In this section we examine findings from meetings with New Mexico Health Choice Network and three of its member centers. NMHC’s predecessor organization was formed by a group of New Mexico Health Centers that came together in the late 1980s and early 1990s to create alliance with the goal of developing an HMO. New Mexico HCN has six member health centers across the state, with a total of 49 sites and 107,895 patients in 2006, the vast majority of whom are uninsured or on Medicaid. NORC visited three New Mexico HCN member centers in the southern portion of the state: La Clinica de Familia, Ben Archer Community Health Center and La Casa Family Health Center.
La Clinica is located in Las Cruces, a city of roughly 90,000 people situated roughly 40 miles from the New Mexico/Texas/Mexico border. La Clinica served 12,477 patients in 2007, 83 percent of whom were of Hispanic descent. La Clinica is both a community health center and a migrant health center, spanning nine medical center sites and 4 dental sites in southern New Mexico. To best meet its patients’ needs, La Clinica offers bilingual care programs and Early Head Start opportunities. Ben Archer is headquartered in the remote village of Hatch, 40 miles northwest of La Cruces. Ben Archer includes seven sites (including a migrant health center) and served 31,399 patients in 2007. Forty-five percent of Ben Archer’s patients were reported to be best served in a language other than English. Because of the rural and dispersed nature of Ben Archer’s health centers, some low-income patients qualify for highly-subsidized transportation services to and from health center locations. After visiting Ben Archer, NORC traveled roughly 280 miles northeast of Las Cruces to Portales, a city of roughly 12,000 people. Located approximately 30 miles from New Mexico’s eastern border with Texas, La Casa includes four health centers (expansion to a fifth site is underway) and served 12,477 patients in 2007. Because of La Casa’s relatively remote location, the center strives to provide “the most comprehensive care in the area,” including pediatrics, women’s health, internal medicine and diabetes support. In addition to meeting with health center leaders, NORC met with New Mexico HCN CEO David Roddy in Mesilla, located just south of Las Cruces.
The health centers NORC visited in New Mexico had vastly different levels of experience and satisfaction with health IT through HCN, ranging from positive and supportive to noncommittal and unsatisfied La Clinica has not implemented an EMR to date, and is “months away” from implementing the Intergy EMR/PM system. La Clinica is one of the six founding health center members of the New Mexico Integrated Services Network (ISN) and maintains an “amicable and supportive” relationship with HCN in Florida. Ben Archer has not implemented an EMR and center leaders hope to be among the last in New Mexico to implement the Intergy suite. Ben Archer staff expressed high levels of frustration with the return on their monthly contributions to HCN and New Mexico HCN, although they remained hopeful that the overall value proposition would improve under the new EMR/PM system. The third health center NORC visited, La Casa, implemented the OmniDoc EMR at all of its sites in 2006. La Casa’s CEO serves on the HCN Board of Directors and maintains close ties with HCN, but La Casa did not seem reliant on HCN, having taken steps to build up its own IT support resources, independent of NMHCN and HCN generally. While only La Casa had implemented an EMR, all three centers NORC visited had implemented the Medical Manager practice management system. Our conversations in New Mexico focused on health centers’ motivations for joining HCN and their overall experience working with HCN for the last few years.
Motivations for Health IT Adoption and Joining A Network
In 1999, David Roddy began conversations with HCN about possibly expanding operations to include an existing network of health centers in New Mexico. Roddy, whose background is in finance, had worked at the National Association for Community Health Centers (NACHC) and at the time directed the New Mexico Primary Care Association and Integrated Services Network (ISN). This confederation of New Mexico health centers understood the importance of improving their approach to IT with the help of a larger organization and actively began researching a shared practice management application. As the New Mexico clinics began looking into the software vendor market, they met with Kevin Kearns from Health Choice Network (HCN) in Florida and this eventually led to the establishment of an HCN New Mexico headed by Roddy.
A number of factors led the New Mexico clinics to formally affiliate their network with HCN and subsequently rename their network New Mexico Health Choice Network (NMHCN). First, they were impressed with the staff and accomplishments of HCN, specifically the software functionality and support service provided to their members. Second, New Mexico was impressed with HCN’s relationship with Medical Manager, a product that rated highly in their assessment of the practice management market.
Finally, more than just becoming customers of HCN, they were offered the opportunity to make a strategic alliance with HCN that involved New Mexico staff joining the HCN Board of Directors and working committees. In their eyes, this relationship offered the New Mexico network an opportunity to help set the direction for HCN overall. HCN’s approach involved regularly scheduled visits to New Mexico by members of the HCN team in Florida. These visits were intended to help ensure close ongoing contact with the satellite network and to build trust based in large part on personal relationships.
As HCN continued to expand its national customer base, New Mexico HCN and its member centers have continued to play an integrated role, both as a customer of HCN’s services and as a leader in the organization. In 2007, New Mexico HCN members’ contributions to HCN accounted for two percent of HCN’s total budget of approximately 22 million annually.
At the health center level, motivations for health IT adoption varied. Improving quality of care was cited as an original motivating factor, especially for tracking measures such as hemoglobin A1Cs among diabetic patients. Health centers leaders also enumerated specific situations and processes requiring data that the EMR would ideally improve, including internal peer review processes and increasingly frequent data requests from payers. One health center thought that the EMR would improve competitiveness both among patients and prospective employees. Other motivations included improved integration of currently standalone processes, the ability to track patient across health centers and improved protections against malpractice claims due to illegible records.
Current IT Capacity and HCN’s Role
NMHCN provides various services for its members including managing the contracts with HCN that provide health centers access to practice management and other network functions. Some health centers noted more success than others in working with the NMHCN to handle problems with HCN in Florida, including delays in changing reports, general unresponsiveness, occasional outages in Florida that affect New Mexico members, overwhelmed HCN Florida staff and the notion that Florida staff were not well versed in New Mexico billing issues. NMHCN also provides finance and billing consulting services to the individual health centers to help them better manage their finances. In addition, the network convenes a local billing committee to share experiences and address issues that HCN employees in Florida are ill equipped to handle. Finally, several New Mexico health centers also access the Dentrix dental health record application through HCN.
As noted above, only one of the health centers in New Mexico has implemented an EMR through HCN and this health center, La Casa, is using the OmniDoc product. While the other health centers in New Mexico are not currently using EMRs, they have adopted other types of clinical applications. For example, La Clinica uses two reporting packages, Practice Analytics and DART (data analysis and reporting tool) to facilitate reporting on quality of care and practice performance.
La Clinica also uses an innovative scheduling system taking advantage of a Voice over Internet Protocol (VoIP) based call center. Under this configuration, patients from La Clinica’s 13 medical and dental sites call a centralized telephone line to schedule appointments. La Clinica’s ten call center workers handle roughly 70 percent of incoming calls and direct patients to the most appropriate care setting. La Clinica’s call center workers not only schedule appointments for their own clinics, but also for other clinics as a fee-based service. La Clinica is currently starting to plan their implementation of the Intergy EMR with HCN. Implementation remains several months away, but La Clinica will most likely be the first New Mexico HCN center on the new system. La Clinica will most likely implement Intergy at four sites initially. They indicated that financial constraints are the only reason they are not implementing across all of their sites at the same time.
La Clinica has a fairly extensive IT team, composed of a CIO, a network manager and five technicians, three of whom are focused on hardware and two of whom are focused on software. In addition, an HCN IT employee who provides application training statewide to the network is based at La Clinica. The health center is also in the process of expanding IT staff, partially in anticipation of the increased demands the center expects to place on IT staff as a result of the EMR implementation and post-implementation usage.
Ben Archer Health Center also uses a number of different information systems to manage its operations. In addition to the Medical Manager practice management system, they also use the Practice Analytics reporting software as well as the PECS software package for chronic disease management (e.g. diabetes and heart disease). All of these software packages are hosted by HCN. In addition, Ben Archer currently uses the Veterans Administration’s VISTA EMR system at one site where they are contracted to provide services for the VA. They also have other information systems such as a pharmacy management system. While Ben Archer has access to several electronic systems through HCN, they reported significant problems (detailed below) and are not currently pursuing an EMR through the network.
Of the three health centers that we visited, La Casa is the most mature and stable in terms of its health IT capacity and usage. They currently use Medical Manager for practice management, and have used OmniDoc as their EMR solution for the last two years. As a result, their clinical operations are now completely digital. Provide.rs use wireless lifebooks at the point of care and exam rooms are fitted with computer terminals. Additionally, some lab orders and results are exchanged electronically through a LabCorp interface. While La Casa has benefited significantly from their involvement with HCN, they rely primarily on their own IT staff to train other staff and support their EMR product.
Health Center Experience with Health IT
Health centers in New Mexico reported a range of experiences with IT in general and their relationship with HCN in particular. Overall, while each health center reported some issues with HCN’s timeliness in responding to support and billing issues, they did, by and large, indicate that the relationship with HCN has been worthwhile. Two of the health centers are ready to move forward with the new iteration of HCN’s Intergy practice management and EMR software offering and expressed enthusiasm for working with the health center on IT infrastructure issues.
Of the three health centers that NORC spoke to in NM, the staff at Ben Archer are by far the least satisfied with the relationship with HCN. Since their implementation of Medical Manager, they have had persistent problems including fundamental issues such as not being able to use the product adequately for billing and overall connectivity. It should be noted that while other health centers did raise issues about their experiences with HCN, they felt that they had the adequate staff to work with HCN to resolve billing problems over time. Some noted that Ben Archer may not have adequate in-house IT capacity to gain the most benefit from their relationship with HCN and effectively make use of networked applications. Another discussant noted that Ben Archer and HCN made a decision regarding entry of historical billing data into Medical Manager that has proven to be the source of many of their issues.
Ben Archer was convinced to convert their transaction histories in the move to Medical Manager. This is notable because Ben Archer was not an initial implementation site. While this has caused significant difficulties for Ben Archer and created substantial unexpected costs, it seems that Ben Archer was the only New Mexico site to experience this problem. Fellow New Mexico centers NORC spoke with were undeterred by Ben Archer’s negative experience. Leaders at Ben Archer also noted that the relative value for what their center is getting from HCN remains low at this point. The center pays $100,000 out of their roughly $20 million operating budget to HCN. Health center leaders at Ben Archer noted that they were close to leaving the network to pursue eClinicalWorks, but were convinced to stay with HCN after considering the Intergy product. Ben Archer’s leaders indicated that tremendous cost of supporting an EMR without the resources of a network led them to stay with HCN.
The staff at La Clinica highlighted the relationship with HCN as essential to their success as an organization. In addition to having access to applications such as Dentrix and Medical Manager, they appreciate having access to a deep pool of expertise in HCN’s staff and trust that HCN officials in Florida have a relative good understanding of their needs. While the team at La Clinica noted that their relationship with New Mexico HCN and HCN is far from perfect, it has been a solid partnership that has taken them much farther than they could have ever accomplished on their own. La Clinica has a relatively robust IT support structure, with a full time IT director as well as an additional IT support role which is currently unfilled. They rely on HCN for vendor selection, training and general accounting assistance and were hopeful that the network could develop centralized billing mechanisms in the future.
La Casa is the only health center in New Mexico HCN to have implemented an EMR. La Casa implemented OmniDoc in 2006, originally with the help of HCN. The health center adhered to the network’s generic rollout procedures, implementing an electronic prescription writing module first. Eventually, the health center migrated 90 percent of its patient records onto OmniDoc, excluding only those who had not visited in the clinic in the previous decade. Moving forward, La Casa plans to add every new patient to the EMR system. La Casa is currently planning to convert their EMR system from OmniDoc to Intergy in the spring of 2009. Health center leaders indicated that they would prefer to be the first site to implement Intergy and that their staff members were entirely bought into the EMR and would not revert to paper charts if given the choice. While La Casa was generally satisfied with HCN, they noted that their success is in large part due to the high caliber of their staff (particularly in IT) and that they had begun teaching HCN about reporting techniques. Additionally, health center leaders expressed some frustration in efforts to exchange data with other providers in the state and concluded that providers feel that patient data belongs to them and not individual patients.
Quality Improvement and Return on Investment
As only one New Mexico HCN center has implemented an EMR, most of our discussion on returns related to improvements in administrative operations, billing and organizational efficiency. La Clinica and La Casa noted improvements in these areas and attributed the improvements to their relationship with HCN, while leaders at Ben Archer found that their operations had generally become more costly and less efficient. Generally, health centers emphasized that by taking part in this network, they have been able to benefit from economies of scale, as well as funding that HCN has been able to obtain separately and make available to its customer health centers. Leaders at La Casa indicated that having clearer diagnostic information, better coding and decreased liability from illegible records and fewer lost records produced significant savings for the center, although they noted that ROI for an EMR is inherently difficult as costs and savings are shifted from certain areas to others.
Despite their overall satisfaction with HCN, many discussants noted that recent reductions in federal grants have placed a significant strain on HCN’s ability to provide timely and active support for its current customers while it also focuses on the acquisition and launch of new customers. Some also noted that HCN had suffered from turnover among their staff, which reduced the deep institutional knowledge necessary to provide high-quality support to the NM health centers. One health center felt that the network was so overstretched in its attempt to achieve sustainability that it was only able to address relatively superficial concerns, such as distributing applications and not more substantive attempts to tie health IT to quality improvement. As a result, the perception of the value provided to health centers by HCN, though still strong, has eroded somewhat.
New Mexico health centers have not experienced significant benefit from their relationship with HCN with respect to quality improvement. La Casa, the center that has implemented an EMR, has largely continued its QI program using the PECS disease management software and has only recently made plans to move away from PECS, towards an EMR-based system to track quality of care. Health centers noted that they make use of monthly reports provided by HCN as a way to compare metrics across centers, but also noted that these reports include very limited clinical data.
As in New Mexico, Utah health centers found it difficult to collaborate on a State-level to address QI and organizational performance issues. Roddy indicated that there was not enough funding at the state or national level within HCN to do robust quality improvement. Additionally, health centers have proven to be less interested in sending clinical leaders to the network to discuss quality initiatives, limiting New Mexico HCN’s ability to capitalize on the diverse and complimentary experiences of its member centers.
Future Direction for Health Choice Network
As noted early in this report, our site visit activities culminated with two 90-minute calls with HCN's national leadership. The bulk of these conversations centered around HCN’s ongoing strategic planning and partnership process which is designed to lead it to a position of longer term financial sustainability independent of federal funding. HCN is also focused on a re-organization that would consolidate decision making authority in the hands of “fully integrated” health center members. There are several key components HCN’s strategic planning process and we summarize some of these below.
Creation of a for-profit subsidiary. HCN’s charter as a non-profit organization calls for it to provide support for health centers specifically. They have purposefully avoided offering services to for-profit providers such as private primary care practices that have approached them over the years.
However, HCN believes that its experience and organizational assets could lend themselves to providing services to private practices. By pursuing this market through a for-profit subsidiary of HCN, the organization could establish a revenue stream to support its non-profit core business and help it achieve even greater economies of scale. HCN leadership indicated that they are considering this option seriously.
Creation of “HCN Florida”. Currently, HCN is involved in multiple services, some of which are targeted to all of HCN’s customers nationally, and others of which are only targeted to the HCN health centers in Florida. The nationally-targeted services primarily consist of the “fully integrated” and hosted offering discussed above. Examples of the Florida-only activities include a cancer prevention initiative and a managed care network. In addition, findings from our site visit suggest that the QI-focused activities of the clinical committee primarily address the wants and needs of Florida members. Since HCN is now much more heavily focused on outreach outside of Florida and since a nationwide network of FHQCs is now buying into HCN, the model of a single HCN providing both types of services is beginning to seem somewhat outdated. HCN may decide to separate the current HCN into a “HCN National,” focused on the delivery of IT and financial services on a nationwide basis, and “HCN Florida,” responsible for leading Florida-specific activities.
New strategic partnerships. Over the last year, HCN has entered into discussions with outside organizations that might be interested in taking a financial stake in its organization.
In this model, an organization such as a private foundation would provide a large infusion of capital into HCN, in return for an ownership stake in the organization. Also, for the first time, individual FHQCs outside of Florida have both become customers and taken an ownership stake in the organization. This model encourages HCN to continue with its nationwide expansion by adding new board members who are very focused on the success for this effort.