The current recession officially began in December of 2007 (Bureau of Economic Analysis, Department of Commerce) and the statistics are grim indeed. The poverty rate has increased by .7 percent to 13.2 percent, and the median household income has declined by $1,860 to just over $50,000. At the same time, the general unemployment rate is above 9.5 percent and the number of people who have lost their health insurance has increased by almost 1 percent – about 4.2 million – so that almost 50 million people are uninsured. Recovery is expected to take considerably longer than during the 2001-2002 recession (Center for Economic Policy and Research, Washington, D.C., http://www.cepr.net/).
Increased unemployment over a longer period of time, and the often attendant loss of health insurance, mean that more individuals and families are likely to rely on Medicaid coverage and get their medical care at CHCs. Let’s look at a few state examples. In my home state of Massachusetts enrollment in the state-run MassHealth program has increased by 80,000 since May 2008 partly as a result of the state’s health reform program, bringing the state’s Medicaid enrollment to 1.2 million people. This is significantly above the projections for Medicaid growth and also substantially higher than the level for which the budget was set.
In North Carolina, the system is quite stressed, despite an innovative statewide Medicaid case management system. The Bureau of Labor Statistics shows that the August 2009 unemployment rate was 10.8 percent, and the North Carolina Institute of Medicine estimated that just over 25 percent of adults aged 18 to 64 years are without health insurance. This has increased the demand for services at CHCs. At HealthServ Community Clinic in Greensboro, increasing demand and longer wait times for new patient appointments ultimately pushed the center to temporarily stop taking new patients (Washington Post, April 29, 2009).
There is some good news, though, in relation to job creation and health center employment. Speaking at the American Health Information Management Association (AHIMA) conference in October 2009, national health information technology coordinator Dr. David Blumenthal predicted that about 50,000 information technology jobs would be added as health care organizations move to meaningful use of HIT. Uniform Data Systems (UDS) data for the last several years also shows that employment at CHCs has increased overall. This is good, because health centers will be busy.
CHCs and HIT
So we know that health centers are going to be busier than ever over the next year, and that infrastructure support must be developed quickly. How can this be done in tight times? Money helps, and the provisions of the American Recovery and Reinvestment Act (ARRA) and other recent legislation have already provided additional funds for CHCs. In addition, a recent study from the Geiger Gibson/RCHN Community Health Foundation Research Collaborative (P. Shin, et al., Estimating the Economic Gains for States as a Result of Medicaid Coverage Expansions for Adults) estimates that every dollar invested in the state Medicaid program generates a return of two to six dollars. Increased federal matching funds could accelerate this multiplier, making state Medicaid investment an important factor in recovery.
HIT can also help, by facilitating improvement in both health care outcomes and the effectiveness of health center operations. The issue now is how to help overcome three threshold issues for HIT adoption including financial, timing and cultural concerns. I’ll address each here.
Certainly, ARRA and the HITECH Act (S.336) provide a lot of funding for the adoption of HIT, specifically certified electronic health records (EHR) systems. This initial funding, along with the Medicaid reimbursement incentives, will go a long way toward alleviating the financial burden associated with acquiring and adopting new systems. However, detailed planning is required to qualify for available funds, as well as to determine how to best use these systems. In addition, identifying and securing a source of funding for ongoing expenses and maintenance of HIT systems is essential. Truly, many financial issues are introduced with the acquisition and adoption of EHR and other HIT systems.
Timing has to be carefully considered. Health centers currently have many compelling needs, including capital improvement, physical expansion and development of new clinical services. ARRA has provided funding for these types of improvements, and priorities must be set in order to take advantage of as many additional resources as possible. It may be tempting to think that since meaningful use has yet to be fully defined – and since it will not be evaluated until 2011 – it is not necessary to jump in to the HIT planning, evaluation and adoption processes. However, we know from experience that this effort takes time – sometimes as long as two years – so starting now is not too early.
Finally, we also know that there are organizational and cultural issues involved in the adoption and use of EHR and other HIT-based applications. These include providers’ reluctance to change familiar clinical workflows, as well as a similar hesitation on the part of health center administrators to change operational processes that have worked in the past. Nevertheless, clinical and operational processes must evolve in order to serve the needs of the growing patient population and to meet federally mandated requirements established in the meaningful use criteria, such as consumer access and privacy.
How HIT Can Help
There are a number of ways that these threshold issues can be addressed. The first involves collaboration, through primary care associations, health center controlled networks or other less formal working groups of health centers. These organizations typically provide some combination of the following:
- HIT vision development and planning;
- Requirements analysis for HIT acquisition;
- Vendor selection and management;
- Deployment and maintenance of HIT infrastructure and applications;
- Operational support; and
Working together, centers can lower the operational costs of acquiring, adopting and implementing HIT.
There is also an opportunity to prioritize the use and acquisition of HIT applications to optimize clinical and operational returns, clinical alerts, ePrescribing and other functionality may improve efficiency and effectiveness at the center to yield favorable operating results. For health centers with co-located services such as dental or behavioral health care, integration of records and interdepartmental communication can be facilitated by configuring decision support and EHR systems.
The current economic crisis presents a very challenging environment for health centers, and creates a critical need for change in both clinical and operational processes. However, HIT can provide an instrument to drive and support such change. The resources currently available for the adoption and use of HIT enable CHCs to seize the opportunity.
David Hartzband, D.Sc. is the Director of Technology Research at the RCHN Community Health Foundation.