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September 29, 2008

It Takes a Community
By Tracy Meadowcroft
For The Record
Vol. 20 No. 20 P. 24

Despite being on opposite sides of the country, Camden, N.J., and northern California share a common trait: Each has adopted electronic technology to help improve healthcare for its underserved populations.

When questions arise about what keeps healthcare organizations from adopting electronic technology in their facilities, providers and administrators can offer numerous answers, including workflow disruptions, a lack of buy-in from staff members, concerns about implementation costs, and too much time required for training. And if the obstacles appear insurmountable for facilities serving the general population, what about those serving primarily low-income populations, people who often jump from one healthcare facility to the next to receive treatment and usually don’t have a primary care physician?

Across the country, these types of organizations are steadily finding ways to implement technology in the quest to help those who may have the most difficulty gaining access to proper medical care.

Born Out of Frustration
During the past several years, Camden, N.J., has experienced its share of problems. Slightly more than 10 square miles in area with about 80,000 residents, Camden was named the country’s most dangerous city in 2004 and 2005 based on its crime rates. Also, approximately one third of the residents live below the poverty line, and 40% speak a language other than English. In the midst of such circumstances, obtaining effective healthcare treatment has proven to be a challenge not only for the city residents but for the members of the healthcare community as well.

But what started as informal breakfast meetings among healthcare providers—many of whom were frustrated with the state of healthcare in the city—has now developed into an organization trying to improve the quality of healthcare for everyone in Camden, especially for those who have difficulty helping themselves. Established in 2002, the Camden Coalition of Healthcare Providers, a nonprofit, multistakeholder organization, is overseen by a 17-member board of directors representing all of the city’s major healthcare institutions, as well as several neighborhood-based primary care practices.

The coalition’s first step was to work with the local data organization CAMConnect to establish what is now the Camden Health Database. “We started out by building a healthcare database, and we managed to get a research agreement with each of the institutions so they would give us names, addresses, dates of birth, dates of admission, dates of discharge, all the diagnoses codes, insurance information, and charges and receipts for every Camden city resident who went to any of the hospitals, so any ED [emergency department] visit shows up in the database,” explains Jeffrey Brenner, MD, a member of the coalition and of the family medicine department at the Robert Wood Johnson Medical School. “The value of doing that and starting out with this data was that we could begin to quantify the inefficiency and the cost of fragmentation, the cost of the healthcare system itself not serving the needs of the residents.”

The Camden Health Database, which was built using Microsoft Access software, currently contains information about city residents’ hospital visits between 2002 and 2007. “The great thing about it [Microsoft Access] is this is like off-the-shelf, simple technology,” Brenner says. To ensure the privacy and security of patients’ personal information, the database is well protected and “lives on one hard drive locked in a cabinet every night behind two locked doors next to a computer desk. Only two people have access to the raw data,” according to Brenner.

Another program called LinkageWiz connects the data supplied by the various healthcare institutions in Camden, making it easier to identify healthcare trends and match up duplicate patient records from each facility. “What makes it most valuable is when you can link Jose Rodriguez who went to one institution to his other visits at other institutions. So when you can take three disparate data sets and link them using unique identifiers, essentially what you do is set up matching fields (eg, name, address, date of birth) and give points for different levels of matching. So if the names are perfect, [the results] get a lot of points. If the names are slightly different, they get fewer points. If the date of birth is off by one number, they get slightly fewer points. And it adds up all the points and gives you a rank order of good matches,” Brenner explains. “So instead of just telling you the number of visits, we can get down to the issue of patients. A lot of health data are anonymous, visit-level data, but it really gets compelling when you can track individual patients and how they use the system.”

For instance, when analyzing one year’s worth of statistics that were collected in the database, Brenner says it was determined that one person went to the city’s EDs 113 times for treatment. Over five years, another person made 324 visits. “People with no access to primary care are coming [to EDs] for everything,” he says. “If you look at the top 10 reasons for visits to the emergency room, they’re all primary care diagnoses—otitis media, sore throats, earaches, cough, runny nose, UTIs [urinary tract infections]. They aren’t happy about going to the hospital, but they don’t know how else to get care and aren’t really well treated.”

The database has also allowed the coalition to track other statistics, such as the rates of diabetes and substance abuse among those seeking treatment at Camden healthcare facilities, as well as financial information, such as how much money the city’s hospitals are receiving for direct insurance reimbursement and Medicare or Medicaid payments.

One project that has been created using information in the database is the Care Management Project. It currently involves managing 50 patients, who were referred by social workers and other healthcare providers as being the most likely to benefit from getting assistance with their healthcare needs. The hope is to move them away from seeking care primarily in Camden’s EDs and have them become established with a primary care physician. The project’s team (a full-time social work manager, a part-time nurse practitioner, and a part-time bilingual community health worker) provides what is being called “transitional” care, offering writing prescriptions and ordering tests as part of care coordination and social work services.

Using Spring Medical’s Spring Charts electronic health record (EHR) program, the project participants’ medical information is also being inputted into the software, with the goal of eventually having the medical histories of the 1,000 people in Camden with the most difficult healthcare histories. The idea is to create more efficient care plans, allowing them to improve the state of their health and relieve some of the stress on the city’s healthcare institutions.

“The patients love it [the Care Management Project],” says Brenner. “They’ve never gotten this amount of attention before. They feel like someone finally cares about them, and there’s strong attachments between the staff and patients.

“The biggest question is can you take really deeply dysfunctional people who are in the habit of going to the hospital over and over [for treatment] and change their habits?” he adds. “Can you bring health and well-being to people who are not very healthy and don’t have a sense of well-being in their lives?”

Along with the Care Management Project, the coalition has instituted the Practice Management Project, hiring an MBA-trained family physician to work with primary care practices around the city to improve their quality, efficiency, and profitability, as well as their ability to handle some of the more difficult patients. The project’s top priority, according to the coalition, is to establish EHRs for the practices so they can better manage patients, especially those who have transitioned from using the ED for all their general healthcare needs.

Additionally, a Web portal is under construction to help facilitate collaboration among Camden’s healthcare providers, as well as increase the amount of coordinated care and improve the quality of care. According to the coalition, the portal is directed toward ED, hospital-based, and primary care doctors and office staff.

Patient-Centered Healthcare
Across the country in northern California, the Redwood Community Health Coalition, a network of nonprofit community health centers, is also utilizing electronic technology to benefit 10 primary healthcare centers with 18 operating sites, including purchasing licenses for eClinicalWorks electronic medical record (EMR) and practice management solutions.

Though a family of four living in the area where the coalition operates typically lives on an annual income of more than $100,000, this is not the demographic the coalition serves. Its patients include a significant portion who live below the poverty line. Additionally, 57% of the population is Latino, the majority of whom speak only Spanish; 37% are children; 40% are uninsured; and approximately 30% are enrolled in Medicaid. In fact, the number of people seeking treatment from the coalition’s clinics has doubled during the last eight years.

To better benefit its patients, the coalition has begun implementing new electronic technology. “The clinic leaders have invested many years into strategic planning, developing a consensus on a shared EHR vision and creating a strong quality improvement infrastructure on which our EHR initiatives rest,” says Pedro Toledo, JD, the coalition’s director of community and government relations. The coalition began rolling out the electronic technology in January, with the hope of finishing in December 2010. “We plan to implement about three to four health centers per year,” he says.

With the EHR it purchased, the coalition plans to utilize clinical alerts for drawing physicians’ attention to drug-drug, drug-allergy, or drug-disease interactions; important laboratory or radiology results; and drug recalls or new warnings for medications. Also, it plans to utilize continuity of care records to create up-to-date summaries of patients’ care that can be shared with other healthcare entities (with simultaneous viewing possible) or used to create a personal health record, as well as e-prescribing and the option for patients to schedule appointments online or communicate with physicians via e-mail. “Patient-centered medical homes is our ultimate goal, and we believe this is only possible with the appropriate technology,” says Nancy Oswald, PhD, the coalition’s executive director.

The coalition went through a period of preparation before beginning the transition to an EHR. “The implementation was a topic at every staff meeting for six months prior to go-live, and they [staff members] were encouraged to ask questions and every question was addressed. As a result, providers and staff embraced the change. One week after go-live, a medical assistant was asked how it was going, and he responded, ‘It’s a lot of fun,’” says Oswald.

For patients, “Flyers in English and Spanish were up at the registration desks two months prior, and several community meetings were held and local press covered them. Patients have been fascinated with the new technology. They are happy that providers have the best tools at hand vs. fighting through old paper charts,” adds Oswald.

Nonetheless, the switch from paper charts to an EHR system has presented some challenges for the coalition’s clinics. “In addition to the $11.5 million in technology costs, there are even bigger costs in loss of productivity for training and learning the system. We have mitigated some of the productivity loss with the strong preparation work, including getting some information from the paper chart into the electronic chart prior to the patient visit,” explains Adrian Williams, the coalition’s chief information officer. “We lowered the technology costs by having the health centers purchase one system together and by building network-based expertise to support the EMR. Health centers have distributed their costs based on their size and are making quarterly payments. These payments have been supplemented by a federal grant and a grant from a joint initiative of three California-based foundations: the California HealthCare Foundation, Tides Foundation, and the Blue Shield of California Foundation.

“However, there are still gaps,” he continues. “Now with the community health centers facing significant cuts in their main source of revenue (Medicaid), they are unable to increase their payments, so we have fund-raising to do.”

Williams adds of implementing such technology, “For all organizations, there is a direct correlation between the amount of depth of preparation and the success of the implementation. This is not an IT project. It is a change in every aspect of delivering care, from making an appointment to making a diagnosis to billing. Every person, patient and staff alike, is involved. If you leave it to your IT people to implement or if you fail to actively engage your staff and providers, it will be a very difficult endeavor. For community health centers, even the best EMR product does not fully grasp our community orientation. So be an active partner with your vendor in every way.”

— Tracy Meadowcroft is the senior production editor at For The Record.