Tools for Clinics: C A L I FOR N I A Four Health Centers Use Chronic Disease Management Systems H EALTH C ARE F OU NDATION Introduction South Central Family Health Center Many providers are finding value in using Located in a densely populated urban area of chronic disease management systems (CDMS) for Los Angeles is the South Central Family Health population-based care management. A CDMS Center (SCFHC). Diabetes is an epidemic in this tracks multiple chronic conditions such as asthma, community of 1.1 million. CEO Felix Aguilar Issue Brief diabetes, hypertension, and depression, and can estimated that at least one-third of SCFHC’s collect and present data for thousands of patients patients are affected. Since April 2004, the center at a time. Also known as an advanced registry or has participated in the Bureau of Primary Health population health management system, a CDMS Care’s Health Disparities Collaborative, which can improve preventive care by automating recall includes use of the Patient Electronic Care System processes based on periodicity, risk factors, or lab (PECS) registry for managing diabetes patients. All results. It can enable providers to scale up their providers use the flow sheets and data generated quality improvement processes to a level that is from the registry. The population in the PECS unattainable through traditional chart audits. registry has grown from 150 in 2004 to 625. This issue brief profiles four health centers Diabetic Program Coordinator Sheree Gordon in California across a continuum of CDMS achieved a great deal with this technology system implementation and use. The populations despite some early resistance from some providers. served by these health centers are low-income, “At first, a lot of the providers didn’t like the forms underserved, and most vulnerable to disparities in that were coming out of PECS,” she said. “But treatment for chronic conditions. Each case study we kept stressing the urgency of…collecting the demonstrates some common principles and success data in a uniform way, and why the information factors as well as individualized approaches to was so valuable despite an awkward format. We quality improvement. were very persistent.” Gordon oversees PECS “ he Diabetic Group Session is very vital. Before I started attending the class I did not T understand what diabetes was. I was not taking care of myself the way I should to make my life span longer. I feel empowered now because I know how to check my blood sugar, I’m taking my medication the way the doctor wants me to, and I now exercise 30 minutes a day.” — Manuel Santos, SCFHC patient D ecember 2008 data entry for accuracy and timeliness. Charts are flagged reinforcement for patient self-management, Gordon with a blue folder to indicate a patient classified as solicits donations from local merchants and provides “uncontrolled”— defined by SCFHC as an HgA1c greater incentive gift packs; each includes a pedicure set, sugar- than 7. free snacks, and a glucose monitor. Under Aguilar’s leadership, SCFHC has expanded Aguilar said data and technology help the staff to arrive at diabetes care from individual visits and patient education concensus-driven decisions. “I don’t push changes because sessions to a model of diabetic disease management visits. the providers are the agents who have to carry them On Tuesdays and Saturdays, 15 to 35 patients attend a out,” he said. “Technology systems help us to validate the session that includes education, lab tests (including an degree to which the changes have been successful, but on-the-spot check from a portable HgA1c machine), patient response is also a big influence on our decision- foot exams, and retinal screenings. Ophthalmology making.” consultations are provided via a store-and-forward teleophthalmology program. Patients also receive peer SCFHC plans to obtain a more advanced CDMS support and a consultation with a provider. through a foundation grant. “We’ll be so much more efficient,” said Information Technology Manager Rodrigo Self-management goals are tracked in PECS and Ibarra. “With interfaces to our practice management information from the group visit guides each individual system, both our reference labs and our inhouse pharmacy visit. “Education and self-management goals are integral system, we can expand tracking efforts to hypertensive to better patient care,” said Aguilar. “Patient feedback patients and women’s health programs with less effort tells us they are happy with the education they receive. than we now expend on the diabetes program data entry.” They are enthusiastic about the visits and feel empowered Aguilar and Ibarra said CDMS has brought the center a by the education. Many times they weren’t aware of the step closer to electronic health records. It also promotes disease state and what they can do at home.” To enhance the organization’s plan to integrate home visits and a South Central Family Health Center Location: Los Angeles, CA Mission: To improve the quality of life for the diverse community of inner-city Los Angeles by providing affordable and comprehensive health care and education in a welcoming multicultural environment. Services: Comprehensive health care for adults and children, including screening, diagnosis, treatment, health maintenance, preventive care, prenatal, well-child and adolescent care, adult education/counseling, behavioral health services, and outpatient care. Dispensary and lab on premises. I n f o r m at i o n s y s t e m Product(s) D at e i m p l e m e n t e d Practice management system MegaWest 2004 Site type: Urban CDMS PECS 2005 FQHC: Yes Number of sites: 2 EHR N/A N/A Annual patients: 10,151* Lab interface Quest, WestCliff Planned Q1 2009 Annual encounters: 44,362* Other interfaces CarePoint, HealthPort Planned Q4 2008 FTE providers: 15.07† i2iTracks, RxAssist *2007 OSHPD data. 2007 OSPHD data. FTE primary care providers include: physicians, PAs, FNPs, certified nurse practitioners, certified nurse midwives, nurses, dentists, psychologists, LCSWs, other providers † billable to Medi-Cal, and other certified CPSP providers. 2  |  California HealthCare Foundation “promatora” (community health worker) program into Know What You Want diabetes care management. Medical Director Christopher Rodarte is the clinician champion for the project. He said it is critical to know Family HealthCare Network what is desired from a CDMS before the process begins: Family HealthCare Network is a ten-site federally “Everyone has their own perspective on how the system qualified health center located in Tulare County, in the should be used and what they want out of it. These needs heart of California’s Central Valley. Implementing a have to be acknowledged and reconciled.” Rodarte said CDMS was delayed while the organization upgraded its an administrator may only need to know that diabetic practice management system and stabilized its billing patients are getting their HgA1c measured every six processes. “You need to know how much change and months, but a clinician needs to know how those values chaos your organization can deal with at one time,” are trending. “If an HgA1c remains at 7 over and over, said Norma Verduzco, operations project director. In that tells me I’m not doing enough for the patient,” said September 2008, Family HealthCare Network launched a Rodarte. “We may be meeting standards of care from pilot of i2iTracks, an advanced CDMS. The health center a reporting perspective, but is that enough?” Unless plans to begin with diabetes management and expand to the data are used to drive the care process, emphasizes other chronic diseases. Rodarte, health centers are “buying a Porsche and just driving it around the block.” Verduzco and Information Systems Project Director Blanca Schmitz manage daily activities while updating Two years ago, Family HealthCare Network restructured the project plan that guides implementation, including in order to standardize clinic processes and establish data interface development and testing, workflow analysis, quality, a decision that now serves it well in its CDMS data conversions, and training. “In community health implementation. Director-level positions were created centers, everyone wears many hats,” said Ruben Chavez, to ensure greater accountability. A clinic manager was vice president of operations. “We realized that if we didn’t appointed for each site and a database analyst was hired dedicate resources specifically for management of strategic to manage data, run data audit reports, and keep accounts projects, we’d be setting up these projects to fail. It’s not accurate. This process focuses on quality assurance for something you can ask someone to do in their spare Uniform Data System (UDS) measures but also identifies time.” duplicate patients, inactive patients, and monitors other data elements from demographic profiles (e.g., language The project is run by a cross-departmental team of code, birth date errors). director-level staff, with help from front-line staff as needed. “The CDMS is an organization-wide system Each month, a “mud list” of accounts with erroneous that will be used in some way by nearly everyone, so or suspicious data is produced. The report is sorted by the project team must be truly multidisciplinary,” said site, and clinic managers are responsible for correcting Verduzco. “Staff must be engaged and take ownership site accounts. Accounts are then audited by another staff of their assigned areas to make the implementation member to verify accuracy and completeness. Director of successful.” To ensure good communication, the project Operations Nancy Banuelos estimated that nearly 10,000 co-directors involve supervisors through public site duplicate accounts have been corrected in two years. meetings. Said Schmitz, “We need people to know that She emphasized addressing data quality on the front end i2iTracks is not a technology project — it’s a tool to and setting expectations for accurate data during new improve care processes.” employee orientations. “There is a quality mindset that Tools for Clinics: Four Health Centers Use Chronic Disease Management Systems  |  3 must be created to ensure clean data,” said Banuelos. each site will have a super-user who can provide frontline “Processes and systems have been created to communicate support. this to staff and supervisors. If data is entered correctly the first time, there is no need to go back and clean it, The project team has taken a hands-on approach to which is time-consuming and redundant.” Consistent developing interfaces and data conversion. Schmitz problem areas are brought to the attention of the staff, organized a conference call with i2i Systems (CDMS), and data accuracy trends are shared in monthly meetings HealthPort (practice management), and Quest (lab with clinic managers. Director of Quality Improvement results). Data elements from HealthPort to i2iTracks Marisol de la Vega said the next major data quality were discussed and mapped. To verify the accuracy of initiative will focus on accurate coding of encounters. the conversion process, a small, 5,000-record test file was converted and examined. Although the spot-checking Although some smaller organizations have dedicated and verification of information took hours to complete, care coordinators at each clinic site to enter the data it resulted in the health center being well prepared for elements not automatically interfaced to i2iTracks, Family the full data conversion. The test highlighted inaccuracies HealthCare Network has instead focused on intensive and expanded the team’s knowledge of the process and training for its medical assistants, known as patient care its possibilities. It also allowed the team to estimate the assistants, or PCAs. The project team members agree that amount of time and system memory that would be PCA buy-in is crucial. Training Director Roger Kirton required for the full 200,000-record conversion. and five staff members designed an intensive, role-specific training program with an eight-module curriculum for Another interface will be developed to send demographic PCAs, and a 22-module training curriculum for front data from HealthPort to Quest. Lab technicians will be office staff. Each clinic manager will be fully versed in the able to enter information on the 60 percent of patients set-up, data standards, and quality improvement processes whose lab specimens are processed locally, without that the CDMS automates. As the system is rolled out, having to re-enter demographic information at the risk Family HealthCare Network Location: Visalia, CA Mission: We provide quality health care to everyone in the communities we serve. FHCN serves nearly 20 percent of the population in Tulare County, making us the county’s largest provider of primary health care services. Services: Preventive, acute, and chronic care services, including family medicine, internal medicine, pediatrics, OB/gyn, family planning, dentistry, clinical laboratory, radiology, mammography, ultrasound, integrated complementary alternative medicine, pharmacy, health education, translation, integrated behavioral health, nutritional counseling, community outreach, and transportation services. I n f o r m at i o n s y s t e m Product(s) D at e i m p l e m e n t e d Practice management system HealthPort v11.07 Upgrade 2008 Site type: Urban/rural FQHC: Yes CDMS i2iTracks September 2008 Number of sites: clinical; 2 administrative 11 EHR N/A N/A Annual patients: 97,828* Lab interface Quest Pilot November 2008 Annual encounters: 389,234* FTE providers: 91.28† Other interfaces Dentrix July 2007 *2007 OSHPD data. 2007 OSPHD data. FTE primary care providers include: physicians, PAs, FNPs, certified nurse practitioners, certified nurse midwives, nurses, dentists, psychologists, LCSWs, other providers † billable to Medi-Cal, and other certified CPSP providers. 4  |  California HealthCare Foundation of data entry errors. Family HealthCare Network is highlight overdue action items such as retinal exams, foot the first health center to attempt this type of two-way exams, dental visits, and HgA1c checks. Because SYHC interface. “Interfaces are really a partnership between offers dental services, patients are encouraged to make all participants,” said Verduzco, “but in the end the dental appointments at checkout. accountability rests with us to make sure we get what we want.” Medical assistants have adapted to the new technology and workflow easily, according to Director of Nursing San Ysidro Health Center Margarita Espinosa. “Because they work as a care team, San Ysidro Health Center (SYHC) is a nine-site federally now they really feel like they are more involved in the qualified health center serving more than 65,000 patient’s heath,” she said. In fact, the visit summaries patients annually in the greater San Diego area. For a have contributed to improvements in average hemoglobin year and a half, it has been using a CDMS to manage A1c measurements from 8 to 7.7. CMO Weeks predicts, diabetes patients at its main clinic site and to enable “We’ll eventually want to have a patient visit summary for a comprehensive quality improvement program. After all patients.” seeing a demonstration of i2iTracks, SYHC eagerly moved forward with Chief Medical Officer Matthew Weeks as Remaining Roadblocks clinician sponsor and Quality Manager Gabriela Alvarado Some challenges persist. There have been data integrity as implementation manager. They quickly saw the value issues with the practice management system, leading to of using the program. “Traditional quality assurance problems with the interface between the two systems. programs are based on pulling doctors out of clinic to “It really hit me that the data quality in the PM system review charts,” said Weeks, “whereas i2iTracks makes peer was very poor,” said Weeks. In addition, PECS data review so much easier. The number of chart pulls required entry error rates were between 7 and 8 percent, even is drastically reduced. Statistics show that each time you with graduate students entering the data. With medical pull a chart it costs between $5 and $10.” assistants doing the data entry into i2iTracks in the course of a busy day, clinic staff is concerned about higher error Like many federally qualified health centers, SYHC began rates. The clinic plans to address these issues before monitoring diabetes patients through the federal Health expanding the program to more patients. The team Disparities Collaborative, using PECS as its registry. views data integrity issues as an opportunity to clean up The target population has grown from 100 in the PECS the demographic and coding data that drive so many registry to nearly 400 monitored with i2iTracks over the decisions and processes. past year, with two providers participating. While working through data integrity, workflow, and Outreach to patients through appointment reminders conversion issues, SYHC has instituted innovations and letters is difficult because between 40 and 50 percent using searches and queries in the CDMS. Quality are returned due to bad addresses. Instead, SYHC Manager Gabriela Alvarado (who displays more than 40 focuses on being ready for each patient as he or she searches, or report templates, on her monitor) and Weeks comes through the door. Diabetes patients are assigned a discovered the power of querying the data collected tracking code that makes it possible to run a daily report through the practice management system and brought showing which diabetes patients will be seen the next day. into the CDMS through the interface. The intent is to Medical assistants working with providers in the diabetes set up these searches to correspond to the performance management program prepare visit summaries that standards they have derived from national guidelines, Tools for Clinics: Four Health Centers Use Chronic Disease Management Systems  |  5 HEDIS indicators, or internal standards of care, and run they will be seeing patients the next day who are eligible the reports for benchmarking purposes on a regular basis. for the Coverage Initiative. The query took him less than One search creates a list of new health plan members an hour to write and has the potential to increase patient requiring comprehensive health assessments so that they care as well as revenue. “We’ve taken i2iTracks out of the can be encouraged to make appointments. In addition, chronic disease pigeon-hole and turned it into a tool to i2iTracks is used to provide a weekly report for the promote insurance coverage,” said Weeks. Border Infectious Disease Surveillance project of the San Diego Department of Public Health. “If I didn’t have a system like this, I don’t know what I’d do,” said Alvarado. “Otherwise, I’d have to request reports from the IT “Most health care organizations devote less department, fill out a work order, make a formal request, than 1 percent of their budget to quality. and have it go into the queue to be prioritized with so Think about it: Would you buy a product many other requests. This is quick, easy, and I have the from a company that devoted less than information at my fingertips.” 1 percent of its budget to quality?” In addition, Weeks has developed a search protocol for — Matthew Weeks, M.D. the county’s Health Care Coverage Initiative, which targets diabetes and hypertension. The goal is to establish a medical home for enrollees who inappropriately Based on experience with rolling out a referrals module, utilize emergency departments. The CDMS query finds SYHC recommends going slowly. “We tried to do too patients who are scheduled for visits, are uninsured, and much too fast and it didn’t go well,” said Weeks. “You whose records indicate one or both targeted conditions. need to ask yourself, ‘How much disruption can the Typically, the search identifies 100 to 125 patients per organization handle?’” The next goal involves HIV care. week, representing 20 to 25 patients per day, who could “We’ve looked at the tables for HIV care in i2iTracks, and be eligible for this funding. Weeks alerts physicians that it’s really well-suited for this,” said Alvarado. San Ysidro Health Center Location: San Ysidro, CA Mission: To improve the health and well-being of our community’s traditionally underserved and culturally diverse people. Services: Primary and specialty care, OB/gyn, dental care, mental health services, hearing screening, nutrition services, pharmacy, vision screening, podiatry, HIV/AIDS services, immunizations, WIC, and preventive care. Enabling services include case management, eligibility assistance, health education, outreach, and transportation. I n f o r m at i o n s y s t e m Product(s) D at e i m p l e m e n t e d Site type: Urban Practice management system HealthPort January 2000 FQHC: Yes Number of sites: 9 CDMS i2iTracks June 2007 Annual patients: 52,050* EHR (1 site) HealthPort February 2003 Annual encounters: 182,764* FTE providers: 61.63† Lab interface Quest Diagnostics June 2007 *2007 OSHPD data. 2007 OSPHD data. FTE primary care providers include: physicians, PAs, FNPs, certified nurse practitioners, certified nurse midwives, nurses, dentists, psychologists, LCSWs, other providers † billable to Medi-Cal, and other certified CPSP providers. 6  |  California HealthCare Foundation Redding Rancheria Indian Health The data entry process was originally assigned to medical Services Center assistants as part of the patient visit process, but this Redding Rancheria Indian Health Services Center did not work well, and the clinic hired Trina Arreola, a in Northern California provides “womb to tomb” medical assistant, to serve as the “Tracks Officer.” “We care for members of Native American households. In needed someone who can read the chart, who knows 2002, Ron Sisson, senior health services director, saw what the data means, who had worked on the floor with a demonstration of i2iTracks. Sisson, who has an IT providers, who is detail-oriented and appreciates the background, understood the potential of this system to consequences of inaccurate or missing data,” said Sisson. help the health center obtain meaningful data from its All charts go through Arreola, who enters critical data practice management system. Redding Rancheria received elements from each encounter into the CDMS database. special help from i2i Systems to aggregate and present For the average 100 visits per day, data entry is accurate data in the format required by the Federal Government and up-to-date within 24 hours. Arreola said, “I can go Performance and Results Act (GPRA). Federal reporting, back to a nurse immediately and say ‘you forgot to mark notes Sisson, is critical to the clinic’s funding: “If there’s this.’ It serves as a great feedback loop while it’s still fresh no data, there’s no proof.” in their minds. It’s the teachable moment.” Based on the high prevalence of diabetes in Redding Award-Winning Program Rancheria’s population, the clinic obtained grant Family Nurse Practitioner Carrie McLaughlin, who heads funding to purchase the system in 2002. The diabetes the diabetes management efforts at Redding Rancheria, educator saw how i2iTracks could be used for abstracting is pleased with the impact on patient care. “Having one information from large volumes of charts, thereby freeing knowledgeable, dedicated person assigned to tracking up patient care resources. The CDMS was implemented data is extremely helpful and makes the process easier and with the diabetes educator serving as implementation reliable,” she said. Using the CDMS, Redding Rancheria lead and with support from Sisson, Medical Director Paul has built an award-winning diabetes management Davies, and IT Manager Ed McCarthy. program, earning them a place as one of 25 IHS clinics to participate in the national Healthy Heart Program. The importance of accurate data was obvious to the CDMS use has been expanded to immunization and team. “Tracks is immediately populated with all the women’s health. Next up: pharmacy management. data from the practice management interface,” said Quality Coordinator Hal Paquin, R.N., “and you will Medical Director Paul Davies acknowledges the important be amazed at what you find.” For example, the data role that technology has played in quality improvement. revealed that for two years, billers had submitted claims “Previously, to track diabetes required an annual chart for Td immunizations (tetanus, diphtheria) because that audit. It was tedious and you couldn’t manipulate the was easier than billing for Tdap immunizations (tetanus, data. In women’s health, Paps were being tracked by diphtheria, pertussis). The consequence of inaccurate index cards. Now, we have automated that process and data was like having “the Sword of Damocles hanging expanded our abilities.” The clinic also tracks childhood over you, but you just don’t know it,” said Paquin. The immunizations and does outreach to patients, contacting CDMS has enabled the clinic to move from what Paquin them via secure mailers to make sure children are up-to- describes as a passive approach to a much more active date with their immunizations. Because of the success of system of patient management, including screening for the childhood immunization program, the clinic is now depression, domestic violence, and all GPRA measures. Tools for Clinics: Four Health Centers Use Chronic Disease Management Systems  |  7 tracking prenatal care and adolescent immunizations. Conclusion Asthma patients will be next. A chronic disease management system is a very valuable tool, but for it to work, every employee must participate. “Ten years ago we were not providing true primary care,” Properly used, a CDMS becomes part of the daily said Davies. “We were putting out fires. There was no routine and organizational culture. Critical success factors active health maintenance, preventive care, or chronic include: disease management. Now we can say that we’re truly a K The organization must have a vision for quality primary care clinic.” improvement communicated by its leaders with clear lines of authority and opportunities for input from all After five years of experience, Paquin offers this advice to employees. new CDMS users: K Data have the potential to be used to improve .Define your goal. Pick one thing to track and give it 1 clinical, financial, and workflow processes on an adequate time for development. Set a timeline to see ongoing basis, and can be used in unexpected and whether the goal was met. creative ways. .Use a flow chart. You will identify all the “black 2 K Data are only as good as the individuals entering holes” through this process. them and, therefore, identifying dedicated resources and accountability structures is essential for data Sisson added “Be very proactive about the data. quality. Understand the cost of good data and build that into your operating expenses. Good data can cost more to Implementing any new system is best done incrementally maintain, but for research, grant funding, and patient and at a pace appropriate to each organization’s abilities. care, data is king. This is a core value of the health Because implementing a new system requires changes in center — data and technology systems are right up there.” workflow and culture, moving slowly but steadily is best. Redding Rancheria Indian Health Clinic Location: Redding, CA Mission: To develop and provide responsive, cost-effective, high-quality health care services that meet the needs of the Redding Rancheria Tribal members and other Native American Indians residing in the service area. We are committed to excellent care, a compassionate, respectful attitude, and full involvement of the patient and family in health care decisions. Services: A full spectrum of men’s and women’s health, behavioral health, contract health services, outreach programs, nutritional services, diabetic education, pharmacy, transportation, substance abuse counseling, Indian child welfare, and traditional healing. I n f o r m at i o n s y s t e m Product(s) D at e i m p l e m e n t e d Practice management system NextGen May 2007 Site type: Urban FQHC: No CDMS i2iTracks March 2002 Number of sites: 1 EHR None Annual patients: 5,000 – 7,000* Lab interface LabCorp/i2i January 2007 Annual encounters: 16,000 –18,000* FTE providers: 12† Other interfaces Pharmacy/i2i January 2007 *2007 OSHPD data. 2007 OSPHD data. FTE primary care providers include: physicians, PAs, FNPs, certified nurse practitioners, certified nurse midwives, nurses, dentists, psychologists, LCSWs, other providers † billable to Medi-Cal, and other certified CPSP providers. 8  |  California HealthCare Foundation Author SA Kushinka, M.B.A., is co-founder and principal of Full Circle Projects, Inc., a San Francisco-based consulting firm whose mission is to help community health centers and safety-net providers improve quality of care and delivery efficiency through the effective use of technology. About the F o u n d at i o n The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. Tools for Clinics: Four Health Centers Use Chronic Disease Management Systems  |  9