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ACCEL
(Access El Dorado)
El Dorado County Wide Health Initiative
April 16, 2008
Greg Bergner, M.D. & Sandra Dunn, MSc
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Briefing Topics
History & Evolution of Goals
Health Information Technology (HIT) Programs
Care Pathways
Privacy Practice
EMPI
2008 ACCEL Focus
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Background
ACCEL (Access El Dorado) is a county wide health collaborative serving the uninsured,
underinsured and residents of El Dorado County, approximately 178,000 people
Situated in east central CA, 1,805 square miles of rolling hills, mountainous terrain
(the Sierra Nevada range), topographically divided into two zones, Lake Tahoe Basin and
the Western Slope
ACCEL Participants
Hospitals: Barton Memorial & Marshall Medical
Clinics: Tribal - Shingle Springs Tribal Health
Rural Clinics - Divide Wellness & Barton Community Clinic
FQHC - El Dorado County Community Health Center
County: Department of Public Health & Department of Mental Health
Private Providers
Marshall Physician Services
Tahoe Family Physicians
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ACCEL History
Accomplishments
2002 2003 2004 2005 2006 2007
•Health Alliance •Community needs •ACCEL formed to •Care Pathways •New areas of •HIE business case
convened by assessment improve EDC health (CP) introduced collaboration between developed
Board of Superv. •Recommend health •Outreach, enrollment •Calif ornia Kids hospitals and small •Formal governance
initiatives to improve program started to (Gap) insurance businesses established
access increase access •Joined CalRHIO
•HIT plan identif ied •Care Pathways
•Provider network •EMPI & Health Inf o •Mounted technology implemented SLT
development Exchange vendor RFI f or CP
•Vendor agreement
•Education & practice investigated •Community clinics share
management best practices •Technology
•HRA employee
Bs.Rules f or Care
•Com. Clinics improved screening •Regional Healthy Kids
Pathways & EMPI
•Barton rural clinic insurance
•Privacy & Security
expanded •1st Care Pathways Policies/Procedures
•FQHC opened implemented WS
2002 2003 2004 2005 2006 2007
Funding
Tobacco Master TMS TMS, TMS, HCAP, TMS, HCAP, • AHRQ
Settlement (TMS) HCAP Grant to PHD AHRQ Planning Grant AHRQ (multi-yr) AHRQ, •Blue Shield Found.
HCAP
techn. Implem. Blue Shield Found. 4
• Planning f or f uture
grant f unding
Evolution of Goals And Objectives
2002 - 2005 Goals 2006 - 2009 Goals
1. Improve access to medical care for 1. Improve the quality of health care and
individuals, particularly children and the administrative efficiency in El Dorado County
uninsured, in El Dorado County by: by:
– Continuing to improve access to medical
– Developing an outreach, enrollment
care through ongoing program nurturance
and retention program to assist and the development of enabling technology
individuals enroll in low and no cost
– Creating county-wide shared patient records
public health insurance across institutions (EMPI & 1 st Gen HIE)
– Securing a „Gap‟ insurance product for – Establishing standardized processes with
children up to 300% of FPL who did measurable outcomes (Care Pathways) to
not qualify for public insurance coordinate care at critical entry junctures
2. Reduce the barriers to care for the – Building community trust and program
publicly insured by: linkages
– Increasing clinic capacity through clinic 2. Enhance health surveillance through the
redesign monitoring of aggregate data
– Public health early casefinding
– Expanding rural clinics
– Chronic disease monitoring
– Establishing a new FQHC
3. Identify long-term strategic goals
– Developing public network utilizing – Implement personal health record accessible
private physicians to providers
– Create a county-wide Health Information
Exchange which can link to CalRHIO
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Health Information Technology Programs
ACCEL emphasizes implementation:
Staged technology enabled programs: 1. Care
Pathways, 2. EMPI, 3. HIE
• Formal governance established
• Privacy & Security Policies & Procedures
• Long-term financial sustainability pursued
2. EMPI:
• Notification of Privacy Practices (NPP)
• Initial „demographic‟ data sharing
1. Care Pathways: 3. Health Information Exchange
• Cross Agency Multiple Pathways 1st (HIE):
implemented (via paper process) • Business Case completed
• Vendor procured, business rules defined, • High level clinical data Identified
IT specs, configuration & test, training dev, • EMPI is foundational to goal
end user training, Go-Live Feb 2008 achievement
• NPP implemented simultaneously • Technology vendor alternatives explored
• 1st Gen demonstration project explored
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Care Pathways
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Care Pathway Background
Care Pathways Constructs Care Pathway Development Realities
• Adapted from Ohio CHAPs program • Focuses currently on children at or below
• Definition: Outcome focused Cross 300% of FPL
Agency patient case management with • Takes 6-9 months to define & test
standardized processes (mimics • Requires substantial time commitment
industrial production line concept) from multiple Agency representatives
• Requires clear Identification of the • Development / implementation time line is
Problem to solve and Outcome to dependent upon Participant agencies
achieve level of engagement
• Uses a „coach‟ (Community Health • Problem selection should take into
Worker) as the patient navigator account the incidence of problem
• Captures barriers, issues that stall patient occurrence, more numerous problems
progress and /or prevent Outcome support quantified value proposition more
completion readily
• Common language, patient eligibility • Current reimbursement policies are
criteria, cross agency work steps & user based upon payment for activities versus
responsibilities defined outcomes; without change sustainability
may be jeopardized
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Care Pathway Background
ACCEL Care Pathways Defined Care Pathway Problem & Outcome
1. Securing Health Care Coverage 1. Problem- no health insurance;
Outcome - enrollment of child in public
or privately funded health insurance
2. (Newborns) Securing Health Care
2. Problem- no health insurance;
Outcome- newborn enrollment in
Coverage health insurance
3. Problem- non urgent child presenting
at ER for primary care; Outcome- child
3. Obtaining a Medical Home has one visit in new medical home
4. Problem- no newborn medical home;
4. Utilizing a Medical Home Outcome- 4 well baby visits + IZs
5. Problem- PCP needs consult for
pediatric case w/ MH issues; Outcome-
5. Pediatric Mental Health Consults expedited MH visit with eval to PCP
6. Problem- Insurance at term; Outcome-
6. Annual (insurance) Eligibility Review renewal supported, eligibility extended
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Care Pathway Status
Care Pathways Web software is live! Participant technology implementation has been staged to
support training / QA, on-site testing and the simultaneous activation of NPP
Barton Hospital is ACCEL‟s technology hub. Barton‟s Director of Technology is ACCEL‟s Chief
Technology Officer
Public Health Department is ACCEL‟s hub for Community Health Workers who educate, coach
patients
2 of 6 Care Pathways are in use electronically. All should be in use by early summer.
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„Securing a Medical Home‟ Results
Demo Start August 2006
Client Criteria Pediatric ( >1 yr / age at or below 300% FPL) non urgent
patient presenting at ER w/out PCP
Referral Source Marshall ER
# of Clients 252
Outcome Medical Home secured w/ 1 visit with PCP post ER
% Success 202 kids ((80%)
Pending 9 kids (4%)
Barriers no parent follow thru, moved out of county, no shows at clinic
PCP assignment 60 % FQHC, 6% Tribal, 34% Private Providers
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Privacy Practices
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Process Taken to Address Privacy Practices
Guidance from key sources: Connecting for Health Framework
(www.connectingforhealth.org), Tennessee MidSouth eHEALTH
Alliance (http://www.regionalinformatics.org/, outside legal counsel, HIPAA, California State law
Workshop educated multi-disciplinary stakeholders on Privacy topics
Steering Committee adopted overarching principles
• Notification of Privacy Practices NPP
• Privacy & Security Policies are the driver for Technology not the other way around
• Security addressed separately from privacy
Chartered Privacy & Security workgroup to recommend policy language to Steering
Committee
Participant Memorandum of Understanding, governance agreement was
Developed, adopted
Participant Operations Cost to implement ACCEL NPP were defined, e.g. changes to existing
privacy forms, printing, distribution and training with staff to implement, programming 13
of registration systems to capture/track ACCEL patient NPP status
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Notification Privacy Practice (NPP) Principles
Definitions
inclusive NPP process assumes patients confirms sharing of information to ACCEL Participant
unless they specifically decline or “opt out”
common language means that the wording for ACCEL NPP is identical across all
network Participants regardless of registration process
applies to all network Participants indicates that patient verified NPP outcome at any location applies
to all ACCEL network Participants (“global vs.. local”)
Rationale
Maximum acceptance, simplicity and comparative ease of implementation outweigh potential risk
of inadequate patient understanding
Implications
Participants insure their internal policies and procedures are current, apply to access to ACCEL
System and use of ACCEL services
Process for withdrawal of NPP must be developed across all Participants with cross agency
communication process established
Patient education and notification efforts should be consistent across all network Participants
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Participants will apply „consent, Opt-in‟ for special patient categories
Notification Privacy Practice (NPP) Status
ACCEL NPP common language, Fact Sheet & Talking Points (for end users interface with patients)
Were created for use by Participants. Materials are in English and Spanish.
ACCEL NPP and Care Pathways technology have gone live in a staged manner. By April 21, 2008
All Participants will be administering the NPP
Evaluation of NPP Opt-outs frequency will be viewed in total and by registration site 120 days
from April 21st by the Steering Committee
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EMPI
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EMPI
EMPI demonstration project is between Department of Public Health, Barton
Hospital, Barton Community Clinic and Tahoe Family Physicians
Objective for EMPI with NPP is that it will support pre populating patient
demographic information into the Care Pathways technology and ultimately support
a more efficient patient registration experience. A future objective is that ultimately
the EMPI will serve as master patient rolodex for both the Care Pathways and HIE.
Tracking patient NPP status will be handled in the EMPI. Assuring that this
occurs accurately and timely, requires thorough review of NPP patient scenarios to
clarify business rules, that the rules are compliant with ACCEL NPP policy, and
clear definition of technology programming specifications
Patient Data into EMPI will be from Participant NPP Go-Live date
Demonstration project sites have reviewed their patient types for any special
Patient carve outs
Data interface feeds will take 2 different formats (XML, HL7) given different
Participant patient technology, in-house IT bench strength, etc.
EMPI Console, Participant specific repository will capture patient NPP changes
and as well as inaccurate patient data to be amended in Participant MPI 17
2008 ACCEL Focus
Complete implementation of Care Pathway‟s technology at all Participant sites
Complete EMPI implementation demonstration pilot
Extend important foundational HIE work
Extend specialty referral network / patient access program, improving quality of
referrals and confidence in primary care work up and treatment
Embark upon expanded community engagement with ACCEL
Revisit Governance Agreements and Policies, amend as needed
Define and commit to a long term Sustainability Plan
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Thank you!
ACCEL http://www.acceledc.org/index.asp
Greg Bergner, M.D. bergner@sbcglobal.net
Sandra Dunn, MSc, (916-939-7039) sandadunn@mindspring.com
This project was supported by grant funds from Blue Shield of California Foundation.
And, the project was supported by grant number UC1HS016129 from the Agency for Healthcare Research and Quality.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the
Agency for Healthcare Research and Quality.
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