The Boston area is a major center for health care and medicine, with an unusually high concentration of medical schools and teaching hospitals to serve the area’s 4 million residents. As with the rest of the health care system in Boston, the area’s health care safety net includes a large, varied landscape of providers with shifting organizational affiliations. The area includes 25 consolidated health centers and numerous free clinics as well as major public hospitals that provide care to the underserved population. Given the overall size of the safety net in Boston, we focus our site visit on a major subset of consolidated health centers in Boston — those affiliated with the BMC and the BHN network.
Boston Medical Center and the Health Care Safety Net. Boston’s health care safety net environment changed significantly in 1994 as a result of a major hospital merger between Boston City Hospital and the Boston University Medical Center. Prior to the merger, each of these hospitals provided care to underserved populations, with Boston City Hospital serving as the largest inpatient safety net provider in the City. Boston City Hospital had long fostered relationships with many of the consolidated health centers in Boston. The merger created a new institution, the Boston Medical Center (BMC). Currently BMC is the largest single safety net institution in Boston, providing approximately $300 million of free care in 2003.
BMC also serves as the base institution for the Boston HealthNet network (BHN), a network of 15 consolidated health centers in the Boston area that had strong relationships with Boston City Hospital prior to the merger. BHN acts as a convening body, providing coordination, logistical and organizational support for initiatives to help health centers make the most of their affiliation with BMC and access government and private grant funds. Several of these initiatives including Boston CareNet, the BHN HCAP project and CHART focus on designing, implementing and supporting community level health information systems (IS) including a community-wide electronic medical record (EMR) and data warehouse. In this report we describe the work of these initiatives and the related experience of Section 330 supported health centers.
Characteristics of the BHN health centers. As described above, BHN includes 15 of the Boston area’s approximately 25 consolidated health centers. Of these 15, seven are community health centers (CHCs), one is a Health Care for the Homeless Center and the rest are Federally Qualified Health Center (FQHC) “look alike” centers. The other health centers in the Boston area do not share a strong referral link with BMC and do not participate in BHN.5 Referrals from the 15 BHN health centers provide nearly one quarter of BMC’s annual inpatient volume of 27,500 admissions. The network’s partners provide primary and specialty care, outreach, prevention, and dental services to their patients. The health centers enjoy a strong relationship with BMC and have set up a range of programs that facilitate patient transitions between primary care and hospital stays, provide the partner health centers with greater access to capital and medical personnel resources and enhance the ability of members to work with managed care. The affiliation with BHN also affords these centers benefits related to the IS initiatives introduced in the following section.
Consolidated HealthCenter Respondents
|Dorchester House Multi-Service Center||Dorchester House is a CHC founding member of BHN and is closely affiliated with Codman Square Health Center. The CHC had 89,458 encounters in 2003. Dorchester house has implemented the Logician EMR system.|
|Harvard Street Community Health Center||Harvard Street is a CHC and BHN partner. In 2003 the health center saw 30,000 encounters. The center recently implemented the Logician EMR system.|
|Whittier Street Health Center||Located in Roxbury, WSHC saw 32,614 encounters in 2003. It is a BHN partner and has fully implemented the Logician EMR system.|
|East Boston Neighborhood Health Center||EBNHC is the largest CHC in Massachusetts, seeing over 250,000 encounters annually. It is a BHN partner but implemented the EpiCare EMR system years prior to the HealthNet EMR initiative.|
|Boston Medical Center (BMC)||BMC is the largest safety net provider in New England. It is a private, nonprofit hospital formed by a merger of Boston University Medical Center and Boston City Hospital in 1994. It had more than 854,000 encounters and provided more than $300 million of free care in 2003.|
|Boston HealthNet||BHN is a loose provider network comprised of BMC, Boston University School of Medicine, and 15 consolidated health centers around Boston. The network coordinates care for the underserved population of Boston and leads several IS initiatives. We spoke with BHN leadership, as well as BHN affiliated staff who run key IS programs such as CHART and the HCAP project.|
|BMC CareNet Plan||CareNet is a BHN collaboration that allows uninsured city residents to maintain a relationship with a primary care provider throughout changes in insurance status. CareNet also houses and maintains the community data warehouse server and individual CHC EMR servers.|
Site Visit Methods. The site visit to Boston, which took place on May 12 and 13, 2004, involved initial telephone and email contacts followed with in-person interviews with eighteen respondents representing seven institutions involved in the city’s primary health care safety net. Table 1 above lists all health centers and other stakeholders interviewed as part of the site visit and follow-up telephone calls. Telephone and in-person interviews with respondents were conducted using open-ended discussion guides, providing a consistent structure to each exchange while allowing sufficient flexibility to capture all relevant information from respondents. In addition, a table shell was emailed to information systems staff at respondent health centers prior to the site visit to facilitate collection of standard information relating to infrastructure and technical capacity. For each scheduled site visit interview, the NORC team prepared materials that outlined our preliminary knowledge of the respondent and highlighted outstanding questions to address during the interview. Examples of the discussion guides and other materials can be found in previous site visit reports.