses for visits (A) Ancillary services by user, provider (Q) Obstetrics (M) Frequency report is produced: A=Annually Q=Quarterly M=Monthly

7 Page 7 of 9 Most clinics aren t using their data to guide management and decision-making. Clinics ability to manipulate and analyze the data they collect varies widely. A significant number of clinics are not producing what many would consider some of the most basic reports required for effective clinic management, such as unpaid and rejected claims, primary and secondary payor sources and provider productivity reports. For most clinics, management reports do not go beyond financial issues. If they produce any reports on clinic issues, such as patient flow or ancillary services, the reports tend to simply count what has happened each month. Few community clinics and health centers understand how to produce analytical reports that could help them better understand business or clinical processes. Most don t connect their financial and clinical management data, nor do they use their data to measure progress toward service-level benchmarks. Clinics want to use their clinic management and patient tracking data but don't know how to extract the information. About one third of the community clinics and health centers currently produce reports on topics such as utilization, patient flow and an analysis of ancillary services by users and providers. An additional third say they would like to review this type of information but can t figure out how to get their information system to produce it. Most clinics track a wide range of health data elements but their ability to manipulate the data is limited because their data collection systems aren t automated or integrated into their overall information management system. In general, the clinics collect data in the areas of maternal and child health (e.g., low and very low birth weight, childhood immunizations, abnormal mammograms) and chronic disease (e.g., diabetics, hypertension). Only five percent of clinics report that they track no basic health status elements. However, the clinics ability to use this information for ongoing health management is limited because only about 30 percent of the health data elements are tracked in an automated fashion. Clinics regularly exchange data and information with outside organizations, such as other clinics or consortia, but most of this exchange is handled either verbally or in print not electronically. Electronic data exchange has focused on transmitting billing-related information. Most of the community clinics and health centers have established electronic data exchanges with some of their key payor sources. Over 70 percent use electronic data exchange to share information with MediCal. Forty percent use electronic data exchange with Medicare and 30 percent use it with Health Plans. Only 15 percent of the clinics use electronic data exchange to share information with private clearinghouses. Very few clinics exchange any clinical data with health care partners in ways that might start contributing to the larger public health knowledge in their community.

8 Page 8 of 9 Table 4: Clinics regularly exchange data and information with many organization, but most of this exchange is handled either verbally or in print--not electronically Electronic Non-electronic Proportion of Community Clinic Initiative Grantees State, Fed, Gov't Hospitals- Clinical Consortia- Admin Consortia- Clinical Statewide Ass. Other Clinics- Clinical Other Clinics- Admin Mgd Care- Clinical Mgd Care- Admin Hospitals- Admin III. Effective Strategies for Building Information Management Capacity At Community Health Clinics Top clinic managers need a comprehensive vision of how information systems can support clinical operations. Clinics guided by a big picture vision of how information technology can support clinic operations and decision-making are more successful at information technology project implementation. These clinics have a vision for the role of information technology in their agency-wide strategic plan not just a strategic information technology plan developed in isolation of overall clinic goals. All members of the management team need to understand and buy into this vision. Understanding the big picture provides an important framework for making appropriate small picture planning on specific information technology issues. Clinics with top management who lack a basic conceptual understanding of information technology or who feel uncomfortable with technology have a difficult time developing their overall vision for technology -- even if they have capable and skilled mid-level staff. Most clinic managers need to become more educated on how information technology can support business and clinical operations. They should focus on gaining conceptual not technical knowledge.

9 Page 9 of 9 Clinics need to get their medical staff more involved in information management planning. Clinics making the most progress tended to have a Medical Director who has a good conceptual knowledge of information management issues and who is actively involved in the clinic s information management planning process. This is the position best suited to move the use of information technology beyond billing and scheduling support towards improving medical care for patients. However, the needs and priorities of medical staff are not well represented in the clinic information systems planning process. Only 34 percent of the clinics involve their medical director in software planning and decision-making. Often there are also other medical providers on staff with a keen interest in information technology issues who could contribute valuable expertise as well as build confidence in the planning process among other providers. Time invested in information technology planning yields more effective systems. Most clinics did not budget adequate time for planning their new information technology project. However, they appear to be learning from their experiences. The proportion of community clinics that report having a formal information technology plan has increased significantly since the inception of CCI, from 31 percent of June 2000 grantees to 50 percent of December 2000 applicants. However, most clinics still do not include information technology goals as part of their over strategic business plan. Clinics should begin budgeting for information technology as an on-going clinic cost center. This information technology budget should include maintaining and upgrading hardware and software, information technology staffing and regular training for all clinic staff. A comprehensive, cost-center approach to budgeting will support more effective integration of information technology with overall clinic operations. Most clinics currently distribute their information management costs throughout their budget. This method means that many costs, such as training, get hidden and are never adequately accounted for. Moreover, most clinics view hardware as a one-time capital expense, to be funded by grants, rather than as part of information systems annual maintenance. An interdepartmental team should manage information systems planning. Ideally, this team should include the Executive Director, Medical Director, Chief Financial Officer, Director of Clinic Operations or Clinic Manager, and Head of IT. This team approach promotes technology planning with an eye to overall clinic operations rather than just the needs of one or two departments. The team also fosters better project management and implementation that meets, anticipates and coordinates the needs of all departments. Finally, this approach helps the management team continually assess how information management affects everyone in the organization. Comprehensive, continuous, and inclusive training plans are critical to information technology system success. Effective training plans that involve a wide sector of staff and occur regularly enhance staff confidence in technology and promote maximization of a clinic's practice management system. Concentrating information technology skills in one or two professional information technology staff can actually impede a clinic s ability to develop a comprehensive vision of how information technology supports overall clinic operations. This concentrated staff configuration can make it easier for people who may be less comfortable with technology, such as the Executive Director or the Medical Director, to think that someone else is handling the information technology so they don t have to worry about it. Moreover, it leaves clinics very vulnerable to staff turnover because if the one knowledgeable person leaves, there is no institutional knowledge of the system.