Assessment of Health IT and Data Exchange in Safety Net Providers: Final Report Appendix. Network Level Findings

01/01/2010

In discussions on their role in the area of information systems, CHCN emphasizes QI activities and seeks to find the optimal intersection of QI and IT. CHCN’s role has included providing assistance to the selection, contracting and implementation of day to day applications such as practice management systems (PMS’) being used at health centers and automated interfaces with clinical laboratories. They currently play a particularly active role in the ongoing installations of i2i Tracks for chronic disease management in their member health centers. They also maintain an application called EZ-Cap which is used for the network’s Medicaid managed care and CHIP patients, together which are approximately 20-30% of each clinic’s patient population.  EZ-Cap processes member eligibility, claims, payments, tracks detailed data on utilization, and supplies reports and analyses on managed care patients. Finally, they help coordinate the use of the county hospital based e-referral system, and a system which connects their health centers to county hospital inpatient, emergency, and specialty care clinical information.

CHCN does not host any of the applications utilized by member health centers. However, CHCN’s data warehouse pools data from a variety of applications including all encounter data from health center PMS systems, and all lab results; hospital, pharmacy and ED claims for managed care patients, and (very soon) i2i Tracks. In the sections below we highlight CHCN's role as it relates to each of these information tools.

i2i Tracks. i2i Tracks is a chronic disease management application that pulls data from existing health center systems such as PMS’ as well as clinical laboratories to establish panels of patients with specific characteristics and tracks care delivery and clinical results variables associated with each panel. It serves the function that registries such as PECS and CV DEMS, which function as chronic disease database applications that track quality of care using a system of computer and paper based tracking tools and act as a tool for providers at the point-of-care.  But i2i uses automated interfaces instead of manual data entry and analysis as a means to define panels, track measures, and act as a point of care tool. i2i provides advanced functionality such as the ability to define new panels “on the fly” and integrate with mail merges to generate reminder mailings or telephone calls with a subset of patients.

Upon our meeting with CHCN four of their centers had begun the process of implementing i2i. The grant from Tides is covering approximately half of the full cost of the i2i implementation in these health centers. CHCN’s role in the i2i Tracks project includes assistance in contracting and project managing the implementation with local clinic teams.  This role has involved convening a learning community with others in the Alameda County to share “best practices’ in the implementation and use of the i2iTracks systems.  All the major safety net providers, including the county medical center have adopted i2iTracks. Moreover, CHCN has helped their health centers standardize definitions for chronic conditions. For example, in order to examine diabetes across the entire universe of health centers came to agreement on shared indicators such as frequency of testing for A1C levels as well as how to define and code basic measures such as height, weight and blood pressure.

CHCN is also helping health centers adjust documentation practices to support robust use of i2i Tracks. For example, because there is a greater need for consistent and comprehensive documentation of intake information including chief complaint, some health centers are working with their medical assistants to re-work their process for entering these data into PMS’. Specifically, CHCN has helped “re-work” centers’ intake and billing forms that are used by health center staff to improve data quality. They have also worked with health centers to assure that clinicians and coders record care processes such as “conduct of foot exams” that are sometimes overlooked in documentation.

Given the incentives laid out in ARRA, it is likely that member health centers will look to implement EHRs in the near future. CHCN is assisting their health centers to monitor and prepare for ARRA incentives and EHRs.  In the event that a selected EHR will not be able to meet meaningful use standards, i2i could be interfaced with the EHR, and operate as a parallel system using PMS and lab interfaces.

EZ-Cap. CHCN uses EZ-Cap software, a well established tool for MSOs to receive, store and manage encounter data from health centers, inpatient providers and Emergency Departments (EDs). EZ-Cap also tracks data on services provided by clinical laboratories, pharmacies and specialty care providers to CHCN health center patients enrolled in the contracted health plans. Although EZ-Cap’s primary function is to process claims and generate reports required by Medicaid HMOs, it also provides an important source of data for a data warehouse maintained by CHCN that houses data for all patients treated in CHCN clinics.

One-E-App. One-E-App is a web based application adopted by the State of California and its county governments to verify eligibility for a variety of state and locally administered insurance programs. The implementation of One-E-App varies from county to county and therefore the entities for which eligibility is being verified differ.  In Alameda County, any provider can use One-E-App to check the Medicaid or CHIP eligibility of a patient using a web-based interface that uses state government data to assess eligibility. There is no direct relationship between One-E-App and CHCN’s data warehouse or individual health center PMS. CHCN helped define and implement the system, and coordinate ongoing assistance for the member health centers to use and access the application.

Merritt and Other PMS'. As noted above CHCN does not host PMS’ for use by member health centers. However, CHCN does help centers maintain their PMS’ by providing guidance for managing vendor relations and providing legal support for contract negotiation. CHCN played a pivotal role in brokering a deal to acquire Merritt, a practice management system (PMS), that four of their health centers use and helps host that system at La Clinica de La Raza. In addition, CHCN played an important role in brokering a deal between Axis Health and NextGen. We provide more details on PMS use among CHCN health centers in the subsequent section of this report.

E referral and Hospital Interface. Increasingly, CHCN has been moving towards adoption of functionality designed to facilitate coordination of care between ambulatory and inpatient settings. They found that there was substantial demand among their health centers to access ED and inpatient hospitalization records of their patients, particularly from Alameda County Medical Center, the primary safety net hospital in their area. In response, CHCN helped negotiate and establish a web-based virtual private network (VPN) connection that allows the clinicians to access hospital systems to view inpatient, ED, and specialty consult records.

Originally hospitals refused to give access privileges to staff other than medical doctors, over time they extended access to nurses and the medical assistants. There are other issues with the current system which is the inability to print and the multiple layers of passwords needed to access the application. CHCN and the hospitals are working together to choose IT upgrades for improving this connection.

CHCN has also helped establish a separate Alameda County Medical Center e-referral web portal known as Reftrack.  The hospital’s Reftrack system allows health centers to access a separate bi-directional referral system which allows clinicians to submit and look at referrals to and from hospital-based specialists and add notes to documents. Guidelines and reminder prompts for specific types of referrals pop up when entering a referral.  Notifications such as whether a referral request has been booked for appointment or the patient has canceled, are sent securely by email to the submitting provider.

Originally hospitals refused to give access privileges to staff other than medical doctors, over time they extended access to nurses and the medical assistants. CHCN and the hospitals are working together to choose IT upgrades for improving this connection. CHCN reported occasional issues with printing, referrals and with the time and energy that goes into receiving an alert via email and then having to track the patient and report back to the physician. In addition to Alameda County Medical Center, Sutter Medical Center and Children’s Hospital of Oakland also participate in this hospital interface and e referral program.

Altruista Case Management and Data Warehouse. As previously outlined, CHCN works with a variety of IT applications and data from those applications is extracted and pooled within their data warehouse. These data are collected from health center PMS’, i2i Tracks, EZ-Cap, hospital systems and laboratories. The data warehouse currently supports a series of QI reports that are generated by CHCN and discussed on a monthly basis by medical directors and QI directors from across the network.

To optimize use of these data, and to help managed the patients who could most benefit from coordinated care, CHCN will implement a new web-based case management system, Altruista. When we met with CHCN their implementation was forthcoming. CHCN is looking to Altruista to extract patient level data from their EZ-Cap system and data warehouse to track patient care. The following anecdote was given to us as a case in which Altruista would be of service.

“A week ago I was reviewing the case for a patient seeing many specialists. As I was reviewing his case I learned that he was admitted to the hospital following a visit to a health center. This guy had a metastasized fracture. I realized that once he is ejected from the hospital then there would be no one to coordinate all the other help he would need like all the equipment such as a wheelchair and other loose ends and everything else that he will need in the days to come. I realized I didn’t have a tool to alert the outreach staff at health center to reach out.”

CHCN intends to use Altruista as a way to alert providers in the cases where synchronization between health care delivery services and outreach services is required. This may be done through automated alerts generated through the use of algorithms that are being designed by Altruista and CHCN or through the identification and tracking of panels of patients with a combination of complex health care and social service needs.

A few weeks following our site visit we followed up with CHCN on their progress with Altruista. At that point they had data coming into Altruista and they were “playing around” with the software. So far the system was in use only for managed care patients.   They were enthusiastic about the upcoming case management of all of their patients, but noted that this stage of the project would require generating an enterprise master patient index (EMPI) to link the diverse data sources. An EMPI would provide the means to quickly associate any particular event to a unique patient.

In the future, CHCN thinks that Altruista will be able to look at hospital visits, watch for frequency of re-admittance, ensure that patients make it to their follow up visits following hospital discharge, monitor compliance with prescriptions (i.e., track whether a prescription was picked up) and confirm that that appropriate equipment was purchased by individuals with special needs.  They also anticipate that since Altruista is available over the Internet, it can extend the service to the hospitals so that an ER doctor can reconcile key information such as medication history at the point of care.

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