Since its inception, BHN has leveraged funds from federal grants and private donations directed to BMC to support improvements in IS infrastructure and applications available to affiliated health centers. In 1997, BHN received a three-year $250,000 ISDI grant that supported specific improvements to the consolidated health center IS infrastructure. Subsequently, in 2001, BHN (through BMC) received a $6 million grant from a private corporation to implement a common EMR system in eight partnering CHCs. That same year, BHN received their first HCAP grant geared towards the construction of a broader and more comprehensive infrastructure for gathering and analyzing data related to uninsured patients. The two major products of these initiatives, a data warehouse and EMR system, are described below.
Data warehouse and HCAP initiatives. The data warehouse project, spearheaded by staff from CareNet and the Boston HCAP project, compiles data on care delivered to the uninsured across health centers and the BMC (inpatient). The data warehouse allows BMC and health center leadership to identify utilization and cost trends and enhance services across the continuum of care. Specifically, the project seeks to reduce inappropriate use of Emergency Departments and to foster appropriate management of ambulatory care sensitive conditions such as diabetes. The project focused exclusively on the uninsured because of the dearth of knowledge on this population relative to BHN’s Medicaid population many of whom were covered by BMCHP which monitors utilization and costs for their population separately.
The preliminary form of this warehouse was a Master Patient Index (MPI) that simply compiled and updated demographic information on uninsured patients seeking care at BHN institutions. A later version, implemented in 2003, provides CHCs with timely information on the CareNet populations’ inpatient encounters such as the top diagnoses, patients whose costs have exceeded $100,000, and the number of diabetic patients that are inappropriately admitted. In recent months, CareNet and HCAP have begun disseminating center-specific reports highlighting key cost and utilization measures relevant to uninsured patients treated at each health center. The warehouse currently contains nearly four years of data on the target population — the nearly 80,000 uninsured individuals who are enrolled in the CareNet Plan.
While the majority of data included in the warehouse comes from interfaces developed to extract data from health center practice management systems and BMC’s administrative systems (for inpatient care), HCAP and CareNet staff have begun to include EMR data specific to diabetes patients in the data warehouse to support the HCAP project’s goal of improving management of diabetes care. In order to assess diabetes care and patient outcomes, HCAP staff worked with health center and BMC physicians and nursing staff to identify 10 EMR-based measures of diabetic care adequacy and four measures of disease control. These include checking HgbA1C levels and blood pressure at least once in 7 months, checking BMI, LDL, monofilament, microalbumin, and eyes at least once in 15 months, among other such “best practices”. HCAP staff are currently developing periodic reporting mechanisms for these performance measures at the individual clinician (PCP and nurse) and CHC level, as well as at the HealthNet community level (by geographic, socioeconomic and ethnic groupings). HealthNet has already collected baseline data on hemoglobin levels and found health improvements over the course of one year, such as that 69% of patients with A1C levels >8.5 had a reduction of at least 1 point. More complex reports are still pending adequate data and EMR template revision.
The CHART project and EMR implementation. In 2001, a strategic planning committee from the BHN Board proposed moving to electronic records in health centers as an important next step in developing the IS capacity of the network. After garnering approval from participants at their annual retreat, BHN leadership brought this idea to BMC’s development office who then met with a private corporation that agreed to fund the initiative. This corporation gifted $5.9 million to BMC to implement EMR systems in eight partnering CHCs. This grant supported the purchase of PCs, licenses for General Electric’s (GE) Logician EMR, implementation assistance from GE and staffing. The donor channeled the funds through BMC, and consequently BHN, to coordinate and facilitate implementation in health centers and provide oversight. The initiative was titled the Community Health Automated Record Technology “CHART” Project. Implementation across 8 CHCs began in 2001 and is still ongoing, though mostly complete. HCAP funds supplemented resources available through the donation during critical phases of implementation.
While CHART was initially geared towards implementation, the project’s focus has now shifted to maintaining the technology and enhancing its use. Several committees within BHN support the CHART project. The CHART working-group consists of a subcommittee of BHN leadership and IS representatives from each of the eight CHCs who discuss overarching issues such as implementation budgeting, planning and allocation. The Clinical Computing Collaborative, chartered by BMC’s Division of Community Medicine, convenes CHC medical directors and other staff to discuss specific end-user issues and discuss the use of technology in the HCAP initiatives described above.