As mentioned above, site selection for the current project depends largely on the presence of ongoing activity related to building health information system capacity and infrastructure among consolidated health centers. As such, many of the sites selected are States or local areas where consolidated health centers and other safety net stakeholders are collaborating around community, State or regional approaches to enhancing information system capacity. This site visit focused on two of these collaborations: CCNV, a for profit management services organization providing business and systems support to consolidated health centers and other providers throughout the State, and REACH, a smaller initiative focused on supporting safety net care in the Richmond metropolitan area. This section of the report describes both of these initiatives in greater detail.
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3.1 The Community Care Network of Virginia
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This site visit focuses primarily on health center experience working with the Community Care Network of Virginia (CCNV), a for-profit provider network of safety net health centers and small private practices incorporated in 1996 and supported through federal grants and revenue-generating services. CCNV’s activities range from provider credentialing to establishment of a central billing office and, importantly for the current project, the establishment of a common platform for accessing practice management software through a subsidiary called Comcare, LLC. Although the consortium has considered the potential for implementing an electronic medical record (EMR) as well, they indicate that their current funding cannot support such an initiative. The organization is owned and managed by 17 consolidated health center shareholders, who elect CCNV’s Board of Directors. In addition to these 17 shareholder consolidated health centers, the network includes three participating providers or smaller private primary care practices that are customers of CCNV services. Three of the four consolidated health centers in Richmond are members of CCNV.
Organizational structure and staffing. In 1996, CCNV was governed by a nine-person Board of Directors. VPCA staff played a prominent role in early organizational activities, but after grant funds were secured the search for full-time CCNV staff began. A Chief Executive Officer was hired in 1997. Currently CCNV supports 21 full-time employees (FTEs) and three independent contractor staff. The Board of Directors is still made up of nine members who are all shareholders and serve for three year terms with staggered classes. Bylaws require 51 percent governance 4by health centers, but so far health centers have maintained 100 percent control. The remaining shareholders who do not have a representative elected to the Board are assigned to the Board member from their region for direct representation.
CCNV’s corporate senior staff members include a CEO, a CIO, and the Directors of the major programs: medical management, contracting, credentialing, and the central business office. A compliance analyst ensures that the network members are in compliance with government mandates and provides coding audits, training, and development activities. Currently, CCNV serves 19 health centers. The 3 additional participating providers are private physician practices or clinics that are located outside the service areas of the owner health centers and have hired CCNV to manage their practices — a funding source that contributes to CCNV’s outside income stream. By adding these participating providers, CCNV hopes to create economies of scale, further spreading the fixed cost of application services, and increasing savings for member centers.
CCNV Origins. In 1994, Virginia applied for and received a federal waiver to transition their fee-for-service Medicaid program to a mandatory managed care model. Through the VPCA, health centers in the State sought to organize around meeting the administrative and policy requirements of their new environment. The substantial resources and expertise needed to deal with these changes went beyond those currently available through the VPCA or the health centers themselves, so the steering committee decided to establish a separate health center network which became CCNV.
In preparation for starting the network, each participating health center contributed $1,500 of seed money. After organizational structuring and marketplace analysis, the centers reached the conclusion that they needed to form a new corporation, separate from the non-profit VPCA entity, which would give health centers corporate flexibility in the marketplace. This decision resulted in the formation and incorporation of CCNV as a Virginia stock organization in November 1996. All of the Section 330 health center grantees in the state purchased stock in the organization.
Funding sources. Once CCNV was incorporated, all 17 community health centers in the State became owners of the organization, contributing $6,000 in stock options as start-up money to pay for the shares. CCNV received an ISN grant in 1995, which added $217,000 to CCNV’s capital base. Their annual operating budget has grown from $122,000 in 1996 to its current level of around $1.5 million. Revenue is 17 percent grant-driven, 37 percent driven by user fees, and the remaining 46 percent stems from commercial activities. Since its inception, the organization has received continued grant support from the Bureau of Primary Health Care including the ISDI and SIMIS developmental network grants and their predecessors. Outside income is drawn from credentialing activities, financial management activities, and practice management technology provided to health centers and private physician practices. These activities are described in greater detail in the following sections.
State-wide practice management history. During CCNV’s early development, many of the state’s major health centers were using stand-alone practice management software owned and managed by a local vendor, Monet. In late 1998, Monet notified the health centers that it would be pulling out of the market due to issues surrounding Y2K, leaving the centers faced with the need for an alternate practice management vendor. Although Monet recommended that health centers use Medical Manager as their new practice management provider, CCNV leadership decided to conduct a vendor scan and selection based on the centers’ perceived needs. The network decided to take advantage of the federal government’s growing interest in health centers’ use of information technology and, in talks with the BPHC, laid out a plan for acquiring technology as an integrated network.
Vendor selection process. Initially, CCNV used consultants to learn about different applications and to develop criteria for evaluating options. CCNV sent out 27 RFPs to targeted vendors and received 14 proposal responses. A steering committee of health centers that did national review work scored every RFP against the evaluation criteria to narrow down the potential candidates. Four potential vendors conducted demonstrations of their products concurrently on both ends of the state, rotating between Richmond and Roanoke, Virginia. The health centers then scored each vendor and requested Best and Final Offers asking each of the four finalists to address specific questions. After extensive negotiation, Companion Technologies (with its practice management software suite Megawest) was selected as the winning vendor.
Following the acquisition of the software, in 1999, the decision was made to set up a subsidiary limited liability company (LLC) called ComCare to acquire, house and manage the statewide practice management system. This decision was made in order to protect the grant assets from any risks associated with supporting practice management, as CCNV would be its sole member and all assets would flow through CCNV. CCNV, via ComCare (with assistance and services provided by Companion Technologies), has implemented the MegaWest practice management suite at health centers in Virginia and Georgia. The MegaWest application is accessed via the Internet via a virtual private network (VPN) connection to a central server where the application and associated data are stored and maintained.
Non-Virginia Activities. CCNV provides credentialing and network services support to several health centers and one network in six other states. Credentialing services are provided to health centers in four of these states, including New Mexico, Delaware, Iowa, and Kentucky. These activities represent a major business line for the network. CCNV also provides training and Level 1 Help Desk Support for the Georgia Primary Care Association Management Information System Network. This strategy allows CCNV to use the business-related services they provide for their health center members and expand that model to out-of-state health centers and networks to generate revenues and keep costs to shareholder health centers low down.
ComCare Technical Infrastructure and Services. The ComCare approach is built on the application service provider (ASP) model in which an application and its associated data is hosted and maintained at a central location. This system allows health centers access to the practice management application and data using a virtual private network without having to install and maintain software and data at their own site. In the case of CCNV, there are some nuances to this model: Companion Technologies is the ASP vendor, and MegaWest is the hosted application. ComCare procures and manages the services received from Companion Technologies, and in delivers the services to the centers. This arrangement was designed so that ComCare could add value as an intermediary between the centers and the vendor itself.
The value added extends to both the centers and to Companion Technologies, as the centers are able to focus on their mission (while receiving assistance from ComCare) and Companion Technologies is able to take advantage of the many centers being represented by a single entity. As Companion Technologies is the ASP vendor, health centers using MegaWest access the vendor’s server via the Internet — hosted at a Companion Technologies site — using a virtual private network (VPN) connection. Approximately 20 health centers, over 48 individual clinic sites (including 2-3 health centers located outside the State of Virginia) and 400 users are provided with access to MegaWest using this system.
In addition to providing access to the practice management system, ComCare provides some support to health centers in ensuring connectivity to the Internet. Health centers we interviewed typically access the Internet (and, thus, the ComCare VPN) via T1 or DSL connections with local providers. All CCNV connections to the MegaWest server are routed through a central communications hub in Richmond allowing for a single circuit for communication with the vendor’s main South Carolina server. In many cases, shareholder health centers initiated the creation of a high speed Internet connectivity infrastructure specifically to access MegaWest software. ComCare is responsible for managing telecommunications costs associated with use of the software and typically helps health centers ramp up for enhanced connectivity if necessary. The telecommunications fees and maintenance costs are passed on to health centers. Health centers also pay for any upgrades to operating systems, desktops or network hardware necessary for building out their high speed Internet connectivity infrastructure.
In addition to securing access to the application and associated data, ComCare also provides one level of user support to health centers using the MegaWest software. ComCare mans a “Level 1” Help Desk to assist users with basic software and hardware issues related to their connectivity to the MegaWest server and use of the software. Under current staffing, one technician employed by ComCare is responsible for responding to inquiries coming into this line from all 400 users. In many cases, advanced questions regarding software functionality are referred to a “Level 2” Help Desk that is provided by Companion Technologies.
Relationship with Companion Technologies. While CCNV understands that the level of customization that can be provided by outside vendors is limited, they expect Companion Technologies to act as “a partner.” Overall, CCNV characterizes the relationship as mutually beneficial, noting that the initiative provided Companion Technologies with a valuable entrée into the community health center market. However, there was also a general feeling among CCNV respondents that Companion viewed the Megawest software (which was created by a separate company later acquired by Companion) as a relatively minor product and not a priority for internal research or marketing investment. We discuss the implications of this perception in greater detail under Conclusions.
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3.2 Richmond Enhancing Access to Community Health Care
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“Richmond Enhancing Access to Community Healthcare,” or REACH, is a partnership between more than 13 public and private health stakeholders in Richmond, including safety net health centers (both CHCs and free clinics), an academic health center, the City Health Department, the Bon Secours Richmond Health System, HCA Healthcare, the Central Virginia Health Planning Agency, and the Richmond City Department of Social Services. REACH’s stated mission is to increase access to a comprehensive continuum of quality healthcare services for persons who are uninsured or underinsured. The consortium, which was incorporated in 2002, provides a resource for data about health care for uninsured people, assesses community health needs, assists low-income individuals in applying for low cost health care options, and coordinates both non-technological and technological efforts across its partnering providers. Services provided to REACH partners include site-specific training, user groups hosting, limited on-site technical support, maintenance and software upgrades of software, and booster trainings. The majority of these services are coordinated through the MORE Access software system.
MORE Access. REACH’s MORE Access (Medical Online Resource Enhancing Access) system, which was described by REACH respondents as the “hub” for the organization’s IT initiatives, was designed to facilitate eligibility assessment and patient information sharing, provide a foundation for data warehouse, and serve as a communication tool. MORE Access was built for REACH by a local vendor, XPerts that was selected during a competitive procurement process in 2001 following the consortium’s reception of an HCAP grant. The software collects and maintains data on clients and encounters, including demographic and financial information (including client tax forms). It also supports automated eligibility determination for Medicaid and other State and local assistance programs. Like CCNV, REACH provides its partners with access to the MORE Access software via the Internet using VPN connections.
Although MORE Access is primarily a data entry system for patient financial and demographic information, it also contains built-in applications for data warehousing, GIS mapping, document imaging, financial screening, eligibility determination, and limited report generation. REACH staff anticipate that the system will improve collaboration between providers, for instance by enhancing understanding of patient utilization across different health centers.
Interfaces. Important features of MORE Access that enhance the potential for its use among a wide range of community providers are built in interfaces that allow the online system to “talk” with health center practice management systems. To date, REACH has developed two specific interfaces. One is with ComCare’s Megawest system, as many REACH partners are also CCNV participants; the other is with a separate practice management program used by a health center that is part of the Virginia Commonwealth University Health System (VCUHS), where the MORE Access servers are housed.
The need for the Megawest interface was recognized early on in the program’s development, as one of REACH’s main goals is to reduce duplication of efforts across the region’s health center networks. ComCare participated in some of the discussions around this interface. REACH paid Companion Technologies to design the actual system, which creates a text file incorporating the data elements from Megawest that is then uploaded into MORE Access. This process is not seamless: the text file must be extracted and made available on the ComCare server, then copied to a ComCare staff member’s PC, then transferred via SSH Secure File Transfer Client to the ftp server at Virginia Commonwealth University, where it can finally be uploaded to MORE Access. Although there has been some discussion about a more direct interface (one that does not require multiple active processes), this has not yet been designed.
Data entered by health centers is stored and maintained in an Oracle database. REACH leadership envisions the database and reporting infrastructure as a precursor to a community level data warehouse that could produce basic encounter and client level information from across the community, as well as support individual health center UDS reporting.
Early Experience. REACH is in the process of re-implementing health center utilization of the system this spring, having experienced problems with the eligibility determination function during the initial rollout in 2002. The revamped MORE Access system is currently being rolled out at the consortium’s three participating health systems and will soon go live at the community-based health centers across Richmond, as well as the Richmond City Department of Public Health. REACH respondents explained that their go-live strategy called for implementing the new MORE Access at the health systems first to facilitate the development of a training package for the centers that would correspond exactly with the needs and requirements of the health systems. They have encountered a few setbacks with one of the health systems, but anticipate bringing the health centers on-line towards the end of April.
Interestingly, REACH respondents indicated that they had had no knowledge of CCNV during their consortium’s initial stages. They felt that this was in part due to the high staff turnover among the local health centers. The respondents regretted not having known about CCNV’s existence during the start-up, but they thought that the two consortiums would be collaborating more in the future. REACH does currently work with the VPCA and the state Primary Care Office. In the section that follows, we present an overview of health center experiences working with both CCNV and REACH. Exhibit 1 below provides an overview of State and local initiatives described above and their relationship with CHCs in Richmond and statewide.
Exhibit 1. Overview of State/Local CHC-focused IT Initiatives
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