Developing a Network of Community Health Centers With a Common Electronic Health Record: Description of the Safety Net West Practice-based Research Network (SNW-PBRN)

The Founding of Safety Net West

Safety Net West: A Practice-based Research Network of Community Health Centers

The combination of factors—a multistate network of safety net clinics, an EHR with rich data linked across the network, and support from OCHIN′s leadership—provided momentum for developing capacity to improve care quality in the safety net by optimizing practice through research. To that end, OCHIN began collaborating with two local academic researcher centers: the Center for Health Research (CHR) at Kaiser Permanente Northwest, and Oregon Health and Science University (OHSU). In 2005 to 2006, CHR and OCHIN developed a “Guide to Conducting Research in the OCHIN Practice Management Data.”³ Next, two OCHIN member organizations partnered with CHR investigators to develop an obesity intervention for Latino children. These first projects illustrated the feasibility and potential benefits of OCHIN-based research and piloted the development of the contractual agreements needed to facilitate such research.

OCHIN′s board, led by Dr. John Saultz, chair of OHSU's Department of Family Medicine (DFM), supported the establishment of the Safety Net West PBRN. Two of the four OHSU health centers are OCHIN members that were among the first to adopt and implement the OCHIN electronic health record. The Community Engagement program of the Oregon Clinical and Translational Research Institute (OCTRI), an OHSU-CHR partnership funded by a Clinical and Translational Science Award, supported a part-time Safety Net West Director from 2007 to 2010. The PBRN, registered with the Agency for Health care Research and Quality in 2007, was housed at OCHIN to maximize its independence and focus on community-based research. Its mission is to encourage research with the potential to directly benefit safety net patients, to develop and improve OCHIN′s data resources for research purposes, to partner with interested researchers, and to translate research findings into practice. Safety Net West includes members from all OCHIN-affiliated clinics; coordinates with OCHIN′s Clinical Oversight Group, a workgroup of OCHIN medical directors and clinicians that directs the content and structure of OCHIN′s EHR, and OCHIN′s Data Stewardship Committee, charged with ensuring the appropriate use of OCHIN data.

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Figure 1.

Safety Net West and Oregon Community Health Information Network (OCHIN) Partnership Structure.

Facilitators and Barriers

Several factors facilitated the successful creation of the Safety Net West PBRN. In addition to the synergy between strong leadership, the unique patient population, and the linked EHR, OCHIN leaders had a vision that extended beyond supporting the delivery of clinical care in safety net settings. There was interest in developing resources to improve practice and to influence policy. As a health center–controlled network, the organization also developed early processes that enabled representation and voice from all members and encouraged collaborative decision making.

Similar to barriers encountered by most PBRNs, while there was strong expressed interest in research among OCHIN members, they generally felt limited in time, money, and expertise. Most affiliated clinics had little infrastructure to support research activities and already felt stretched to meet the many competing demands of caring for an underserved patient population. Some expressed concern that research might interfere with their own internal quality improvement plans. Most were more enthusiastic with studies that focused only on available EHR data and didn't require changes in clinic workflows or processes or add to their staff workload. The use of OCHIN's unique and unprecedented data resources for these “data-only” studies required the development of policies to address who owns the data, what are proper uses of the data, and how best to secure and share the data.

Infrastructure Development

Recognizing the need for research infrastructure, OCHIN, CHR, and OHSU collaborated to obtain two development grants made available through the 2009 American Recovery and Reinvestment Act. The first, an RC4 from the National Library of Medicine, “Collaborative Research Efforts Aimed at Translating Evidence and building Community Capacity,” is designed to (1) strengthen the capacity of the Safety Net West “community PBRN laboratory,” (2) engage OCHIN′s members in formulating and conducting research,^4,5 and (3) facilitate translation of research results to improve the health of disadvantaged populations. The second grant, “Building Research Infrastructure to Develop and Generate Comparative Effectiveness Studies,” made Safety Net West a research node in HRSA's national Community Health Applied Research Network (CHARN). It was designed to advance Safety Net West's ability to conduct comparative effectiveness research (CER). These projects will further develop Safety Net West's technical and personnel infrastructure.

Building Technical Infrastructure

In 2009, Safety Net West members collaborated on a pilot project to use OCHIN′s data in population-based research⁶ and to validate linkages between OCHIN′s care utilization data and Medicaid claims.^1,2 Concurrent technical infrastructure developments aim to validate the quality of EHR data through comparisons with manual chart review, and to ensure that valid aggregated data are easily accessible for researchers in de-identified formats. In addition, bidirectional data sharing capacity (e.g., pharmacy and immunization data) and analysis of EHR free text are being developed.

Building Personnel Infrastructure

The research team at Safety Net West includes an executive director, operations director, project manager, research coordinator, information architect, and two research analysts. Team members from OCHIN and OHSU are paired with the goal of fostering collaboration. The team coordinates and supports the Safety Net West steering committee, which works to support a transfer of research expertise between academic researchers, OCHIN staff, and CHC partners. Through this partnership, the Safety Net West team has gained knowledge about federal research compliance, contracting, and business practices; academic researchers have learned about OCHIN′s data and the CHC practice environment, communities, and patient populations; and CHC partners have learned about framing research questions and testing hypotheses using their own data.

Portfolio of Research Projects

Table 2 summarizes all Safety Net West research projects since 2006, which include data-only studies, translational research, text analysis, Comparative Effectiveness Research (CER), and research infrastructure development. Safety Net West emphasizes both “bottom-up” and “top-down” research ideas—studies conceived by OCHIN practitioners that are brought to researchers to develop, and ideas generated by academic researchers that are brought to practitioners for feedback and direction. One bottom-up study seeks to translate a quality improvement initiative from an integrated care setting into 12 OCHIN clinics; the idea came from an OCHIN clinician, funding acquisition was led by a CHR researcher, and the study is being implemented collaboratively. One top-down study is developing methods for evaluating asthma care using data extracted from free-text analysis of clinic notes in OCHIN′s EHR. This idea came from a CHR researcher and was embraced by Safety Net West as an innovative approach to using OCHIN′s data to improve care quality.

Goals for Expanding Safety Net West's Infrastructure and Research Scope

The Safety Net West “community-based laboratory,” based at OCHIN, is positioned to become an important resource for many studies including: evaluation of the real-time impact of health care reform on uninsured populations; development of new models of primary care delivery; dissemination and translation of interventions from other EHR-based systems (e.g., Kaiser Permanente) into the community health setting; and analyses of factors influencing disparities in health and health care access.

Governance and Operations

As Safety Net West matures, we will strategically develop its governance and build appropriate operations mechanisms. We will maintain the core steering committee and have established three subcommittees to support the steering committee's work, including (1) Data and Research Development (2); Communications and Community Engagement; and (3) Policies and Governance. These committees will oversee continued network development and undertake tasks related to: building policies for data use and sharing; developing capabilities for data extraction, quality improvement, linkages, and sharing; disseminating information and strengthening partnerships with community stakeholders; refining organizational infrastructure and relationships between PBRN members; and developing research priorities and projects. Through these processes, we hope to build a robust collection of secondary data that will be available to research collaborators from across the country who have not previously had access to electronic health care services utilization data on underserved and uninsured populations.

Bridging Practice Transformation and Research Activities

Many Safety Net West member clinics are participating in cutting-edge practice transformations that go beyond demonstrating HIT's potential in facilitating primary care improvements. Partnering with OCHIN, researchers, and payers, many practices are organizing themselves as Patient-Centered Medical Homes.^7–12 We envision a synergy between practice transformation and research activities, strengthened by a “learner's bridge”that provides opportunities for community partners to learn the skills for implementing and evaluating practice interventions. The Safety Net West PBRN will thus serve as a laboratory where students, clinicians, and researchers can collaborate and learn from each other. Although there is significant value in quality improvement activities, partnering with researchers who can evaluate and disseminate findings increases the likelihood that successful interventions can be replicated and sustained. This type of partnership ensures that meaningful activities will be documented and will contribute to the growing fund of knowledge about evidence-based, best practices in primary care.^13–19 Further, engaging learners in this partnership further strengthens the benefit for spread of innovation and sustainable future change.

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Figure 2.

Synergy Between Practice Transformation and Research.

Strengthening Partnerships, Sustainability

Network partnerships and sustainability must be built together. We believe that sustainability will be attainable as our PBRN matures, expands, and proves its worth to a diverse group of stakeholders. To that end, we aim to strengthen key partnerships between Safety Net West, OCHIN, community health centers, researchers, policy-makers, and funders. It is these partnerships, creative ideas, and data resources, plus a track record of contributions to practice transformation and ultimately, the improvement of our populations' health that will determine our success.