As noted above, though the focus of our site visit was CCHN, this network is a subsidiary of a long standing council of safety net providers in San Diego. This entity, the Council of Community Clinics ( CCC) was founded in 1977 by local community health centers to take advantage of economies of scale and to advocate for the interests of their patient base. Since that time, the CCC has expanded to offer its members a variety of services through three organizational units all operating under the CCC umbrella (the third unit is Council Connections, an organization devoted to group purchasing). Unlike other networks we have visited, a relatively large number of CCC's 16 member health centers started out as independent safety net clinics and have only recently become Section 330-funded health centers. CCC is governed by a board of directors, composed of its member health centers' Executive Directors. The core CCC organization handles advocacy and fund development; a subsidiary unit called "Council Connections" provides a group purchasing vehicle for non IT products and services.
CCHN is a second subsidiary unit to CCC. CCHN provides software acquisition and hosting, quality of care and disease management programs and other related IT and quality of care services. CCHN has over 30 participating health centers and is governed by a nine-member board of directors. CCHN board of directors members occupy a number of positions in their home health centers, ranging from chief executive officers to program managers. We provide more detail on CCHN services below and in the remainder of the report we refer to CCHN by name or as "the network".
Network services and functions. CCHN offers a specific set of services around quality improvement, disease management, consulting, project management and hosting software. These services include conducting quality of care audits and reporting on behalf of health centers, developing RFPs and providing vendor selection support for software acquisitions, negotiating and supporting enforcement of agreements between health centers and vendors, and, increasingly, serving as a central hosting and technical support site for numerous applications used by health centers for clinical initiatives.
CCHN members pay a small amount in membership fees (Five percent of CCHN's total revenue) which allows them to help define these service offerings through direct input. They can then purchase specific "canned" services from the network through an a la carte schedule. In addition to a Board of Directors comprised of Executive Directors from all member health centers, CCHN convenes two subgroups representing their key constituents among the health center staff. There is a Physicians' Council comprised of Medical Directors and the CIO (Chief Information Officer) Council. In addition to helping shape the service offerings and priorities of the network, these two groups offer members a chance to learn from each others' experiences.
The network indicates that the Physicians' Council performs the following functions: setting quality and patient health improvement priorities, partnering with other innovative health center organizations and overseeing clinical improvement and disease management programs. The CIO Council provides a forum to share best practices and meet with health IT vendors. In addition to convening these groups and providing the types of services described above, CCHN offers grant writing services and opportunities for the network and its members and in some cases has served as a "network grantee" for funding that flows through them to the health centers. We describe some of the core CCHN functions that are central to this study below.
Support for key applications such as EHRs and registries. As noted above a key role for CCHN is helping its members navigate the software acquisition, adoption and use process, particularly as it relates to clinical applications. In doing so, CCHN works with a range of health center applications and approaches to IT and looks for ways to facilitate learning across the various models employed with member health centers and facilitate adoption of best practices in the acquisition and use of software. Table 1 below provides a summary of the current software environment as it relates to practice management systems, electronic health records and other clinical applications in CCHN health centers we visited as well as their plans for moving forward with new software acquisitions.
In the past year, CCHN has helped to facilitate EHR selection for its members. In selecting vendors, members considered service capability, integration with clinics' practice management systems and overall expense. While the network serves as a conduit between vendors and health center members, the network has concluded that no single solution will satisfy the needs of all of its members. Currently, CCHN hosts eClinicalWorks and supports NextGen, Practice Partner and Epic. In addition to supporting these EHRs, CCHN also supports disease management and reporting software such as the Patient Electronic Care System ( PECS) and i2iTracks and has begun implementation of a stand-alone e-Prescribing system on a pilot basis at two health centers. i2i Tracks is a chronic disease and preventive health management system that allows providers to track groups of patients, such as diabetic or asthmatic patients. I2iTracks resembles an EHR in that it provides direct access to patient data for providers, but it differs in that it does not include an entire patient record. I2iTracks can interface with EHRs and other systems to facilitate disease reporting. CCHN members hope to use i2iTracks to improve quality without having to make a commitment to a full EHR.
Table 1: Software Environment at Select CCHN Health Centers
|Health Center||Current or Legacy||Planned (Go live date)|
|Vista Community Clinic
Federally-Funded Health Center with 5 sites and 188,000 visits / year
|Used Script and Mysis for practice management (PM) and disease management.||Switched to integrated PM/EHR NextGen - went live in July 2007|
Federally-Funded Health Center with 10 sites and 221,000 visits / year
|Have used both Sage (old Medical Manager) and HealthPro for PM with PECS for disease management||Planning to switch to a combined PM/EHR either Epic or eCW - their goal is to do this in 2009|
Federally-Funded Health Center look alike with 2 sites and 40,000 visits / year
|MegaWest for PM||Implemented open source ClearHealth application for PM in 2007, planning to integrate with a ClearHealth EHR in late 2008/early 2009.|
Federally-Funded Health Center w. 10 sites and 250,000 visits / year
|MegaWest for PM, Dentrix for dental EHR, i2iTracks for reporting, they have one site running an EHR||Planning to switch to a combined PM/EHR at all sites but has not yet made a selection.|
Federally-Funded Health Center w. 3 sites and
65,000 visits / year
|MegaWest, Dentrix, i2iTracks||Planning to switch to a combined PM/EHR at all sites but have not yet made a selection.|
A number of CCHN member health centers have implemented MegaWest practice management software. While CCHN currently does not support practice management applications, they are working with health centers that are looking to migrate to a new comprehensive PM/EHR system to be hosted by CCHCN. Importantly, CCHN "support" of an application can include serving as a direct provider of day-to-day technical support or as a conduit between the health centers and the vendor support staff, it can also include development of interfaces across applications and with outside providers such as clinical laboratories.
Support for quality improvement and reporting. In addition to supporting acquisition and use of clinical IT applications, CHCN plays a role in helping health centers improve quality of care. This support includes CHCN-organized chart audits to produce summaries of performance and progress on the part of health centers in specific areas such as delivery of preventive and diagnostic care or management of chronic illness. CHCN works with health centers to support reporting on quality measures as now required under UDS and in building interfaces to public health resources such as county and state immunization registries. Finally, CHCN is a network grantee for the Tools for Quality program which is a California Health Care Foundation (CHCF) program that provides resources for health centers to implement and use i2iTracks in their organizations. In its role in Tools for Quality, CHCN is helping their own member health centers with implementation and interface set up, but also convening learning sessions for all CHCF Tools grantees in Southern California.
Looking towards health information exchange. As in other parts of the country, safety net involvement in regional health information exchange efforts in Southern California is relatively modest. Outside of exchange of clinical laboratory results and some limited eRx and connectivity to immunization registries, there is not a lot of formal exchange taking place. CHCN is beginning to establish a vision for safety net provider engagement in HIE including establishing a clinical data warehouse and applications allowing access to inpatient and ED records and to records from different ambulatory care sites. CCHN convenes local safety net providers, including its member centers, to form a group called Connecting for Care. This group has existed in multiple forms over the last several years, having initially focused on telemedicine. They are now hoping to mobilize multiple partners in the area to move towards establishing a health information organization to govern exchange of health care data among safety net providers in San Diego.
CCHN budget. CCHN's most recent annual budget was $3.5 million, out of CCC's annual budget of roughly $10 million. Network leaders estimate that roughly five percent of the network's revenues come from membership fees, while grants account for the majority of revenues. Fees for services also contribute to CCHN's overall revenue. Grants typically cover startup costs for new initiatives. Most grants come from private foundations while HRSA and other federal grants provide important financial support as well. In some cases, the network will expand its services or expand to a new geographic area without a clear source of grant support to do so.