Community Health Center Information Systems Assessment: Issues and Opportunities. Final Report. Appendix A. Examples of site visit discussion guide and preparation materials

10/30/2005

Tillamook County Health Department
9th Street and Laurel Avenue, Tillamook, OR
Phone: (503) 842-3900

Respondents
John Robinson, Executive Director
            -Mr Robinson also sits on the OCHIN Advisory Board.
Ron Wallace, Assistant Administrator
Jeff Underwood, IS Coordinator

Interviewers: Mike Tilkin and Alana Ketchel

Logistics
We will be meeting with John Robinson and Ron Wallace, an assistant administrator at Tillamook County Health Department as well as Jeff Underwood, the IS contact for the center.  We will meet with them at their building on the corner of 9th St. and Laurel in Tillamook, OR.  We were instructed to leave approximately 1 hour and a half for travel.  John Robinson warned us that he might be called away for another meeting he might have to attend but we will at least be meeting with Ron Wallace and Jeff Underwood.  We previously spoke with Darlene Dannis, finance manager, via phone.
Further directions: Take Highway 6 into Tillamook, come to the 101 and hang a left at the 2nd stop light.  We will be coming into town one-way and will watch on the left for 9th St. where we will hang another left.  After we pass the 101 coming the other way, their building will be on the next block at the corner of 9th St. and Laurel. 

What we know

  • Tillamook County Health Department is both a county health department and community health center located in Tillamook County, OR. They are an IPM partner in the OCHIN System.  
  • Prior to OCHIN, the Tillamook County Health Department was having difficulties maintaining a practice management system because software companies were not able to stay in business.  They started out with MDX Software and moved onto the Physicians Computing Network (PCN) which was then bought out by Medical Manager.  They were having concerns about continued support for the software given how often it changed hands.
  • Also previous to OCHIN, they had trouble b/c all the health centers were providing different information in different formats to the State and Feds.  Now, as one unified network, they all can share the same language with the State.
  • Besides the EPIC practice management system, the clinic is currently utilizing separate care management/tracking systems.  One relates to the Diabetes Collaborative and the other relates to Evidence-Based Data (the PECS Software).
  • They interviewees identified several critical functions they perform as a CHC for which the OCHIN system provides support.  The first was that OCHIN simplifies the process of producing the UDS report.  Also, being able to go through the OCHIN clearinghouse for direct billing allows them to bill in a way that is less expensive with a faster turnaround.  Finally, they are looking forward to the prospect of an EMR system which, without the financial backing of OCHIN, they could not develop alone.
  • Ron Wallace noted that as a county health department, the IS infrastructure at Tillamook (e.g. e-mail systems, etc.) must fall under county standards which can be handicapping.  To enroll in the EPIC system, they had to pay for some changes in the EPIC program such as extra software training and systems upgrades b/c their system wasn’t up to par with the requirements of EPIC
  • The health department offers the perspective of an IPM partner that is affiliated with a local health department. We have contacted Jeff Underwood to obtain basic information on their non-OCHIN related network and system resources. Please refer to the summary of OCHIN and their network which the Tillamook County Health Department and CHC has access to as an IPM partner.

Basic Information

Tillamook County Health Department

Clinic Address: 801 Pacific Ave., PO Box 489, Tillamook, OR 97141
Phone: 503-842-3900
Web Site: www.co.tillamook.or.us/gov/health
Additional Sites: Rockaway; Dental Clinic, Tillamook; Cloverdale
Clinic Type: Federally supported Community Health Center

Services Provided:

  • Comprehensive primary medical and dental care services for acute and chronic disease management, public health and preventive services
  • Women's Health Care
  • Dental Care
  • WIC
  • Home Nurse Visits
  • Teen Clinic
  • School Nurses
  • Public Health Services e.g., immunizations, environmental health, vital statistics, family planning clinics, TB screening and treatment, HIV/AIDS case management, etc.
  • Enabling Services including: Outreach, transportation vouchers, OHP eligibility assistance, interpretation/translation, special education program

Patient Profile

Patient Profile
Patients 2001:  6,086
Number of visits:  20,437
Ethnicity  
Hispanic  15%
White 83%
Amer Indian/Alaska Native 1%
Asian 1%
Payment  
Medicaid 20%
Medicare 9%
Uninsured/private pay 45%
Commercial Insurance 26%

Staffing
Total Staff: 35

Clinical Staff

2 Physicians
2 Nurse Practitioners
1 Dentist
1 Dental Hygienist

What we want to learn

  • We will query them extensively on their center’s IS resources, management and longer term strategy and the role of OCHIN.
  • Also, we will query on the their experience with using the EPIC suite of practice management software and the gains they expect through using this system and participating in other planned OCHIN initiatives such as data warehousing and electronic medical records.
  • Specifically, we want to find out more about the experience of being a health department and CHC in terms of their ability to become a partner in OCHIN’s practice management system and other ventures given the county standards they must adhere to.  What exactly did it take for them to sign onto be an IPM partner?  What did they gain/sacrifice?
  • We would also like to find out more about the non-EPIC patient care tracking software they are using such as the Diabetes Collaborative.  Find out more about the PECS (sp?) software they referenced above.
  • Note: Mr. Wallace wanted to make sure that if we had input on their infrastructure and what it might be lacking in comparison to other health centers/ health departments, we would let them know.

PROTOCOL
Note: skip questions answered above such as those in italics
Center/Systems Background Information

  1. What is your organization’s mission and how do IS play a role?
  2. What is your center’s systems related budget?
  • As a percentage of your overall budget?
  • How much of this are costs associated with OCHIN participation?
  • Has OCHIN increased or decreased your investment in systems?
  • How are financial decisions related to IS made at your center?
  1. How does your clinic finance OCHIN related expenses?
  2. Please describe your decision to participate as a IPM partner
  3. How is your center different from other primary health care providers or CHCs, and how what IS needs follow from those differences?

Applications Dimension

  1. What are the major benefits of the OCHIN software applications to your center, how would you prioritize their importance to overall center objectives?
    [PLEASE QUERY SPECIFICALLY ON EACH OF THESE…]
  • scheduling and resource management
  • claims submission, billing — including under capitated arrangements
  • tracking eligibility and insurance status and verification
  • administrative reporting to HRSA and other federal agencies
  • tracking payments and accounts receivable
  • other administrative and financial functions
  • Eligibility tracking for Medicaid/SCHIP
  • Tracking of specific outcomes or exposures (e.g., birth weight, exposure to environmental hazards)
  • Availability and utilization of specific “free” resources (e.g., pharmaceuticals)
  • Other features?

Which of these practice management functionalities are currently not available, but needed? Which ones do you have access to but don’t use?

  1. Are there other systems applications that you would like to see initiated? How would you prioritize these?
  • electronic medical record or e-health record
  • clinical decision support applications
  • others?
  1. Are you currently, part of the Health Disease Collaborative or any other disease management or quality improvement program based on electronic tracking of patient care? Please describe the applications used for those programs (e.g., PECS or CV-DEMS for the Collaborative) and how they might interface with an EMR.
  2. What application development technologies and methodologies does your organization use?  What systems have you developed vs. bought off-the-shelf? How was this decision made?
  3. What is the future plan for the application architecture (individual applications as well as integrated systems)? How are future plans made and then revised over time? How much of this is driven by OCHIN decisions?
  4. How do you use/plan on using data resources available through your participation such as the Master Patient Index or data warehouse reports?

Technology Domain

  1. To what extent has OCHIN standardized hardware used at your center?
  2. What are your strategic plans for updating it, assuming more applications will operate in a more broadly networked environment? 
  • Describe any integration challenges/successes across the consortium with respect to networking and infrastructure.

Process Domain

  1. In general how are technology decisions made at your center? How is the process consistent with center goals?
  2. How are requirements collected, technologies or vendors selected, and “build vs. buy” determined?
  3. Specifically what do you rely on vendors or consultants to provide in this area? What do you rely on OCHIN to provide?
  • IS strategy, technology selection
  • implementation, systems support
  1. How would you characterize your relationship w. vendors and OCHIN?
  2. What has been your experience working within the OCHIN network to access/use Epic practice management software? (e.g., ease of connectivity, benefits from enhanced functionality, support, initial start-up etc.)
  3. Describe process for supporting user community (help desk, on call system administrators, ad hoc)? How much of this function does OCHIN or EPIC provide?
  4. How would you rate your satisfaction to date with OCHIN/EPIC, why?
  5. Describe how you learn about new technologies and technology best practices. How do you share this knowledge with your colleagues within the CHC and the broader consortium?
  6. What kind of training occurs to help keep your IS staff current?
  7. Describe any formal processes your organization has for insuring that policy and clinical procedures are working in concert with and are appropriately balanced with healthcare IS.
  8. Please describe the organizational relationship between the key actors in your organization (e.g., clinicians, administrators, patients, technology professionals, decision makers and policy makers) with regards to healthcare IS as related to the business process of clinical care.
  9. Please describe to what extent healthcare IS in your organization is able to be measured against key desirable outcomes (e.g., reduced costs, improved efficiency, high quality of care, improved patient safety).

Location Domain

  1. What technologies (e.g. web) are used to mitigate the challenges of distance? Do you feel that technology is adequately able to mitigate these challenges? Can you please describe why or why not?

Organization Domain

  1. Describe your Center’s organizational structure as a whole.
  • Describe your overall health information vision and strategy:
  • How is health information used in the organization?
  • How does this information and the IS used to manage it contribute to accomplishing the organization’s overall mission?
  1. How are technology decision made at your center? For example, please describe how you arrived at your decision to participate in OCHIN as an IPM partner.
  2. What are the organization’s goals for improving the use/management of health information? How has this changed after OCHIN?
  3. Please describe the nature of the IS unit of your organization:
  • How is it funded and staffed?
  • What is its level of expertise?
  • What is its capability to provide end-user support alongside “back office” support?
  • How is it perceived by the users?
  • What is the current use of or need for outside technical assistance?
  1. What is the organization’s IS staffing capacity to meet its technology goals? Do you outsource?  If yes, what tasks?
  2. How much do you rely on OCHIN for IS expertise? Has OCHIN increased/decreased the IS staffing in your center?

Environment Domain

  1. How do you, with OCHIN and EPIC manage to comply with regulatory requirements (especially HIPAA privacy and transaction standards)?
  • How do you understand the regulations and the impact they have on your organization?
  • How do you stay informed of changes?
  • How does the consortium deal with HIPAA specifically?
  • Who is responsible for monitoring/auditing HIPAA compliance?
  • What challenges does HIPAA present vis-à-vis the consortium?
  1. Do you feel that there are adequate resources available for understanding and complying with HIPAA? If not, who do you feel would be the best provider of this type of guidance?
  2. Please describe other regulatory elements that drive technological decisions.
  3. Please describe any local, regional, or national cultural enablers or hindrances to healthcare IS and to community-based healthcare in general.
  4. Please describe any local, regional, or national political enablers or hindrances to healthcare IS and to community-based healthcare in general.
  5. Please describe any local or regional enablers or hindrances to healthcare information
  • State and federal government payment policies
  • Private sector payment policies
  • Resources
  • Interactions with other providers

Items for Follow-up, If we don’t already have them.
Center/Systems Background Information

  1. What is your center’s federal designation … CHC? M/RHC? SBHC? HCH?
  2. How many sites does your center have?
  3. How many patients do you see on an annual basis, what are the characteristics of your patients in terms of case mix and payor?
  4. Please describe overall how you access health information system resources …
    • What do software/resources do you get through your relationship with OCHIN and access to the OCHIN WAN?
    • What do you do in house?

Applications Dimension

  1. What Non-OCHIN software do you currently use? For example, what commercial general productivity software (e.g. desktop applications such as MS Word) does your center use on a regular basis?

Data Domain

  1. What are your major domains of data (e.g., clinical, financial)? What data is created in the course of your In what ways to you share/exchange data with OCHIN? Other sources? By what means?
  2. In what ways do you use interoperability standards to exchange information (e.g. HL7 and other messaging standards)?
  3. In what ways do you ensure confidentiality/privacy with regard to your data? (See also “External Factors and Environment” Domain.)
  4. Please describe how data is stored operationally (e.g. database platform(s)).
  5. Please describe how data is archived and stored so that an electronic record is preserved. Are the policies and procedures in place with regards to data archives to guard against technology obsolescence and the preservation of knowledge over time

Technology Domain

  1. What type of hardware (e.g., servers, PCs, laptops, PDAs) is typically used at your center?
  2. What type of operating systems?
  3. Please describe your physical plant (e.g. cabling)
  4. Describe your non-OCHIN network (LAN, WAN) architecture.
  5. What kind of connectivity do you provide to the Internet (in terms of bandwidth and access points)?
  6. Do you have a strategy related to wireless communications?
  7. Do you provide any other connectivity options (e.g., proprietary networks, local modem pool)?
  8. Please describe your technical security architecture and disaster recovery capabilities:
    • Processes, Policies, Procedures
    • Technology (e.g. firewalls, Internet VPNs, storage/archival systems for electronic records)

OCHIN Integrated Practice Management Centers
Note: skip questions answered above
Information System Characteristics

  1. What is your organization’s mission and how do IS play a role?
  2. What is your center’s systems related budget?
  • As a percentage of your overall budget?
  • How much of this are costs associated with OCHIN participation?
  • Has OCHIN increased or decreased your investment in systems?
  • How are financial decisions related to IS made at your center?
  1. How does your clinic finance OCHIN related expenses?
  2. Please describe your decision to participate as a IPM partner
  3. How is your center different from other primary health care providers or CHCs, and how what IS needs follow from those differences?
  4. Please describe overall how you access health information system resources …
    • What do software/resources do you get through your relationship with OCHIN and access to the OCHIN WAN?
    • What do you do in house?

Applications Dimension

  1. What are the major benefits of the OCHIN software applications to your center, how would you prioritize their importance to overall center objectives?
    [PLEASE QUERY SPECIFICALLY ON EACH OF THESE…]
  • scheduling and resource management
  • claims submission, billing — including under capitated arrangements
  • tracking eligibility and insurance status and verification
  • administrative reporting to HRSA and other federal agencies
  • tracking payments and accounts receivable
  • other administrative and financial functions
  • Eligibility tracking for Medicaid/SCHIP
  • Tracking of specific outcomes or exposures (e.g., birth weight, exposure to environmental hazards)
  • Availability and utilization of specific “free” resources (e.g., pharmaceuticals)
  • Other features?
  1. Are there other systems applications that you would like to see initiated? How would you prioritize these?
  • electronic medical record or e-health record
  • clinical decision support applications
  • others?
  1. What Non-OCHIN software do you currently use? For example, what commercial general productivity software (e.g. desktop applications such as MS Word) does your center use on a regular basis?
  2. What application development technologies and methodologies does your organization use?  What systems have you developed vs. bought off-the-shelf? How was this decision made?
  3. What is the future plan for the application architecture (individual applications as well as integrated systems)? How are future plans made and then revised over time? How much of this is driven by OCHIN decisions?
  4. How do you use/plan on using data resources available through your participation such as the Master Patient Index or data warehouse reports?

Technology Domain

  1. What type of hardware (e.g., servers, PCs, laptops, PDAs) is typically used at your center?
  2. What type of operating systems?
  3. Please describe your physical plant (e.g. cabling)
  4. Describe your non-OCHIN network (LAN, WAN) architecture.
  5. To what extent has OCHIN standardized hardware used at your center?
  6. What has been your experience working within the OCHIN network to access/use Epic practice management software? (e.g., ease of connectivity, benefits from enhance functionality, support, initial start-up etc.)
  7. What are your strategic plans for updating it, assuming more applications will operate in a more broadly networked environment? 
  • Describe any integration challenges/successes across the consortium with respect to networking and infrastructure.
  1. What kind of connectivity do you provide to the Internet (in terms of bandwidth and access points)?
  2. Do you have a strategy related to wireless communications?
  3. Do you provide any other connectivity options (e.g., proprietary networks, local modem pool)?
  4. Please describe your technical security architecture and disaster recovery capabilities:
  • Processes, Policies, Procedures
  • Technology (e.g. firewalls, Internet VPNs, storage/archival systems for electronic records)

Process Domain

  1. In general how are technology decisions made at your center? How is the process consistent with center goals?
  2. How are requirements collected, technologies or vendors selected, and “build vs. buy” determined?
  3. Specifically what do you rely on vendors or consultants to provide in this area? What do you rely on OCHIN to provide?
  • IS strategy, technology selection
  • implementation, systems support 
  1. How would you characterize your relationship w. vendors and OCHIN?
  2. Describe process for supporting user community ( help desk, on call system administrators, ad hoc)? How much of this function does OCHIN provide?
  3. Describe how you learn about new technologies and technology best practices. How do you share this knowledge with your colleagues within the CHC and the broader consortium?
  4. What kind of training occurs to help keep your IS staff current?
  5. Describe any formal processes your organization has for insuring that policy and clinical procedures are working in concert with and are appropriately balanced with healthcare IS.
  6. Please describe the organizational relationship between the key actors in your organization (e.g., clinicians, administrators, patients, technology professionals, decision makers and policy makers) with regards to healthcare IS as related to the business process of clinical care.
  7. Please describe to what extent healthcare IS in your organization is able to be measured against key desirable outcomes (e.g., reduced costs, improved efficiency, high quality of care, improved patient safety).

Data Domain

  1. What are your major domains of data (e.g., clinical, financial)? What data is created in the course of your In what ways to you share/exchange data with OCHIN? Other sources? By what means?
  2. In what ways do you use interoperability standards to exchange information (e.g. HL7 and other messaging standards)?
  3. In what ways do you ensure confidentiality/privacy with regard to your data? (See also “External Factors and Environment” Domain.)
  4. Please describe how data is stored operationally (e.g. database platform(s)).
  5. Please describe how data is archived and stored so that an electronic record is preserved. Are the policies and procedures in place with regards to data archives to guard against technology obsolescence and the preservation of knowledge over time?

Location Domain

  1. What technologies (e.g. web) are used to mitigate the challenges of distance? Do you feel that technology is adequately able to mitigate these challenges? Can you please describe why or why not?

Organization Domain

  1. Describe your Center’s organizational structure as a whole.
  • Describe your overall health information vision and strategy.
  • How is health information used in the organization?
  • How does this information and the IS used to manage it contribute to accomplishing the organization’s overall mission?
  1. How are technology decision made at your center? For example, please describe how you arrived at your decision to participate in OCHIN as an IPM partner.
  2. What are the organization’s goals for improving the use/management of health information? How has this changed after OCHIN?
  3. Please describe the nature of the IS unit of your organization:
  • How is it funded and staffed?
  • What is its level of expertise?
  • What is its capability to provide end-user support alongside “back office” support?
  • How is it perceived by the users?
  • What is the current use of or need for outside technical assistance?
  1.  What is the organization’s IS staffing capacity to meet its technology goals? Do you outsource?  If   yes, what tasks?
  2.  How much do you rely on OCHIN for IS expertise? Has OCHIN increased/decreased the IS staffing in your center?

Environment Domain

  1.  How do you manage to comply with regulatory requirements such as HIPAA?
  • How do you understand the regulations and the impact they have on your organization?
  • How do you stay informed of changes?
  • How does the consortium deal with HIPAA specifically?
  • Who is responsible for monitoring/auditing HIPAA compliance?
  • What challenges does HIPAA present vis-à-vis the consortium?
  1.  Do you feel that there are adequate resources available for understanding and complying with HIPAA? If not, who do you feel would be the best provider of this type of guidance?
  2.  Please describe other regulatory elements that drive technological decisions.
  3.  Please describe any local, regional, or national cultural enablers or hindrances to healthcare IS and to community-based healthcare in general.

 

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