As with other site visits conducted for this project, preparation for the visit began approximately one month prior to the in-person meetings with initial telephone conversations with HCN national leadership and the Executive Directors of UHCN and NMHCN. These three initial conversations were conducted to share the aims of the site visit, obtain agreement from leadership to participate in the site visit, discuss potential discussants for the in-person meetings and set a date for the in-person meetings. Following these initial telephone conversations, we revised background materials, developed detailed agendas for each meeting and set appointments with clinical, administrative and IT leadership from across HCN member health centers in Utah and New Mexico.
The site visits themselves took place on the week of November 10th 2008. We deployed one team of three NORC staff to New Mexico to conduct in-person meetings with three health centers as well as NMHCN President David Roddy and a second team to Utah to conduct in person meetings with three health centers as well as UHCN Managing Director Chris Viavant. For each meeting, we prepared materials that outlined our preliminary knowledge of the discussant organization and highlighted outstanding questions to address during the in-person discussion. Having multiple team members at each meeting allowed us to have some individuals dedicated to taking notes and documenting the content from the meeting while others focused on assuring that the goals of each meeting were being addressed through engagement with the participants. Finally, after concluding the site visit, we conducted two additional lengthy telephone meetings with HCN National Executive Director Kevin Kearns and Chief Information Officer (CIO) Alex Romillo to follow-up on some of the findings from health center discussions and explore priorities and future direction for the national network. Exhibit 1 below lists the various discussants that participated in the site visit from HCN National, UHCN and NMHCN.
Exhibit 1: Site Visit Discussants
|Health Choice Network, National Leadership|
|President and CEO: Kevin Kearns Senior VP and Chief Information Officer: Alex Romillo||HCN National|
|Health Choice Network, Utah|
|Managing Director: Chris Viavant||Utah HCN|
|Executive Director: Allan Ainsworth IT Director: Godo Delgado||Wasatch Homeless Health Care|
|Executive Director: Mary Winter Medical Director: Kim Macfarlane||Green River Medical Center|
|Executive Director: Yvonne Jennson, Medical Director: Virginia Wheeler||Carbon Medical Services|
|Health Choice Network, New Mexico|
|President and CEO: David Roddy||New Mexico HCN|
|Chief Executive Officer: Harriet Brandstetter
Chief Operations Officer: Martin Lopez
Chief Information Officer: Daniel J. Guevara
|La Clinica de Familia|
|Executive Director: Mary Alice Garay Chief Financial Officer: Mary Rooker||Ben Archer Community Health Center|
Chief Executive: Officer Seferino Montaño,
Chief Financial: Officer: Steven Connelly
|La Casa Family Health Center|
Health Choice Network Background
HCN was founded in 1994, by a group of four health centers in South Florida. The founding health centers, Economic Opportunity Family Health Center, Community Health of South Dade, Helen B. Bentley Family Health Center and Camillus Health Center are all based in Miami-Dade County and a fifth health center; Family Health Centers of Southwest Florida based in Fort Meyers joined the network in 1996. These health centers came together to look for opportunities for achieving administrative efficiencies and economies of scale through collaboration and joint purchasing. Like many health center networks, they were also motivated by the potential to form a health center-based managed care organization.
Eventually a sister organization, Atlantic Care, was developed to address the managed care issue, but members decided that the most important role for the core-HCN organization was coordination on information systems and billing. In addition, there was interest among medical directors in regularly meeting and coordinating on a single approach to achieving clinical quality improvement.
Overall role for the network. Consistent with the theme of coordination around information systems and billing, around 1997, HCN decided to adopt a model they refer to as an integrated delivery system. Although each member health center continued to operate as a separate 501c(3) organization with their own individual grant as a federally qualified health center, they agreed to join together to hire a common chief financial officer (CFO) and chief information officer (CIO) and fully consolidate all computing through a single network operation. The initial senior executive who played both of these roles, Kevin Kearns, continues to lead the network (although Alex Romillo took on the CIO role in 2004).
Under this arrangement; and leveraging HRSA grants such as the Shared Integrated Management Information Systems (SIMIS), the Integrated Service Delivery Initiative (ISDI) and the Healthy Communities Access Program (HCAP); HCN adopted an integrated accounting application, a single practice management system through Medical Manager and initiated a single, central billing office in 2001. Each member health center supported the network through payment of an annual fee and paid additional, transaction fees for making use of the central billing office and consulting services. HCN received approximately 800,000 dollars in grant support from HRSA for these activities. HRSA’s contribution accounted for roughly 30 percent of the infrastructure with the remaining support coming from member dues. HCN runs on an operating budget of close to 12 million dollars annually, 4 percent of which comes from federal grants. The rest is accounted by 28 percent from membership dues, 40 percent from contributions from foundations, 20 percent from HMOs, 2 percent from state grants and those grants designated by HCN as “other” comprise the rest.
In order to achieve further economies of scale, HCN maintains a basic IT infrastructure for their members including maintenance of a data center with redundancy and recovery capabilities. HCN also works with member health centers to assure adequate connectivity to their applications and data.
Supporting EMRs and Quality Improvement. HCN’s initial effort to implement EMRs was guided by medical directors of member health centers led largely by Dr. St. Anthony Amofah, Medical Director at Helen B. Bentley. In seeking to systematize care and encourage use of consistent templates, the medical directors began discussions about EMRs with Kearns and other network officials around 1999. HCN began offering Medical Manager’s OmniDoc EMR to health centers in 2002.
Out of the box, OmniDoc offered a set of basic functions for maintaining a medical record and for e-prescribing, but the Medical Directors invested a great deal of time in developing diagnosis specific templates and automated reminders to facilitate QI and add some clinical decision making components to the EMR. Decisions regarding the configuration of the EMR and ongoing enhancements are made by HCN’s clinical committee made up of the medical directors from across the networks. Almost eight years after initiating EMR implementation, HCN has over 500 custom-configured templates which have allowed them to transform OmniDoc into a health center-centric EMR product.
After having used OmniDoc for several years, the clinical committee, still led by Dr. Amofah, started looking for an EMR to meet more sophisticated requirements around condition specific templates, registry-type functionality, clinical decision support and reporting on specific quality metrics. After considering their options, HCN decided to shift from Medical Manager's OmniDoc product to a combined practice management/EMR solution known as Intergy developed by Sage Health (by this time Sage Health had purchased Medical Manager). The network is currently planning for migration from OmniDoc to Intergy and all new implementations, including several that recently took place in Utah, are to the Intergy practice management/EMR application.
HCN has sought to closely link its EMR and quality improvement efforts. In addition to supporting EMR applications, HCN also supports disease management and reporting applications such as Patient Electronic Care System (PECS) and Practice Analytics. As described above, the clinical committee is responsible for defining all requirements for and enhancements to the EMR system and for defining requirements for a set of quality-related reports that are distributed to all health centers using EMRs supported by HCN on a monthly basis. Initially, the committee’s focus was on automating quality reports for those measures mandated by HRSA related to specific funding opportunities. While some HCN members such as the original founding members have been able to work together on quality improvement beyond the establishment of common reports, HCN currently does not provide more advanced quality improvement services outside of Florida. HCN recommends that these activities get coordinated at the state network level.
An expanding, evolving model. Between the years of 2000 and 2006, HCN staff led EMR and practice management implementation efforts in several health centers with dozens of sites, initially in Florida but eventually spreading out to satellite sites in Utah, New Mexico, New York, Michigan, Hawaii and beyond. This expansion is motivated primarily in an effort to expand their customer base, achieve greater economies of scale and limit their reliance on federal grants. Expansion brought about the need to create new membership options for health centers that sought a certain level of service from HCN. For example, HCN organized membership options for those health centers that wanted to access the Medical Manager practice management application, but were not prepared to join in the fully integrated model with a single CFO and use of centralized billing.
HCN employs 122 full time employees (FTEs) or their equivalent. Twenty of which reside in Fort Myer Florida, all other Florida employees work in Miami and 9 work within the states they serve. Out of those located centrally in Florida 1 or 2 staff are dedicated to each of the states to lead training and technical efforts. HCN has 49 members in its IT staff, 34 in centralized billing, 10 in finance, 10 who work in managed care/clinical/doctors, 8 in development and the remaining staff contribute in a support role such as administrative.
Governance. Maintaining an effective governance model has proven to be a challenge to HCN in recent years. In earlier years, leadership from the original health center members constituted the network’s Board of Directors, the body that is ultimately responsible for key decisions and the overall direction of the network. While the five original members retain more votes on the board than newer members, the model up to this point has been to add one member to the board with each additional health center or regional health center network that joins HCN. This has resulted in a board of over 30 members currently.
In addition to the board, many decisions are made at the committee level and separate committees have been set up to address IT infrastructure, managed care (now spun off as Atlantic Care), clinical care and finance. As with the overall board, in order to provide all members a voice, every health center is allowed to have staff on each committee.
Recently, HCN has also announced a plan to move towards a more streamlined board and committee structure that puts greater voting and decision making authority in the hands of health centers that are “fully integrated” with the network. These are primarily those health centers that are using HCN as their single CIO and CFO and that have fully adopted EMR and practice management software supported by the network. Over time, this will reduce the number of individuals that have a definitive say in key decisions such as those regarding EMR templates, assessment of new vendors or establishment of new HCN services. While other health centers will continue to be able to join HCN and purchase services, they will not have direct input into the direction of the network. This change in governance approach is consistent with the overall future direction for the network that is described near the end of this report.
Relationship with Utah and New Mexico. HCN’s relationship with health centers outside of Florida dates back to 2000 when they began discussions with the Primary Care Association and Integrated Services Network of health centers in New Mexico. Members of this existing organization created NMHCN as a means to leverage the existing HCN infrastructure and provide the practice management and EMR applications to their six member health centers. Today, NMHCN has been a part of HCN for approximately four years, enjoys a seat on the HCN Board of Directors and is considered a “fully integrated” partner with HCN.
In 2002, HCN established a similar relationship with a Utah based association of health centers known as the Association for Utah Community Health (AUCH). A subset of AUCH member centers formed UHCN which also is considered a “fully integrated” member with a seat on the board. Although HCN continues to expand to additional states, network leaders indicated that Utah and New Mexico offer the most comprehensive picture to date of HCN’s experience working outside Florida and of the interaction between state-based networks such as UHCN and NMHCN with the national network.
In subsequent sections of this report, we outline the experiences of health centers in Utah and New Mexico with implementation and use of HCN services and applications including EMR and practice management systems. We then return to the topic of HCN organization and functions to discuss the future direction of the network as articulated by the network's national leadership team.