SFCCC differs from some of the other site visit networks in that it has facilitated health IT implementation and planning, but does not host EHRs or PM systems. Instead, SFCCC has promoted quality and efficiency improvement tools such as eReferrals, i2iTracks and greater access to existing systems like DPH’s Siemens Lifetime Clinical Record (LCR). SFCCC also works in conjunction with city and county officials on the use of applications such as One-e-App as part of Healthy San Francisco. Several factors led health centers to pursue i2iTracks, including the fact that more were joining disease collaboratives, more health centers were planning to do quality improvement at the center level and centers were looking to have data to compare themselves to national standards.
Health centers also articulated a number of motivations for pursuing IT including their existing systems and EHRs. Glide Health Services is one of a minority of SFCCC members that has implemented an EHR. In describing their motivation, health center leaders indicated that they had always been early adopters and that impending pay for performance changes require access to data through an EHR. South of Market Health Center is waiting to pursue an EHR until they move into a new clinic facility. Lyon-Martin Health Services has not implemented an EHR, but indicated that patient recruitment could be affected by not having an EHR in the future. Lyon-Martin’s Executive Director sees an EHR as a way to improve reporting and would most likely stay with their existing PM system rather than adopting a joint EHR/PMS to reduce costs. Finally, health centers did cite new incentives for EHR adoption as a result of the American Recovery and Reinvestment Act (ARRA) though they acknowledged a limited understanding of the nature of those incentives at the time of our site visit.
Motivation at the network level
SFCCC indicated that its IT initiatives are based on needs articulated by member clinics. For example, SFCCC members had difficulty accessing and reading specialty provider reports and progress notes. That led to increased cooperation and eventual access to the LCR and the implementation of eReferral. The LCR serves as a single, primary care record for all care received at DPH clinics and at SF General Hospital. Access to this record by SFCCC clinics provided those clinics access to laboratory results, discharge summaries, visits outcomes, and information on visits to DPH clinics.
In addition, SFCCC leaders saw a need for disease registry software after the retirement of CDEMS and PECS. SFCCC leaders cite reporting mandates from the Accelerating Quality Improvement through Collaboration (AQIC) initiative in California, HRSA Uniform Data System (UDS), California’s Office of State Health Planning and Development (OSHPD) and HRSA/BPHC along with increased attention to network-wide reporting in SFCCC’s strategic plan as reasons for pursuing i2i Tracks at the consortium level. i2i Tracks is a chronic disease management system tool that uses interfaces to generate registries and reports to track care and improve quality for specific panels of patients. SFCCC saw i2i Tracks as necessary to fill in where EHRs were lacking. Specifically, SFCCC envisioned i2i Tracks as a point of care tool for specific groups of patients (e.g. diabetics) in centers that could handle changes in workflow and as a reporting tool to make better use of aggregate data in EHR systems without having to rely on ad hoc reports.
Current Status of IT Use
The applications described above vary in spread and use across SFCCC clinics. Individual health center characteristics contribute to differing levels of health IT use. For instance, one center is waiting to implement an EMR/PMS until it moves to a new location. Some health centers are involved with external funders and care for specific patient groups, leading them to use various health information systems. While implementation and usage differ across health centers, information on current use of each of these applications (and the programs they are affiliated with) is provided below.
One-e-App. One-e-App is a web-based application used by safety net clinics and health centers to determine eligibility for and enroll patients in Healthy San Francisco, a county-program to subsidize health care for low income residents of San Francisco. As of March, 2009 One-e-App could also be used to determine eligibility for and enroll patients in Medi-Cal. One-e-App includes a one way interface with the State Department of Human Services to submit Medi-Cal applications. Once submitted applications are reviewed by state employees and a final eligibility determination is made within 45 days. Healthy San Francisco eligibility is more direct and certified application agents (CAAs) receive eligibility decisions within ten seconds via the One-e-App website.
In determining eligibility, One-e-App collects demographic information such as family size, address and income. These data are transmitted to the vendor host in Sacramento (the Center to Promote Health Care Access) that stores the data in separate databases by county. Counties across California use One-e-App to determine eligibility for and enroll residents in public health care insurance programs SFCCC member centers have hired additional front desk staff to work as application agents for Healthy San Francisco, using the One-e-App application. In some cases, the county has funded these positions, but in most cases health centers provide funding for application agents. Some centers have made changes to their health centers’ physical layout to ensure some privacy for application agents and patients discussing income and other potentially sensitive topics. Technical support for One-e-App comes from a number of resources including DPH, the San Francisco Health Plan, the Center and individual health centers themselves.
While health centers understood and valued One-e-App as a resource, they did note some missed opportunities associated with using it. For example, the application is not interfaced with health center applications and reports from the One-e-App database are not available or accessible to SFCCC clinics. Several individuals noted that because it is increasingly used as a way to check eligibility for low income San Franciscans, One-e-App has come to represent a “safety net” master patient index that, if integrated with the LCR and EHR databases, could serve a critical role in facilitating health information exchange.
LCR/Invision. As noted above, SF DPH maintains its own electronic Lifetime Clinical Record (LCR). The LCR is hosted in Pennsylvania by Siemens and operates on their Invision platform. DPH implemented the LCR as its primary record over 20 years ago. Today, various partners including local hospitals, health centers, the Department of Housing and the county jail system have access to the LCR. In the time since its inception, the LCR has come to serve as a shared, but limited, medical record between San Francisco General, DPH health centers and SFCCC health centers. The LCR houses patient data including registration information, lab, pharmacy, radiology and diagnostic data.
While DPH regulation requires their clinics to use the LCR to comprehensively record care delivery, SFCCC health centers use the LCR in a far more limited manner. SFCCC health center providers have the ability to add progress notes to the LCR, create LCR identification numbers (“B numbers”) for SFCCC patients and access specialty provider progress notes. In some cases, SFCCC health centers task AmeriCorps VISTA volunteers with entering patient information into the LCR. Some centers have moved to integrate the LCR into their operations, changing their patient ID numbers to reflect the “B numbers” used in the LCR system. The LCR does not interface with other systems, including One-e-App, practice management systems and EHRs. This is because the LCR was meant to serve DPH’s needs and has only come to accommodate external viewing and editing after lengthy negotiations between UCSF, the city attorney and others. The LCR does, however, interface with the SFCCC installation of i2i Tracks described below.
i2i Tracks. Many SFCCC members have implemented a disease registry program called i2i Tracks. They initially obtained access to the system through a grant sponsored by Kaiser Permanente. I2i Tracks is a population health management tool used to track care processes and outcomes for patients with specific diseases and conditions. SFCCC members all have access to i2i Tracks, but not all of them use it. Those that do, use the program to track patients with diabetes, cardiovascular disease, asthma and hepatitis C. Some plan to expand their usage to other conditions including chronic pain and HIV.
Typically, i2i Tracks is installed at a health center and is populated through interfaces with laboratory and practice management systems being used at that health center. Because the Kaiser Permanente grant did not allow for individual health centers to obtain their own i2i Tracks license, the application is centrally administered by SFCCC and is populated through the LCR. While this is a cost effective approach and could allow for comparisons across health centers and benchmarking at a community level, it does raise important workflow challenges.
First, because SFCCC sites are not required to use the LCR to enter data on visits or procedures, many of them are doing so for the first time in order to take advantage of i2i Tracks. Over the last year, SFCCC has put considerable effort into establishing consistent coding and data entry practices across SFCCC clinics so that data entered into the LCR appropriate for tracking in i2i. Because considerable new data entry is required, there has been extensive use of Vista and AmeriCorps volunteers to assist with these activities.
SFCCC centers have used i2i Tracks to varying degrees. Most see i2i Tracks as a useful tool for population health management, especially its reporting features. Some centers staple printouts from i2i Tracks into their paper patient records and use additional copies to educate patients about their health status. Additionally, some centers use the “to do list” section of patient printouts to direct medical assistants and future patient visits. This has proven successful in at least one case, with center leaders indicating that under i2i “things just get done.”
While i2i Tracks has proven useful for SFCCC members, some changes have been made to the product. For instance, some additional fields have been pulled over from the LCR and SFCCC has successfully lobbied the vendor to create patient summary reports for i2i Tracks. Additionally, some centers have recoded certain data elements (including making dummy codes) to improve reporting including diabetes, asthma and homelessness. Using i2i Tracks at the point of care has proven problematic as some providers come to see i2i Tracks as an EMR, though it is much more limited in functionality and purpose. A central challenge for SFCCC’s quality team has been to work with member clinics to enter data into the LCR in a manner that would allow their full panel of diabetic patients to be tracked in i2i. the graphic below demonstrates the progress they have achieved over the last year and the varying abilities of different clinics to achieve the 100 pct objective over a specific timeframe.
Exhibit 3 is a diagram depicting the tracking of Diabetics using i2i Tracks in San Francisco from May 2007 and May 2008. The markets targeted are South of Market, San Francisco Free Clinic, St. Anthony's, Native American, Mission, Lyon-Martin, Glide and Curry.
Exhibit 3: Tracking Diabetics using i2i Tracks in San Francisco
Note: Clinics that achieve 100% remained at that level through May 2008 [SFCCC, please confirm]
eReferral. The eReferral application currently in use by SFCCC clinics was created by a physician at a San Francisco specialty clinic roughly five years ago to improve communication between health centers and specialty clinics. SFCCC staff describe it as a basic email application “dropped on top of” the LCR that allows SFCCC clinicians to transmit orders for specific patients to area specialists electronically. Providers access eReferral through the LCR and use it for a number of procedures and referrals, including breast evaluations, cardiology, colonoscopies, endocrinology, gastroenterology, neurology, neurosurgery, neurotrauma, orthopedic surgery, podiatry, MRIs, respite care, rheumatology, sleep studies, urology and home health. Providers can send their interpretations of tests and initial findings via eReferral as well. Providers have seen a marked improvement over the previous system of faxing referrals. The application also sends reminders to specialists for overdue referrals and includes decision support to alert SFCCC clinicians of potentially inappropriate referrals.
Exhibit 4 is a graph chart depicting the effects of eReferrals on Key Measures. The variables are Time spent submitting, Access for urgent issues, Wait time for new appt, Access for non-urgent referrals, Guiding pre-visit work up, Ability to track referrals. Based on a scale of 0 to 100%. The green shows Better, the orange showing No difference and white depicting worse.
Exhibit 4: Effect of eReferrals on Key Measures
Electronic health records. Some SFCCC health centers have implemented EHRs, while the majority has not. NEMS is migrating to NextGen and Glide Health Services has been paperless on Centricity since September 2008. In most cases, however, health centers are waiting to either see which products the San Francisco safety net coalesces around or to move to new facilities. Glide Health Services has worked with the Alliance of Chicago to implement Centricity. They used nursing students to preload data into the system in June and July of 2008. Since implementing, Glide has experienced significant reporting difficulties, most notably in counting homeless patients on their UDS report.
In addressing this problem, Glide sought the advice of the Alliance of Chicago rather than SFCCC as the Consortium does not provide support for the GE system. In working with the Alliance, Glide realized that updates to the system had caused patients that were homeless only part of the year to not be listed as homeless at all. This type of error could have drastic consequences for a health center like Glide that relies on accurate reporting for specific patient groups to maintain grant funding.
Other health centers that have not implemented EHRs are looking to SFCCC and other area providers for guidance. South of Market Health Center is in the midst of planning and constructing a new clinic facility. They are 18 months from completion and hope to include EHR requirements in the physical design and layout of the facility. Lyon-Martin Health Services is a relatively small health center. They have left the possibility of going to an EHR open in a recent move to a new PMS, but are unsure if they would be able to support an EHR given their small size and limited resources.
Practice management system. Similarly, SFCCC centers have chosen various PMS applications. Glide Health Services uses a joint Centricity EHR/PMS. South of Market uses HealthPro from Sage, having recently updated from HealthPro Legacy to HealthPro Excel. Lyon-Martin used a 2007 grant from the California State Treasurer to implement Allscripts (Misys) Tiger and install computers with the PMS in every exam room. Because some patients are not in the LCR and Lyon-Martin does not have an EHR, the center relies on the PMS for certain functions like reminders and reporting. As with EHRs, SFCCC has not decided to support any one PMS application.
Findings: HIE and Interfaces
The Consortium’s many partners and applications have led to a concerted effort to link systems and partners whenever possible. SFCCC and DPH have been funded by organizations like the Tides Foundation Community Clinic Initiative, Kaiser Permanente, federal programs and others to maintain connectivity between systems. I2i Tracks which is hosted at SFCCC gets demographic and diagnostic data from the LCR. This one-way interface only allows updates to demographic data from the LCR. Lab data are also dropped into i2iTracks through a real-time HL7 lab interface with all SF General labs and public health labs that have numeric results. Another interface between additional external data sources and i2i is in development. One SFCCC health center characterized i2i Tracks as a “form of health exchange” and called it a good idea.
Labs are also fed into the LCR, from private clinical labs as well as DPH and San Francisco General. An OpenLink data aggregator maintained by the county unduplicates data, matches data to individual patients and feeds that into the LCR. Despite this, the LCR remains a relatively closed system from the perspective of some SFCCC clinics. SFCCC members expressed some frustration with not being able to interface their practice management systems or One-e-App with the LCR. One-e-App transfers non-health related demographic and eligibility information between SFCCC centers and the State Department of Human Services by way of the Center to Promote Health Care Access in Sacramento. While most SFCCC centers have been able to exchange lab data with San Francisco General, others have existing relationships with other lab providers that are not at that point.
For example, Glide Health Services relies on St. Francis Medical Center for their patients’ labs. St. Francis is part of Catholic Health Care West which uses a Perot Systems application. They have worked to develop an HL7 interface with Glide, but budget constraints have delayed that effort. Others use Quest Care360 to access lab results in a web-based system that is not integrated with any of their own applications. In the future, SFCCC and its members hope to expand upon its HIE efforts. Currently, SFCCC is looking to create a fiber optic network for the safety net in San Francisco to address connectivity issues and connect safety net providers more directly. Others have expressed interest in e-prescribing and generally increasing access to other providers’ information systems.