IT Systems for Rural Indian Clinic Health Care

For Native Americans in California, getting medical treatment at a nearby clinic or hospital can be difficult. Those who get care are often treated in remote locations, making coordination between hospitals and faraway clinics a challenge. But with a doseof information technology (IT), the California Rural Indian Health Board (CRIHB) and the Tribal Health Programs are trying to bridge the distance.

CRIHB serves Native Americans and Alaska Natives in rural California through a network of Tribal Health Programs that are controlled and sanctioned by Indian people and their tribal governments. These clinics are located throughout the state and are associated with various tribes and reservations.

With the help of the 3-year grant from the Agency for Healthcare Research and Quality (AHRQ), the Information Technology Systems for Rural Indian Clinic Healthcare aims to prevent unnecessary hospitalizations by improving health care quality and reducing medical errors. The board is partnering with three of its rural Tribal Health Programs that have implemented electronic practice management systems as a precursor to electronic health records (EHR).

The AHRQ grant will also make it possible for Tribal Health Programs to implement an EHR that they can adapt to their own operating needs, patient care needs and government reporting needs without waiting for a hospital-based system from the Indian Health Service.

Project Provides Lessons Learned For IT Implementations

Along the way, the project has been a learning lab for the challenges that providers implementing health IT face.

"I saw electronic health records as a tool we needed to improve the quality of care," says Linda Aranaydo, M.D., the principal investigator for the AHRQ project and director of medical services for CRIHB. "I didn't understand that this would require all members of the team, from the IT --to medical to the billing staff-- to redesign how they work."

Aranaydo has learned that each phase of IT implementation requires intense investment of staff time. Constant communication is needed among the IT, clinical, and administrative staff at every clinic, working together to adapt and adopt the system. Teams representing these three points of view met weekly for months to address unexpected developments in the implementation. "If you don't have at least three people to look at the implementation from different perspectives, then you don't know what to do next," Aranaydo says.

A strong leadership team is also critical to the success of IT implementations. "There should be a person who holds the vision of why you are doing this, a person who has the oversight to pull in the people who need to be involved," Aranaydo explains. "Otherwise, you lose so much time."

In addition to the cultural changes required for a successful IT implementation, the clinics have faced technical challenges. Clinics were not using standardized ways of entering data, resulting in a hodge podge of information about patients. The clinics are now working on data standardization agreements to eliminate the problem. This will help the project move on to its next phase: using EHRs for population-based health care.

The EHRs, which will include a clinical decision support system, are designed to help clinics better manage patient care and coordinate with local hospitals to help detect and track medical errors. The system will provide a window into hospitalizations and how they can be prevented.

"It promises to make what is now unmanageable, manageable," Carol Korenbrot, research director for CRIHB, says of the project.

Aranaydo says the technology can help solve several care issues for this special, highly mobile population. For example, a woman may deliver her baby hours away from where she gets prenatal care. And patients often show up in the emergency department to seek care. In addition, tribal health programs struggle to keep infants and young children up to date on their immunizations because their families move around so much. Having EHRs at local clinicswill enable physicians at the hospitals to address these and other problems, such as possible medication interactions.

One network of clinics is using its EHR system to examine the health of its patients and improve care at the population level. Clinic staff identified a group of children who needed immunizations after reviewing the EHRs of children at seven health clinic sites. The EHR system also improved patient care by becoming a regular source of performance reporting on more than 30 indicators of primary and preventive care, particularly for patients with diabetes, who require close monitoring of their blood sugar as well as their vision, foot care, and blood pressure.

Unfortunately, many of these patients don't control their blood sugar levels, which may result in loss of vision and amputations. The clinics used the EHR to identify which of the 350 diabetic patients were up to date on recommended screening services. The system revealed gaps in care for these patients, which led to quality improvement changes at the clinics. For example, case managers and providers developed "foot care" clinics and offered vision care for those in need of services.

Project leaders are now creating a diabetes registry to provide individual reports to doctors on how they are managing these patients. In the end, Korenbrot says, the investment in time and energy has been worthwhile.

"We can't not do this in health care," she says. "There is no going back."