EHRs in Underserved Settings

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While little has been published about electronic health records (EHRs) in underserved populations, implementation is proceeding rapidly and with high expectations for these installations to improve quality and reduce disparities. Underserved populations are defined as populations that have fewer providers and worse health outcomes and are designated by the Federal Government (1). They are served by a safety-net of 1100 Federally Qualified Health Centers (FQHCs), and numerous other HIV grant programs, free clinics, and hospitals, many funded by the Health Resources and Services Administration (HRSA).

Adoption Rates

A 2008 survey of EHR adoption in FQHCs done by the National Association of Community Health Centers (2) showed that 49% of the 362 health centers responding were using an EHR (either "all electronic" or "part paper and part electronic"). The government has supported these implementations by funding networks of health centers that work together to implement EHRs. Called Health Center Controlled Networks (HCCNs), about 100 of these exist across the US. These networks assist health centers in adoption by providing shared EHRs, assistance with implementation, and in some cases shared IT staff. In the NACHC report, belonging to a HCCN increased the likelihood that a center was “all electronic.”

Features of FQHC Adoptions

Adoptions in health centers are fundamentally different from those in other settings. First, a health center employs a wide variety of providers including typically all the primary care specialties, often OB/GYN and specialists, and sometimes dentists, and behavioral health providers. This means that a wide variety of templates and workflows are needed at go-live. Health centers also have multiple PA, NP, and nurse-midwife providers. Second, billing at health centers also includes verification of income, as well as a sliding fee scale, something that not every practice management system handles well. Third, there is a long history of quality improvement activities in health centers along with the use of patient registries. Fourth, as federally funded entities, health centers have yearly federal reporting requirements. Much of this data comes from the EHR. FQHCs often have other state, local, and foundation grant reporting requirements which the EHR must also support. Additional business intelligence reporting software is often necessary to complete these reports. Most EHRs do not tackle all of these areas well. Those that do are often targeted at larger provider groups, and are therefore more complex to install and maintain.

Federal Support

Federal support of these adoptions has taken many forms. HRSA has an office of Health IT and Quality (OHITQ) and has created materials to assist health center implementations including webinars, an electronic toolkit, and a list of initial specifications for an EHR. Health center providers are eligible to receive meaningful use payments, and most expect to do so under the Medicaid Meaningful Use program. The Regional Extension Centers chartered in the Recovery act are also expected to support new implementations in health centers.

Related Article

An early look at rates of uninsured safety net clinic visits after the Affordable Care Act.

Electronic health records improve the quality of care in underserved populations: A literature review


(1) Medically Underserved Areas,

(2) Lardiere, MR. A National Survey of Health Information Technology (HIT) Adoption in Federally Qualified Health Centers. NACHC, 2008 -

Links and Resources

HRSA home page -

HRSA on ClinInfoWiki -

HRSA's Office of Health IT and Quality -

Find a HCCN tool -

Submitted by Jeff Weinfeld