In presenting findings from interviews and other site visit activities we begin with an overview and history of CHAN. We then go on to describe the current information systems capability and resources at CHAN health centers and provide details regarding the recent roll-out of EMR and practice management software. We end the section with discussion of CHAN’s role within the larger public health context in the state.
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3.1 The Community Health Access Network
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CHCs in Southern New Hampshire organized CHAN in 1995 to strengthen their collective ability to provide comprehensive primary care to underserved populations. As we’ve seen with the formation of CHC networks in other sites, CHAN developed, partially, in anticipation of Medicaid managed care. Overall, respondents indicated that CHAN’s formation was aimed at:
- expanding health center capacity by hiring more physician staff and broadening services offered;
- ensuring implementation of health care “best practices” across all centers;
- preparing the health centers to deal effectively with the administrative and financial challenges of impending mandatory managed care; and
- improving the centers’ ability to track patient care and enhance quality of care.
Defying some predictions, NH Medicaid did not go to mandatory managed care in the mid-1990s. Even without substantial pressures related to managed care, however, CHAN members decided that collaboration was the best method to remain competitive and solvent. In particular, they saw great value in using the network to support, plan and implement improvements in IS used by health centers. Beginning in 1997 CHAN took advantage of state funds set aside to encourage community interagency collaboration. Two years later CHAN secured its first BPHC SIMIS grant allowing the organization to purchase centralized servers and other components of a network systems infrastructure. Subsequently, CHAN obtained additional grants from the state and BPHC as well as from private donors including corporations and local foundations.
While CHAN has long prioritized development of networked EMR and practice management applications, this goal has become a reality only in the last few years with the roll-out of GE’s Logician package for the EMR system and Millbrook for practice management. Currently, the services CHAN provides to its member health centers include:
- access to shared applications for practice management, EMR and accounting accessed through a Wide Area Network/virtual private network (WAN/VPN);
- technical and user support to health centers using shared applications;
- standardized care management for chronic illnesses including diabetes, asthma and hypertension;
- development of a triage support through a phone notes tool for use in all sites;
- annual survey of patient perceptions regarding quality of care and services provided;
- development of shared corporate management services including compliance and accreditation.
We discuss these services and the health centers’ experiences participating in CHAN in subsequent sections of this report.
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3.2 Health Center Information Systems Characteristics, Capacity and Resources
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In addition to talking with CHAN staff, we interviewed the directors and lead IT staff from three of the five CHAN network health centers. Network participation and collaboration over the last eight years have succeeded in substantially improving the technical infrastructure and capacity at each of the five health centers. All centers have both the Logician EMR and Millbrook practice management systems up and running (except for one site that will implement Millbrook over the next few months), provide a similar set of services to their patients, and participate in network directives like electronic linkages with local hospitals and the BPHC-sponsored Health Disparities Disease Collaboratives.
Health center governance. Each of the BPHC funded consolidated health centers we interviewed relies on a community Board of Directors for overall governance. An Executive Director (ED) typically manages the center and is assisted by senior staff including a chief medical officer and senior administrative or financial officers. The CHAN member health centers have experienced low rates of staff turnover; most of the EDs have held their positions for many years and buy in to the potential offered by CHAN. In addition, all site visit respondents indicated that the level of cooperation between New Hampshire safety net providers in general, and CHAN members in particular, is exceptionally high.
Health center information system staffing. Although each health center does employ some dedicated IS staff, CHAN and member health centers significantly share staff resources. CHAN itself employs 8 FTEs (including both IS and non-IS staff), spread out over fifteen people. Six of these fifteen work exclusively for the network, totaling 4.5 FTE; the remainder are “shared staff” based at one or more of the member health centers whose responsibilities include IS duties for both CHAN and the staff person’s base health center. For example, the CFO/CIO of the CHAN network is also the IT Director for Lamprey Health Care. These shared staff operate the network’s help desk, which is available five and a half days a week and is based at the CHAN central offices. The health centers’ dedicated IS staff is primarily responsible for general office support, such as assisting end users with hardware, database, and minor connectivity issues. They have formal training in information systems but are typically not qualified to do end user support for the Logician EMR system. Specific support related to Logician is provided through the CHAN Logician specialists and from Logician directly.
Information system decisionmaking. CHAN health center IS decisions are worked out through a highly collaborative process. Most of the member health centers have informal internal IS committees made up primarily of their IS staff. These committees assess needs and make suggestions to the wider CHAN IS committee, which is composed of network and health center IS staff, led by the CHAN CIO. This committee receives significant input from the centers’ clinical and administrative leadership. Once a consensus has been reached within committee that an initiative should be pursued following a specific implementation strategy, the proposal is presented to the CHAN Board of Directors (made up of the health center Executive Directors) which then decides whether to go ahead. CHAN’s CIO/CFO noted that since nearly everyone involved in the process wears two hats — health center and network — decisions are made with both responsibilities in mind. CHAN is the source of all IS components of the network, so any changes affect all five centers. The CHAN CIO could not recall a major systems decision being made that was not universally agreed upon by the committee members.
Health center IS infrastructure. Even prior to the development of CHAN, member health centers maintained relatively robust hardware and software to support a range of administrative applications including practice management and in some cases EMR. Under the current model where practice management and EMR applications are housed on a central CHAN-administered server and provided to health centers via a VPN/WAN connection, member health centers still maintain their own servers and support general productivity software such as the Microsoft Office Suite. Each health center connects to the CHAN server and Internet via T1 lines purchased, installed and supported in collaboration with CHAN.
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3.3 CHAN Information Systems Implementations
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In this section we summarize the two primary information systems implementations coordinated by CHAN for the benefit of its member health centers: the Logician EMR system and the Millbrook practice management software suite, both of which are now owned by GE and marketed together as the Centricity Information Systems package. We focus in particular on 1) issues related to implementation of these applications and 2) key functionality and benefits offered by these systems based on health center experiences to date. We note that both initiatives grew out of the perceived need to develop a model for sharing access to and support for mission critical applications across health centers. Both of these activities were accelerated by the initiation of the BPHC’s SIMIS grant program.
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3.4 CHAN and the Public Health Environment in New Hampshire
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CHAN stakeholders attributed the network’s success, in part, to a statewide cultural mindset that favors the sharing of information, resources, and assistance among public health entities trying to build themselves up. This section outlines the public health safety net environment in New Hampshire and discusses a selection of other initiatives going on in the State and their relationship with CHAN.
The OCPH. The Office of Community and Public Health in the N.H. Department of Health and Human Services (DHHS) provides leadership and a core public health capacity for New Hampshire. The Office is organized into five major program divisions, comprised of the Divisions of Family and Community Health, Chronic Disease Prevention, Laboratory Sciences and Environmental Health, Epidemiology and Vital Statistics, and Health Services Planning and Review. The OCPH collects information on pre-natal care, family planning, diabetes, and cancer screening performance measures from consolidated health centers in New Hampshire, including the member centers of CHAN, and provides funding and support to safety net providers. Respondents indicated that the Office works closely with CHAN on issues related to reportable conditions, chronic disease management and public health education among low income populations. CHAN has been the administrative contractor for the NH Diabetes Prevention and Control Program since 1999. Similar developments are underway in NH for Asthma, also through CDC funding support. Although there is no automated electronic reporting between Logician and the OCPH, this functionality has been discussed.
Bi-State PCA. Through a Memorandum of Agreement (MOA), the first of its kind nationally, CHAN also collaborates closely with the Bi-State Primary Care Association, a private, not-for-profit organization with a membership of forty entities in Vermont and New Hampshire that provide and support community-based primary care services. These member organizations include community health centers, rural health clinics, private and hospital-supported primary care practices, health care for the homeless programs, clinics for the uninsured and social service agencies. To assure sensible division of goals and services between the PCA and CHAN, there is overlap between the board of directors of the two organizations and regular communication among leadership regarding new and ongoing initiatives.
Southern NH AHEC. A separate MOA is with the Southern NH Area Health Education Center, a non-profit program dedicated to the development of health professions. CHAN collaborates with the AHEC on the identification of staff development needs and the provision of a range of continuing education services for the health center staff. Training topics range from clinical competencies to cultural and leadership skills. Specifically for CHAN, the AHEC provides education credits for the EMR training curriculum.
New Hampshire Logician User Group. An informal group of health centers have been collaborating on the deployment of EMR since 1997. The agencies work together primarily on the development of end-user tools, which are shared between the organizations, thereby capitalizing on limited resources and technical talent with experience in Logician. CHAN has been an active collaborator of this group; giving and receiving tools and developing the collective intellectual capital. The User Group sponsors an annual regional workshop, named “AutumnLogic”, that showcases the work in New Hampshire and provides opportunity for potential EMR users to interface with EMR pioneers and observe new vendor developments.
The New Hampshire Community Technology Partnership. The N.H. Community Technology Partnership is a collaborative of six regional partnerships, representing more than 50 health and social service agencies in New Hampshire. The partnership’s goal is to implement a statewide, online service that provides clients access to health and human services programs and allows service providers to coordinate delivery of services online. Funded primarily through a BPHC HCAP grant, the coalition is working on developing an electronic “tool box” of program eligibility screening and care coordination tracking software with a central data base for all clients. Currently, the eligibility screening and care coordination modules are online and the central database prototypes are being delivered. Overall, the project seeks to (1) provide a network that connects participating agencies to a wide range of health care providers and human services agencies; (2) streamline intake processes across services and systems by providing a single point of entry; and (3) host a centralized database that maintains client-level information for program eligibility, care history and demographics.
Of the CHAN members, only Health First Family Care (HFFC) is currently involved in the Technology Partnership, although all are eligible. Our HFFC respondent explained that the current tracking software allows secure, confidential, centralized sharing of key data on safety net clients online. In Health First Family Care’s region, network agencies have agreed to create a joint disease management and treatment program that is managed electronically through the Partnership’s IS tools. Although CHAN has not been formally involved to date in the eligibility screening and care tracking initiative, CHAN respondents indicated that they are looking forward to a demonstration of the system scheduled for September 2004 and may play an active role in the project.
Medication Bridge Program. The New Hampshire Medication Bridge Program, a private-public partnership that helps eligible uninsured and underinsured patients obtain prescription medications from pharmaceutical companies’ Patient Assistance Programs, is the fourth prominent state health initiative. Participating sites include hospitals, community health centers, physician offices, senior housing, and non-profit organizations. All five CHAN members participate in the program, which has provided over 200,000 prescriptions for over 14,000 individuals throughout the state since January 2001.
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