As noted above, BHN emerged as an organization during the 1990’s merger of Boston University Medical Center and Boston City Hospital. The network is governed by a Board of Directors comprised of executive leadership from ten of the health centers (10 primary partners) in the Boston area, BMC and the BUSM. Each of the10 CHCs has one vote on the Boston HealthNet Board, BMC has three and BUSM has one. The remaining five CHCs are secondary partners due to their affiliations with other hospitals. These secondary partners take part in BHN programs and do not sit on BHN’s Board.
The health centers and BMC leadership recognize the reciprocal nature of benefits each gets from the partnership. In addition to the IT function, the BHN committees, including the Community Health Automated Record Technology (CHART) Working Group, BHN Human Resource Directors, BHN Chief Financial Officers Forum, BHN Research Subcommittee, and BHN Clinical Committee, meet regularly to examine issues of common concern to its partners.
In the paragraphs below we outline key aspects of our discussions with staff from the network, CHCs and BMC. We include a discussion of the IT functions that have been the focus of the network throughout its history.
Building trust. In the initial stages of the merger, there was some anxiety among health centers that the new BMC organization would absorb all the Medicaid business through its ambulatory care and outpatient clinics. There was also concern that the hospital would want to acquire the existing health centers that had significant existing market share. This represented a substantial concern to health centers that were firmly rooted in their communities, provided a special mix of services to meet the needs of their patients and, in some cases, had been in the community for several decades. In late 1994, eight community health centers, Boston University Medical Center Hospital and Boston City Hospital began discussions regarding the development of a community health care network in Boston to preserve the mission of Boston City Hospital and to foster collaboration among the entities. As a result, when BMC was formed, the hospital reserved several seats on its board of directors for representatives of the health centers. As such, there is Board reciprocity, with health centers being a part of BMC governance and BMC being a part of the network’s governance.
BMC actively solicited health center participation in a network under the BHN umbrella. They sold this as an opportunity to build economies of scale and leverage the unique level of resources available through the new hospital organization. While discussants reported that it took over a year to address trust issues, after a series of retreats and meetings there was an increasing understanding among the health centers that BHN offered opportunities and that there was an interest on the part of the new BMC in collaboration rather than acquisition. There continues to be some apprehension among sharing data across health centers within the city, which still do see themselves as competitors in some sense, but IT opportunities offered through the network continue to facilitate collaboration and understanding even at the health center to health center level.
Initial grant funding. At the baseline for BHN’s IT activities in the late 1990’s, most Boston health centers existed at a fairly rudimentary level of IT adoption. DotWell had a slightly more sophisticated IT structure than most of the other sites but lacked an EHR. The one exception was the East Boston Neighborhood Health Center whose experiences are detailed in the next section. While most health centers had some form of billing and practice management applications, only one health center had invested in an EMR and it had relatively limited connectivity to the main safety net hospital, Boston City Hospital. The connectivity that existed between Boston City Hospital and individual health centers was mediated through barely used terminals in some health center sites that allowed providers to look up whether a given patient had registered as an inpatient or in the ED as well as the location and time of the visit. These terminals were often not operational.
In 2001, the network approached a philanthropic foundation in Boston to fund an electronic health record (EHR) project. The foundation asked the network to supply a proposal to support EHR adoption among member health centers. Many respondents indicated that establishment of the network and the tight relationship with BMC motivated the foundation to make such an offer. Even still, BHN executives were surprised when their proposal was funded in full, initiating a $5.9 million project. The initiation of this grant program and the relationships formed between individual health centers, the network and BMC as a result, solidified the organizational commitment and collaboration and provided a substantial “test case” to determine how each health center could continue to operate independently even with a significant dependency on the network and hospital which hosts the EHR application.
EMR Implementation Approach. From the beginning of the EHR project, later named the Community Health Automated Record Technology (CHART) Project, all stakeholders understood that the health centers would rely extensively on the expertise and experience of IT resources at BMC. A committee of individuals from the network, BMC and the BHN health centers came together to identify requirements and needs, develop an RFP and assess EHR vendors. Based largely on the expertise from BMC’s IT team, BHN selected the GE Logician system as their EHR and began an implementation regimen across 8 out of the 10 primary BHN health center members.
The Logician implementation took place between 2002 and 2004. Numerous work groups support the CHART Project. Initially, the Boston HealthNet CHART Working Group, a sub-group of the BHN Board of Directors, met monthly to discuss “big picture” issues related to the CHART Project such as implementation, budgeting, planning, and resource allocation. Now that these eight health centers are using Centricity, the Working Group continues to meet monthly to address developmental issues, customization and to evaluate and prioritize future CHART projects.
Ongoing Maintenance. The CHART Working Group continues to operate today and is a primary aggregator of follow-up needs and initiatives to be pursued by BHN from an IT perspective. The Working Group is chaired by the Chief Executive Officer of Dorchester House Multi-Service Center and is focused on carrying out the goals and objectives of the BHN IT strategic plan and leveraging hospital systems for the benefit of the overall network. For example, while the CHART Working Group does work on making adjustments to standardized forms, the baseline version these forms were taken from the Internal Medicine outpatient clinics of BMC. Most health center level respondents noted that even when they are working to create custom forms for their own use, they are more likely to look to BMC than the vendor for support in the design and creation of these forms. BMC continues to host the EHR application and is the main point of contact for connecting with the GE vendor.
Connectivity across providers. One of the obvious benefits of vertical collaboration between ambulatory and inpatient providers on IT is the opportunity to achieve greater connectivity and coordination of care. As noted above, prior to BHN, some health centers in Boston had a less than reliable mainframe connection to Boston City Hospital that informed them if a patient had been recently discharged from an inpatient floor or had visited the Emergency Room. When the mainframes worked appropriately, this system still required the health center to then contact the hospital separately to receive information on the nature of the visit. Following the establishment of BHN, T1 lines were set up between each member health center and the new BMC network. Using these T1 lines, health centers were able to access ED or inpatient records on a patient through a read-only Citrix connection. This model allowed health center staff to view and print information about their patients that were seen at BMC and obtain some clinical data relevant to that visit. Later, BMC’s Information Technology Services Department launched myBMC.org, a program that facilitates secure access to BMC’s clinical applications to qualified staff within Boston HealthNet’s network. Providers who want access apply for a security token. Once they receive this token, they can connect to BMC’s clinical applications from work, home or wherever a computer and a version of Internet Explorer are available.
In addition, BMC helped established an external Laboratory Information System (LIS) environment using Antek’s Labdaq for the health centers. In combination with BMC’s interface engine, this environment provides a connection between the EHR and clinical laboratories used by health centers – either commercial laboratories such as Quest or, in some cases, BMC hospital laboratories. The LIS mediated interface functions for both lab orders and results reporting.
Finally, through the work of the CHART Working Group and ongoing work with GE, BHN recently implemented automated routing of prescription requests to pharmacies through the e-Rx feature included in the EHR package. Prior to this initiative, pharmacy orders were entered electronically through the EHR. This form of e-Rx provided the benefit of automated checks of medication history and interaction warnings based on prescriptions previously entered in the EHR. Although prescriptions were entered electronically under the prior system, routing to the pharmacy occurred via fax with a medical assistant printing out the form and faxing it over to the appropriate pharmacy. As currently implemented, pharmacy orders are routed electronically either to a BMC pharmacy or to a number of retail pharmacy chains used by individual health centers. Most health centers reported significant efficiencies as a result of the addition of electronic routing to the e-Rx functionality. We note however, that like most e-Rx implementation, many of the functionalities that require connectivity to payer databases and advanced use of standards such as checking a payer-based medication history at the time of prescribing or requesting prior authorization at the point of care are not currently in place at BHN.
Future directions for HIE. For several years, BHN has been working on opportunities to leverage vertical exchange of data within their network. Earlier in the decade, the network was a recipient of a three-year, $382,000 HRSA Bureau of Primary Health Care (BPHC) Integrated Delivery System Development Initiative (ISDI) grant that supported improving communication and access to BMC Clinics by developing a template in the electronic medical record. BHN also took part in a national demonstration project funded by HRSA to establish a community-wide record locator service (RLS) established and maintained by the Massachusetts Health Data Consortium. Both BMC and the health centers found relatively little value from use of the application deployed as part of the pilot because it offered only a static view into a limited set of data on new patients presenting at the hospital or in health centers. BHN and BMC officials noted that the use of the application deployed in the pilot effort dropped off following its completion because of its limited usefulness and usability.
In 2007, BHN was awarded a three-year grant from HRSA Office of Health Information Technology (OHIT) to implement a network wide clinical information exchange or CIE. This clinical information exchange project, named CHART-Plus, integrates the Centricity EMR of nine BHN health centers with that of BMC allowing BHN clinicians to view patients’ clinical information aggregated from separate EMRs across the network. The information is displayed within the clinician’s local EMR, providing real-time access to clinical. While the initial focus of the grant was sharing laboratory results across Centricity installation, the project evolved in 2008 to include medication lists, problem lists, allergies and laboratory results. The CIE will potentially establish a single master patient index (MPI) across the network that will allow linkages across records from multiple provider data sources in a single data repository that can be queried when a new patient presents in the Emergency Department, in a health center or needs to be admitted quickly and in an unplanned manner. One main benefit is to allow providers to view baseline clinical assessment directly from their local EMR for a patient that has been seen elsewhere in the network. Clinicians find this especially useful when trying to obtain a complete treatment and medication history.
The goal of the CIE is to capture and exchange a full continuity of care document (CCD) message for any patient that has been seen by a provider at BMC or any of the BHN sites. The CCD will include medications, allergies, laboratory results and problem lists going back to the patients’ initial visit to a BHN site and updated with each visit.
In addition to exchanging clinical information, the CIE serves as the platform that will allow health centers to make automated referrals of patients to BMC specialty clinics and electronically access assessments and test results conducted during those specialty referrals. The network’s eReferral Project, a one-year grant from HRSA OHIT, will make it possible for the CHCs to schedule appointments electronically, submit required clinical information to the specialist, receive electronic information about the referral, track patients no-show rates and receive return specialist reports through the local EMR or by opening a web-based practice portal. The objective of the eReferral Project is to eliminate most of the inefficiencies inherent in the current referral process and to enhance the quality and continuity of patient care. The gains in quality improvement of this project will be assessed by observing metrics around colon cancer screening and cardiac diagnostic testing as well as tracking the no show rates.
BHN and BMC leadership noted that in collaboration with GE, they have developed an approach to present the CIE clinical summary to a clinician. They note that each provider must still maintain their own single, comprehensive medical chart on a given patient and that it is not feasible to have automatic updates to ambulatory charts based on procedures or tests conducted in an inpatient setting. At the moment they are working on a user interface that presents the clinical summary information for each patient presented on a separate “tab” within the local EMR. Providers would then have the ability to update their native provider record with more up to date information from the CCD either manually or automatically. At the time of our site visit in April 2009, BHN and BMC officials indicated that two health centers were planning on going live with a demonstration version of the CIE and roll-out is planned for the remaining sites in the coming months.
While still being piloted, all the health centers we spoke with, including East Boston Neighborhood Health Center which operates using an entirely different EHR platform, were very enthusiastic about the initiation of the CIE project, which is unlike state-wide or community-wide efforts, there would be more functionality would be limited and where the focus would not be on their specific patient population. The CHCs were quick to point out potential benefits of an HIE grounded in the major safety net hospital and connected to all health centers and safety net clinics with significant capacity to exchange data (e.g., the full CCD not just an indication of a visit). They were particularly excited about the ability to access information on procedures and test results more efficiently and more easily refer patients to specialists and access assessments from those specialists.
Quality improvement initiatives at the network level. While there is active collaboration between BMC and health centers and across health centers as it relates to the IT components of the EHR as well as operational functions such as human resources, financial planning and Joint Commission accreditation, we found limited coordination across health centers on quality improvement initiatives. BHN staff from BMC and BHN’s CHCs have collaborated on the development of a network-wide Ambulatory Standards of Practice, which focus on increasing access and the coordination of services to patients and improving communication to providers. BHN staff noted that the CHART Working Group offered some standard forms such as a diabetes form that was used by many health centers. Historically, QI projects are discussed and presented at both the BHN Clinical Committee and Board meetings. BHN officials noted that most health centers develop their own registries and customize reports for their own site.
With the recent award of the two HRSA funded HIT projects, BHN has begun to work toward a network-wide Continuous Quality Improvement (CQI) initiative. The participating health centers have integrated the CIE and eReferral measures into their existing CQI programs. The projects will also initiate network-wide standards setting and performance measurement for patients with diabetes and heart disease as well as for cardiac diagnostic testing and colon cancer screening. A QI subcommittee has been established and is meeting monthly to discuss the integration of CHART-Plus QI and eReferral measures into their health centers overall QI goals. BHN is also planning a network-wide QI program based on the needs of the CHCs.
As described in the health center findings section below, several health centers have challenges using the EHR for quality improvement purposes. We describe anecdotal observation of improvements in quality in the section below.
Discussants noted that one approach to network level QI initiatives was pursued earlier in the decade through a Healthy Community Action Program (HCAP) grant that made use of common diabetes templates being used across many health centers to generate a series of reports on diabetes measures that were shared on a regular basis with medical directors at participating health centers. Although this was a centerpiece of BHN’s quality improvement programs at one time, at the time of the current site visit they noted that this was one of many attempts to use the EHR to more formally establish QI programs on a network level and it was lost after the grant period, though it should be noted that an HCAP diabetes template is still in use at several of the sites. Use of the diabetes template populates the flow sheets with current data and future templates. They note that the current strategy of establishing an MPI and a comprehensive data warehouse as part of the CIE initiative will produce better more sustainable opportunities for network wide QI initiatives.