Download Urban Health Plan, Inc. 1065 Southern Blvd. Bronx, NY 10459

Nicholas E. Davies Award of Excellence
Community Health Organizations
Urban Health Plan, Inc.
1065 Southern Blvd.
Bronx, NY 10459
urbanhealthplan.org
Transformation of a Community Health Center
&
Health Care in the South Bronx
The Vision of Urban Health Plan, Inc. is to be recognized as the premier community health center in the
country. It will be dedicated to developing a strong network of community based patient centered health
centers with a focus on incorporating state of the art technology with old fashioned concern to meet the growing
needs of its patients and will remain a nationally acclaimed model of innovation in community health care and
disease prevention.
Urban Health Plan, Inc.
CHO Applicant Identification Form:
Who Is the Applying Organization?
Section A1. Individual CHO Identification Form
1. Community Health Organization Name: Urban Health Plan, Inc.
2. Address: 1065 Southern Blvd.
3. City: Bronx
State: New York
ZIP code: 10459
4. Telephone: 718-589-2440
Fax: 718-589-4793
5. E-mail: [email protected] Web site: urbanhealthplan.org
6. Name and title of application author: Alison Connelly-Flores, Clinical Systems Admin.
Dan Figueras, Chief Technology Officer
Paloma Hernandez, Chief Executive Officer
7. Type of CHO: (see list in Section 4. “CHO Applicant Qualifications: Who Can Apply for the Davies CHO
Award?”) FQHC
8. Member of collaborative entity/health network? Yes/No If yes, name: ___________________________________
9. Number of sites: 3 clinics, 5 school based health programs, 2 homeless shelters, adult day treatment center
10. Annual number of patient encounters: _201,000
11. Number (or percentage) of annual patient encounters documented in EHR: 100%
12. Number (or percentage) of providers and staff using the EHR 80-100% of the time: 100%
13. When did the initial EHR implementation go Live? March 2006
14. When did the CHO meet the Organization-Wide Adoption Test (the EHR is being used in all care settings by
at least 80% of providers all the time, or, at least 80% of patient visits are being documented in the
electronic chart as part of day-to-day care delivery, with a resultant reduction on paper-based processes):
September 2006
15. Services offered:
Direct (Yes/No)
Referral (Yes/No) N/A
Adult Medicine
Yes
Pediatrics
Yes
Women’s Health Yes
Dental
Yes
Radiology
Yes
Laboratory
Yes
Mental Health
Yes
Emergency Care No
Urgent Care
Yes
Pharmacy
No
Other Services
Yes, specialty care, enabling services
16. Staffing (number of FTEs):
Physicians
26.80 Psychiatrists
2.13
Dentists
2.85
5.73
Other licensed
Clinicians
8.43
Care
managers
15.45
Physician
Assistants
10.35
Nurses (RN/LPN)
Nurse
Practitioners
2.07
Medical Assistants 68.01
Urban Health Plan, Inc.
Information systems
staff
Other FTEs
(administrative,
executive, fundraising,
etc.)
9.35
171.93
Lab Technicians
3.52
Dental Hygienists/
Technicians
Imaging
Technicians
1.27
Other medical
personnel
7.17
Certified
Nurse
Midwives
Other mental
staff
.32
5.02
17. Describe hospital affiliation(s):_We are affiliated with Columbia Presbyterian Hospital, Bronx Lebanon Hospital
and Our Lady of Mercy Hospital. Providers have admitting privileges only.
18. Provide detailed information regarding any commercial/employment agreements with the vendor/s of EHR
hardware/software. If no such arrangements/agreements exist, please indicate “No commercial/employment
relationships with any vendor of our EHR system.”
There are no commercial / employment relationships with any vendor of our EHR system.
19. Names and titles of EHR implementation team:
Alison Connelly-Flores, Clinical Systems Administrator
Dan Figueras, Chief Technology Officer
Samuel DeLeon, Chief Medical Officer
Paloma Hernandez, Chief Executive Officer
20. Will all be considered as authors of the application? Yes
Urban Health Plan, Inc.
Introduction
Urban Health Plan, Inc. (UHP) is applying for the HIMSS Davies Award of Excellence to offer its
experiences, both triumphs and lessons learned, during its transition to full implementation of its electronic health
record (EHR). UHP is proud of its corporate culture which has historically been the driving force motivating the
Health Center to be at the cutting edge of innovation. The strategic planning process and the organization’s drive for
continuous quality improvement resulted in the successful implementation of eClinicalWorks (eCW) in 2006. The
implementation of our integrated EHR, which has been fully operational for three years, has been a synergy of
personnel, purpose and technology at UHP. This highly advanced, powerful and tailored system has transformed the
provision of care to the at risk and vulnerable residents of the South Bronx community and the organization itself.
1. Purpose
Community Served: UHP serves the South Bronx community in New York City. The residents of our
service area suffer from significant economic challenges as well as from racial/ethnic health disparities. Most residents
speak Spanish as a first language and many are linguistically isolated. UHP is located in one of the poorest
congressional districts in the country. The Bronx ranks in the highest 2% of U.S. counties in poverty and has an
unemployment rate that ranks it in the highest 1% of U.S. counties. (See Appendix 1 Table 1-1). The
community also suffers from high rates of diabetes, asthma, obesity, HIV/AIDS, and mental health when
compared to NYC rates. (See Appendix 1 Table 1-2). These variables made an EHR essential to track the
community’s health needs and to assist in the development of evidence-based programs that can be evaluated for
improvement in health outcomes.
Organizational Description: UHP’s mission is to continuously improve the health status of underserved
communities by providing affordable, comprehensive, and high quality primary and specialty medical care and by
assuring the performance and advancement of innovative best practices. Founded as a community health center in
1974 by a local physician, UHP has grown to be one of the largest providers of ambulatory care services in NYS. In
1999, UHP earned the designation of a Federally Qualified Health Center (FQHC), under which it offers a broad array
of primary and preventative medical services, dental, mental health and specialty services. We provide services in
three traditional clinic sites, El Nuevo San Juan Health Center, Bella Vista Health Center, and Plaza del Castillo Health
Center, five school-based clinics, two homeless shelters, an adult day treatment center, and a Boys & Girls Club. We
are currently in the process of opening a site in Corona, Queens, another NYC borough. We also operate a WIC
(Women, Infant Children) Nutrition Program that served 5,000 participants in 2008, and other grant funded programs
that enhance our core medical services. To further address health disparities, UHP has recruited and trained
Promotoras as lay health advisors and have established a storefront Health Literacy Center where local residents can
go to learn about health care issues affecting their lives. In 2008, UHP’s 340 FTE staff and 60 providers served 31,045
patients in 201,604 visits, an increase in visits of 15% over the previous year and 35% over 2005 - the last year prior to
full EHR implementation. (See Appendix 1 Table 1-3). UHP has a $34.5 million operating budget.
UHP serves as a “hub” for the community and continuously works to expand our network of health care
centers and strategic partnerships. UHP has a robust performance improvement program that permeates throughout the
culture of the organization. Our desire to accelerate the capabilities of our health care delivery system and to improve
the quality of care provided to our community motivated us to self-fund an EHR. We were one of the first health
centers in the country to adopt and successfully implement an EHR.
EHR Program Objectives: UHP collects and analyzes market data annually to improve how we provide
health care. This data and input from various stakeholders guides our strategic planning process. In the most recent
strategic planning meeting held in October 2008, information technology goals were focused on maintaining the
technological edge required to meet organizational needs by supporting our current systems, remaining cognizant of
new technologies, evaluating new technologies, and recommending methods for evaluation after implementation.
Specific objectives related to our EHR system are as follows (detailed in Section 10):
Objective 1: Improve Health Outcomes by expanding Clinical Decision Support Tools
Objective 2: Improved Care Coordination
Objective 3: Improve Patient/Family Satisfaction
Objective 4: Improve Reporting
Objective 5: Improve Efficiency by increasing staff and provider productivity
Objective 6: Enhance Revenue and Decrease Expenses
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2. Populations: Anticipated Impact on the Patient Populations Served
We expected that the implementation of an EHR system would lead to improved access to care, reduction of
health disparities and improvements to our Performance Improvement program. Enhanced care coordination, new
public health functionality and biosurveillance capabilities were other anticipated benefits.
Access to Care: As a result of an integrated practice management and EHR system, appointment scheduling
and tracking has become more efficient. Providers can now schedule appointments for their patients within the
confines of their exam rooms. This allows for individual tailoring of appointments in terms of times and dates, which
in turn leads to improved attendance or “show” rates. “No-show” reports are generated daily to improve care
management which includes contacting “no-shows” to make new appointments, accommodating walk-in patients, and
improving our ability to construct provider schedules. Prior to the EHR, the “no show” process was time consuming,
requiring the use of a special dot matrix printer that frequently broke down or became jammed. Now, reports are run
to turn the missed appointments into “no-shows” and to generate a letter that is automatically folded and stuffed by a
folding machine. Utilizing the same principle, targeted mailings and reminders are sent to patients alerting them of
upcoming health maintenance appointments. Patient access has been enhanced as a patient can now receive care at any
one of UHP’s network of service sites as they are all connected to a single patient database. This assures that a
patient’s information will be available to all sites immediately. An added feature is our ability to collect data on
patients’ cycle time. This has been an area identified for improvement, and through the use of the EHR, we can easily
track a patient from entry into the facility through discharge. This has resulted in a 42% decrease in cycle time in our
busiest clinic, Walk In.
Health Disparities and Performance Improvement: UHP began participating in the Health Disparities
Collaboratives (HDC) supported by the US Department of Health and Human services in 2001. The focus of the HDC
was to close the health disparity gap among community health center patients. The collaborative models emphasized
making rapid cycle improvements while identifying patients with a given illness, assuring that evidence based
guidelines were utilized and empowering patients to take care of their own illness. UHP was quite successful in
implementing the models and making significant improvements to the care provided to our patients. Significant
improvements were also made to the care our asthmatic patients received. We have spread and sustained these results
across all of our sites for all our patients. This has resulted in a reduction in asthma hospitalization rates for children
ages 4 to 12 of over 60%. We were awarded the National Exemplary Award for our Asthma Management Program by
the United States Environmental Protection Agency and have been recognized as a high performing health center by
the Health Resources and Service Administration (HRSA).
We have adopted and integrated the HDC models into our Quality Improvement Program and currently
support 12 internal performance improvement teams. (See Appendix 2 Table 2-2 for descriptions and a sample of
projects). The implementation of an EHR system has facilitated the collection of data so that improved analysis can
better direct the teams. Prior to the EHR, UHP had developed disease registries that were created using Microsoft
Office Access databases. Progress notes, data collection sheets, and test results of collaborative patients were
photocopied and sent to a team of staff members for database entry. Once eCW was implemented, we were able to
capture registry data in the EHR. Data was initially entered into both the Access databases and eCW. Once the
performance improvement teams, the Chief Technology Officer (CTO), and the EHR Project Manager verified that the
reports from both systems matched, we decided to only use eCW - thus eliminating the need for stand alone Access
registries (and data entry). In addition, we have been able to customize interventions according to severity levels by
segregating patient data that allows for enhanced analysis. For example, we have been able to identify our patients
whose diabetes is significantly out of control and intervene accordingly, rather than continuing to work on the entire
diabetic population. We have also worked with eCW in developing their Registry function which permits easier
retrieval of structured data elements.
Decision support tools embedded in the EHR have further served to impact health outcomes. Providers are
reminded on a real time basis of evidence based guidelines that assist in assuring patient needs are properly addressed,
such as aspirin for diabetics with ischemic vascular disease.
The electronic prescribing functionality has proven to be critically important as it allows us to quickly and
accurately identify and notify patients of drug recalls. This process which would have been nearly impossible to do in
the past is now completed in a matter of minutes.
Care Coordination: We have improved care coordination by working with eCW to enhance many of the
application’s features. For example, the UHP Referrals Department is responsible for scheduling and re-scheduling
appointments and tracking consults to ensure patients received their specialty care. With the help of eCW, we are able
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to track how many referrals are made, how many specialist appointments are made, the percentage of appointments
kept, and how many specialist consult reports have not yet been received by UHP. Specific documents (labs,
diagnostic imaging) can now be attached to each referral so that the specialists have the required information to treat
patients.
Continuity of care is enhanced through these features as well as our ability to follow up on all patients sent to
the emergency room. A referral is printed along with all other relevant clinical information including a medical
summary and given to the Emergency Medical Service to take to the hospital with the patient. The referral is
electronically assigned to the staff member designated as the ER Tracker, enabling them to follow-up on the patient’s
disposition, course of treatment and schedule necessary appointments.
Telephone case management is integral to UHP’s care model. The use of eCW greatly enhances the
capability of telephone case managers, whose sole function is to coordinate care by assuring that patients receive the
necessary services. They are able to query the system by using a variety of data elements that produce lists of patients
who meet criteria for follow up, such as patients with a PHQ-9 score greater than 10. This allows them to document
the telephone conversation in the EHR and assign a note to the provider. Now there is a systematic method of
documenting communications with the patients assuring improved care coordination.
Public Health Functionality and Bio-surveillance: UHP has worked diligently with the New York City
Department of Health and Mental Hygiene (NYCDOHMH) and eCW to build public health functionality into the
system. On a daily basis, UHP sends to the NYC DOHMH extractions of clinical data. Traditionally, emergency
department visits were the largest source of syndromic data. Because of our early adoption of health information
technology, we were selected to be part of a pilot project to test transmitting this information. Two to three week
earlier detection of the flu was found when analyzing our data against emergency room data. Information transmitted
includes patients with respiratory complaints and temperatures greater than 100.4 degree F, enabling the City and the
CDC to predict influenza and other communicable disease outbreaks (see Appendix 2 Table 2-3). As a result, it has
now become the standard for primary care facilities to transmit syndromic data to the NYC DOHMH. We will soon
begin to transmit patient de-identified “Chief Complaints” to the NYC DOHMH on a pilot basis to attempt to improve
syndromic definitions that can enhance surveillance and detection outbreaks of influenza in the NYC population.
The recent Swine Flu pandemic demonstrates the rapid response time and flexibility the EHR has given the
organization to respond to emergencies. On the same day that the NYC DOHMH and Centers for Disease Control
(CDC) alerts were issued, UHP created a template and clinical decision support. The following morning all clinical
staff were trained on the new protocols. In addition, because all data was created in a structured format, daily reports
are being run to monitor patients with suspected infection, providing the ability to follow-up rapidly if needed.
3. Personnel: Leadership, Governance and Key Staff
Leadership: The core Project Team consisted of the Chief Executive Officer (CEO), the Chief Medical
Officer (CMO), the Chief Technology Officer (CTO) and the Project Manager (PM). The composition of the team
was critical to the success of the project because it assured the support and buy-in of the most senior level staff in the
organization. We had relocated our main site to a state of the art facility, had developed a robust performance
improvement project, and wanted to add health information technology as a means of further improving the quality of
care that our patients received. We also recognized that space was at a premium and that eventually our paper records
would outgrow their space.
With senior leadership intimately involved in the implementation, the Project Team was able to make critical
decisions on a real time basis and facilitate the redesign of key processes throughout the organization. During
planning/implementation, the Project Team met weekly to review milestones, track progress, plan next steps, and
troubleshoot problems.
One of the most important decisions that senior leadership made was in the selection of the PM. After
deliberation between the CEO and CMO, it was decided to attempt to select a PM from within the organization. The
person selected was both a licensed practicing clinician and an experienced clinic administrator. The PM’s
combination of formal clinical and administrative backgrounds, when combined with her IT skills, has proven ideal in
communicating with the large variety of stakeholder groups including providers, nurses, line staff, and administration.
Her clinical background afforded her credibility with providers because she was practicing medicine along-side them
and also performing the steps she was asking the others to take. In addition, during her clinical sessions, she could test
the “roll-outs” in live settings under real-life conditions to determine feasibility and effectiveness. As a site
administrator, she understood what policies and procedures were in place as well as the corporate culture. With this
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information, she was able to gauge the success of the process and the amount of pressure line staff were experiencing
during implementation and adjust the work plan accordingly. In the past two years, the Project Manager has presented
at many conferences in the Northeast detailing UHP’s EHR implementation, most recently, at the IT Adoption
Conference held by the Medical Society for NYS. (See Appendix 3 for biographical sketches of Project Team
members).
The CMO took a lead role in working with the PM on a daily basis. Working with provider groups to design
and tailor the templates for the new system, they carefully selected the super users from each site/department and then
trained and cultivated them so they could respond to and walk providers/staff through questions as they arose.
Questions challenging the Super-user were referred to the PM and as needed to the vendor.
After implementation was completed, the PM position was transformed into the Clinical Systems
Administrator (CSA) position. In the new role, the CSA participates as a member of the NYC DOHMH/eCW
development team ,which is discussed in section 4, while also conducting in-house duties such as customizing software
and protocols, building enhancements, developing new interfaces, providing continued support, and assisting with the
implementation of the Bronx Regional Health Information Organization (Bronx RHIO).
The Medical Records Department was integrated into the Health Information Department and now provides
UHP with a different level of service than before. The Health Information Department staff performs required IS
functions such as systems analysis, programming, EHR training/support, release of information, chart audits, and
scanning functions. A quality control function has been added to monitor scanning and other electronic functions.
Governance: UHP is governed by a Board of Directors that meets the requirements of an FQHC. The Board
selects/evaluates the CEO, and with the senior management team, comprises the health center’s leadership. A majority
of Board members are patients and represent the community. The Board utilizes a committee structure to fulfill many
of its responsibilities including finance, quality management, development, and human resources. The Board functions
as the voice of the community and provides policy-level leadership to the organization. Both the Board and most of
the committees meet on a monthly basis.
The Board plays a key role in the annual strategic planning process which was instrumental in the decision to
implement an EHR system. On a monthly basis, the CEO and project team kept the Board apprised of progress in the
EHR selection process, oriented the Board to the new IT system, and informed them of progress made on the approved
plan. The Board works with the senior management team to review and provide feedback on recommendations. The
Board understood that this was a wise and needed investment to enhance our ability to serve our mission and as part of
the annual budgeting process, they approved the purchase of the EHR system as a capital investment
Skill Sets/Resources: This was our second attempt at implementing an EHR. We had worked for three years
to plan, install, and implement the first EHR system and learned valuable lessons that were used to interview, select
and negotiate with vendors. We understood the need to have particular support and services written into the contract,
such as training and on-site response. eCW was able to incorporate these services and structure the contract on a
milestone completion basis. We established a strategic partnership with the vendor based on trust and mutual
understanding, noting that we expected a long term relationship to be fostered. Our experience with performance
improvement also assisted us in selecting the vendor. We looked for a vendor that understood quality improvement
and who was willing to work with us in modifying their system to make registry reporting an integral part of their EHR
product. eCW and UHP worked to make the eCW Registry function a reality. Thoroughly and deliberately
redesigning workflows was also given top priority. We recognized that eCW was not a quick fix for all of our
challenges and that in order for the system to work for us we would need to accommodate the system without losing
our own efficiencies.
4. Partnerships: Collaborations for Community Health
Collaboration: UHP and eCW. UHP was the first FQHC to implement eCW in the country. As a result,
we were in the unique position to assist them in customizing their system to meet the demands of both New York State
and the Federal government. These customizations included the design of their registry functionality, the integration of
structured data for improved ease of reporting, the creation of sliding fee scales, and ultimately the billing
enhancements to the practice management system to comply with all of the NYS nuances that exist.
Collaboration: NYC Department of Health and Mental Hygiene (NYC DOHMH) and eCW. NYC
Mayor Michael Bloomberg announced his commitment to invest $30 million into health information technology at
UHP in the fall of 2005. Shortly thereafter he convened a committee led by the Primary Care Information Project
(PCIP) and the NYC DOHMH to issue a Request for Proposals to choose an electronic health record system for
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NYC’s most vulnerable populations. After a very deliberate and transparent selection process that included multiple
site visits to UHP and interviews with UHP staff, the Mayor’s Committee chose eCW as the EHR for the City of New
York.
Due to early health information technology adoption and prior experience with eCW, UHP’s EHR Project
Manager was asked to participate on the City’s eCW Development Team to create the “New York Build.” The goal of
the project, which began in early 2007 and is still underway, is to add sophisticated public health functionality to eCW.
This allows the NYC DOHMH to collect data from the many eCW users within the City each day and use clinical
decision support to improve the health and outcomes of New Yorkers. The “New York Build” has been a unique way
in which UHP has contributed to public health in New York. The system is currently used by more than 1,100 NYC
providers, a number that is added to every day. (See Appendix 4 for Thank you letters from NYC DOHMH and
eCW).
Collaboration: Centers for Medicare and Medicaid Services (CMS). UHP was the pilot site for a
program called eMedNY through which UHP obtains Medicaid eligibility and data on prescriptions filled in the past
90 days for patients based on NYS Medicaid claims data. UHP has tested, implemented, and works actively with
CMS/ eCW/ NYC DOHMH to modify functionality to continuously improve the system’s usefulness for patients and
providers.
Collaboration: eHearts (also Healthy Hearts) Pilot Project with the NYC DOHMH. The Robin Hood
Foundation, Inc. funded NYC DOHMH to perform a pilot demonstration through the use of an incentive program
called “eHearts,” designed to improve heart/cardiovascular health among poor New Yorkers in an attempt to close the
disparity that exists. This project recognizes and rewards EHR-enabled practices that achieve excellent patient heart
health outcomes. The program that begins May 2009 will monitor UHP’s compliance with a core set of quality
measures named the “ABCs:”
A Aspirin for patients with Ischemic Vascular Disease, Diabetes Mellitus (DM),
B. Blood pressure control in patients with hypertension or DM,
C Cholesterol controlled to recommended levels in patients with hypercholesterolemia,
S Smoking cessation treatment or counseling.
5. Preparation: EHR Readiness/Workflow Design--Comparing First and Second Implementations
Initial EHR Implementation: UHP first attempted to implement an EHR in April 2001. After 3 years, some
successes were evident (providers were writing prescriptions, viewing scanned images and using the new Summary
Sheet that consisted of problem lists, hospitalizations, allergies, medications, and surgeries). However, only eight of 60
providers were writing electronic progress notes due to the difficulty of learning and using the modular system. After
multiple attempts to complete implementation including training, contacting the vendor for assistance, etc., UHP made
a business decision to move away from a modular EHR to a fully integrated EHR. In retrospect, early signs of trouble
we missed included difficulty installing the system, lack of an implementation plan, inexperienced vendor training
staff, lack of vendor project coordination, poor vendor response to issues, upgrades that always resulted in system
crashes, and difficulty in using the EHR system. The last straw was the previous vendor’s decision to no longer
support the product and have us migrate to their new application at a ”discounted price”.
However, with failure came valuable experience. The project team was now better educated and providers at
all levels (versus department heads) were involved in the second selection process, helping to remedy residual issues
regarding buy-in from the first implementation attempt. Providers learned to value different parts of the system, e.g.,
the rapid access to diagnostic imaging reports and consult reports that were scanned immediately upon arrival. They
had also become dependent on the prescription writing system that provided drug-drug/drug-disease interactions and
formulary checking. The Patient Summary Sheet aided in our first Joint Commission survey in 2003. Most providers
were “hooked” by at least one efficiency in the first implementation giving the impetus to “buy into” the second
implementation. We developed an understanding of the type of vendor we wanted to develop a relationship with, the
features that were critical, and the difference between an integrated and interfaced PMS/EHR system.
Preparation and Readiness for the Second EHR Implementation: The Project Team conducted meetings
with each department to map the organization’s existing direct and indirect patient care processes. These processes
were redesigned and improved in conjunction with an eCW trainer to fit into an electronic world. One of the factors
most instrumental in the success of the second implementation was training the vendor on UHP processes and
workflows. The PM gave the vendor’s trainers written instructions on how they would train UHP staff. This made the
product work for us. The Team conducted weekly “super-user” meetings, and the super-user group included providers
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from the main clinical departments including Adult Medicine, Pediatrics, School Health, Physical Therapy, OB/GYN,
Walk-In Clinic, and the satellite health centers. The Project Manager additionally met with each specialist to develop
templates. Additionally, a thorough bandwidth analysis was performed to ensure rapid application response time and
room for scalability.
The Project Team provided roll-out updates through Medical Board Committee meetings, medical staff
meetings, general staff meetings and UHP’s newsletter. “Milestone reports” were used to document the project’s
planning, implementation, progress measurement, and challenges.
Demographic, appointment, medication and immunization data from the previous EHR were migrated before
the “go-live” date. The pilot site, Bella Vista Health Center, was chosen because its functions mirrored, on a smaller
scale, those of the main site and because Bella Vista had become fully functional with the first EHR.
Using an integrated EHR required a training schedule different from the one used for the modular EHR.
Training on the modular system was piecemeal and time-consuming with each provider being scheduled to train over
several weeks, which reduced productivity and income. Training the pilot site staff to use the integrated eCW system
required only one week. Training consisted of 3 four-hour sessions for providers and 2 four-hour sessions for medical
support staff. The following week the entire site was “live” in all areas. Two trainers and the PM provided on-site
support until the department was fully functional (typically one week). In addition, we trained departments not located
at the pilot site but affected by the implementation because they provide administrative support. These included the
Call Center, Diagnostic Department and the Referrals Department. With workflows re-designed, templates created,
trainers trained, and initial system set-up complete, our first site went live on March 13, 2006.
The successful rollout of the remainder of the organization’s sites/departments occurred quickly and were all
completed by September 2006. (See Appendix 5 for the full 2006 eCW implementation schedule). During the
transition period, each department documented their visits electronically but printed progress notes to maintain the
integrity of the medical record until the entire organization was “live.” Simultaneously, all incoming diagnostic
imaging reports and consultation notes were scanned into eCW, making the system valuable to providers upon “golive”. Instead of scanning all existing paper charts, each chart was available to providers for 12 months after the “go
live” date; however, charts were to be used solely for reference and no additions to the chart were permitted. Providers
were instructed to enter any important information from the paper chart into the EHR.
Two months into the eCW implementation, a bumpy rollout at one of the largest departments caused a
modification in training format, resulting in our “Hot Seat” concept. With this new method, instead of learning
information didactically, each trainee was asked to demonstrate learning throughout the session. Staff members took
turns sitting at the terminal, and trainers asked trainees to demonstrate answers to questions regarding documenting
various elements in the system. This experiential learning method greatly improved staff results.
6. Purchasing: Vendor and System Selection in 2005
After deciding to abandon the first implementation and to proceed with a second, the Project Team continued
to meet on a weekly basis and re-engineered the processes that led to a successful EHR implementation in 2006. The
Team selected a group of providers to assist with vendor and EHR selection and constructed the following vendor
requirements, based upon the initial EHR experience:
• Comply with industry standard features
• Strong support capabilities
• Outstanding customer service
• Committed to CHC’s
• Financially viable firm
• Integrated PM/EHR
After research the team created a shortlist of EHR vendors based upon the above criteria and developed a
functionality grid. The team then interviewed vendors, conducted site visits of live systems for the top contenders and
spoke with end users, not supplied by any given vendor. After a 10-week selection process and four week negotiation
period, UHP executed a contract with eCW.
Financial planning and budgeting for this project was part of our annual operating and capital budgeting
process. This initiative was a high priority for both the senior leadership and the Board of the organization with reserve
funds being used for this purpose.
7. Product: Software/Interoperability/Hardware/Networks
Software and Functionality: eCW is a fully unified electronic medical record and practice management
system that contains the following key components: patient-centric dashboard, clinical decision support system, order
sets (standards of care based upon medical condition), progress notes, referrals, e-prescribing, patient portal and
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practice management. The practice management system includes scheduling, patient recalls, electronic remittances
and automatic transfer to secondary insurances.
eCW also uses a “patient hub” that permits a patient’s information to be accessed across any care line
and delivery. Clinical decision support is built in and all population based registries are integrated into the core
product which are also client configurable as chronic disease state reporting changes. All disciplines including,
but not limited to, medical, specialty, dental, social services, mental health, laboratory, and billing utilize the
same system. All clinical services are documented by the provider, claims are generated, and electronically
transmitted to the clearinghouse.
UHP has implemented all of the originally available functionality. In conjunction with eCW and the
NYC DOHMH, we will be the only CHC to participate in a text messaging pilot. For more details, please refer
to “Next Steps.”
Interface: Improved functionality through interfaces.
• Iris Recognition – UHP is a pioneer in clinical biometric patient identification. Using a small camera attached to
a clinical computer, the patient is identified in seconds using their iris pattern (more unique than a fingerprint).
Integrating this patient identification technology into our patient flow streamlines clinical functions, virtually
eliminates mistakes of patient identification and the need for patient identification cards, a significant savings in
money and time. See Section 11.
• LAB - UHP maintains a bi-directional interface with an outside laboratory company to make laboratory results
available for providers as soon as they have been resulted and transmitted into the patients chart. This step
improves patient care and saves time because providers and clinical staff can access the results for review and are
visually alerted to abnormal results. Providers can review results throughout the day and recall patients with
abnormal results the same day. Critical value reporting and follow-up is facilitated. Administrators can monitor,
in real time, the number of result reports not yet received, as well as result reports that have been received from the
laboratory but not yet reviewed by a provider. Measuring the times between the activities is used to address time
lags and set goals for improvement, such as the number of days it takes a provider to review a lab.
• Phone Tree - UHP has established an interface with “Phone Tree,” a telephone appointment reminder system, that
calls each patient twice, three days before and one day before an appointment, saving staff time and improving
show rates.
• PACS- an interface with the Picture Archiving Communication Systems (PACS) system has improved workflow.
Orders of x-rays are now transmitted electronically to the Radiology Information System (RIS), eliminating the
need for the radiology technician to manually enter orders.
• Spot Vitals - Vital sign machines capture BP, temperature, and heart rate and transmits them automatically into
the appropriate field in eCW, assuring accurate readings and eliminating the possibility of entry error.
• EKG/Holter Monitoring/Spirometry - EKG results notification and verification have been improved because
real time consultations between a UHP provider with a specialist cardiologist are now available. Both provider
and cardiologist can review and discuss the same EKG result and holter heart monitoring. Spirometer readings are
automatically captured by the EHR, eliminating the need to file reports and giving rapid access to providers.
• NYC Citywide Immunization Registry (CIR) - The NYC CIR contains a record of all vaccine information on
patients entered by all NYC providers. Vaccine data for those less than 18 years of age are electronically
transmitted to the City’s immunization database on a daily basis. Prior to the EHR, the City required all data be
entered into a web based application, wasting valuable time for the pediatric nurses. The City is currently working
on developing this into a bidirectional interface.
• eMedNY – Medicaid eligibility checking and Prescription History
Connectivity and Networking are provided by UHP which hosts its own servers. The wide area network is
comprised of an Ethernet based Transparent LAN Service (TLS) from Verizon, cablevision Optimum Online and a
Quest T1 Internet connection. Most locations are in the Bronx, with the exception of our Corona site, which is in
Queens. There are five sites that are connected through a Verizon TLS and five schools connected through VPN
tunnels using Cablevision Optimum Online. All five sites have Verizon TLS circuits creating a private network.
Hardware/Peripherals: The CTO designed and acquired a hardware configuration that could reliably
support the entire enterprise and includes the following: a database back-end runs in a Microsoft clustered server
configuration with automatic fail-over; the application (front-end) servers are load balanced using Tomcat services and
Triton “ftp” services transparent to users for imaging, storage, and retrieval. There are also servers for reporting
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(Cognos and Registry). This setup permits a very fast response across a WAN, scalability to support additional users,
and affords full redundancy. (See Appendix 7 for a diagram of the system).
Additionally, UHP has a server for the training and testing environment, reports servers and a fax server. The
training server is utilized to conduct all training sessions for new employees, and training to existing employees on new
features prior to an upgrade. It is also used to thoroughly test all new releases prior to installing them on the production
server.
Each examination room is equipped with personal computers and printers for prescriptions and patient
education. Physical Therapy providers use tablets. The ability for numerous clinical and billing staff to have access to
a patient’s record across the institution simultaneously has been invaluable.
8. Proof: Data Collection, Management, and Measurement
Improvements in data collection and utilization in operational, financial, and clinical realms have been
realized. In the area of Operations, lost charts are no longer an issue. Prior to implementation, an average of 75 charts
per month were “lost” as shown in (Appendix 8 Table 8-1). Staff can now invest time in patient-related activities that
were previously spent searching for charts. Searching one hour for each of 75 lost charts per month would result in
about 0.6 FTE of a staff member’s time which amounts to approximately $21,000 in lost salary each year. In addition,
time spent by staff in reassuring patients whose charts are “lost” has been eliminated.
Evidenced by the change in the ratio of visits per staff member, UHP has become more productive. In 2005,
291 FTE staff produced 149,549 visits (514 visits/staff member). In 2008, 340 FTE staff produced 201,606 visits (593
visits/staff member). The increase in productivity from 2005 to 2008 is 15.3%.
Premium space has now been put to more productive use. Our Community Room which was designed to
serve as a venue for community members and organizations to meet, was being used for the storage of paper records
that no longer fit into the main records room. This has been returned to its original use.
In the area of Finance, we have significant operational savings as detailed below:
Annual Supply, Support/Maintenance Savings Before and After EHR
Pre-EHR
Post-EHR Annual Costs
Scannable Encounter Forms
$28,620
Charts and Dividers
$55,050 Maintenance
$63,900
1,900Sq Ft Medical Records
$69,000 Support
$42,000
space and other rented space
Support/Maintenance for
$230,060
Practice Mgt Modules of first
EHR
Total COSTS Pre EHR
$ 382,730 Total Costs
$105,900
Post EHR
In addition, the Medical Records staff has been reduced, though attrition, from 12 to six FTEs, saving an
additional $140,000 in salary and benefits on an annual basis. Medical Record Overtime in 2005 was $ 59,686.
Annual Summary of SAVINGS: $140,000 (salary)+ $59,686 (OT) + $278,830 (pre/post savings)=$476,516
Patient visits in 2008 exceeded the visits in 2005 by 52,000, a 35% increase. The number of users increased
19% from 2005 to 2008. (See Appendix Table 8-2 for details). The number of billable visits increased by 23% from
2005 to 2008 resulting in a corresponding jump in revenue of approximately $2,852,671. However, the number of
billing staff has not been increased, creating an additional benefit. Procedures and tests performed during the patient
encounter are now automatically captured, coded and billed by the provider. We are able to bill significantly more
claims due to system efficiencies.
The EHR integrates clinical and practice management information, allowing for enhanced financial studies
and reporting to stakeholders, a request that developed from the strategic planning process. The EHR enabled UHP to
roll out an incentive program for providers that assisted in improving productivity. Capturing additional data for the
incentive program absent an EHR would not be reliable, valid, sustainable or cost effective.
Although we were already a high performing health center, as recognized by HRSA, we used the EHR as an
opportunity to improve efficiencies. The ability to extract data allowed us to develop a corporate dashboard that
identifies key performance indicators on a monthly basis. (See Appendix 8 Graph 1/Table 8-3). The dashboard
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reflects the organization’s strategic goals and includes financial, access, operational, and clinical indicators and
provides management and the Board with a snapshot in time of how the organization is performing. All of the data
needed to populate the dashboard comes from eCW, without which it would be nearly impossible to do because of the
intensity of the work that would be required to gather and complete it. Having this tool has enabled us to better
manage the organization since site specific and departmental dashboards have also been created.
In the Clinical area, UHP had made great strides in collecting data prior to the implementation of the EHR
system. However, performance improvement work was generally done through a collaborative with a population of
focus chosen by time consuming chart reviews. With the EHR, we have been able to transform the way we capture
information and manage knowledge. For example, we were concerned with the small improvements in the aggregated
HgbA1C’s in our diabetic patients. Our diabetic patients seen between 2/1/08 and 1/31/09, had an average A1C of
7.8. Drilling down into the data we found that there were 442 patients with an average A1C of 11, and the
remaining 1819 patients were well controlled with the average A1C at 6.9. Armed with this information, we
decided that our focus needed to be on the small subset of uncontrolled patients whose average HgbA1C was over 9%.
The ability to capture data at the point of care for our performance improvement teams was made possible
through the integration of identified process and outcome measures into provider templates. The reporting of such data
is now well enhanced since it is captured through the use of structured data and SMART Forms. SMART forms ask
and collect data in a structured format, with some answers triggering additional questions (e.g. Do you smoke? If yes,
how many packs). These forms have the ability to calculate the severity of certain conditions (asthma, depression,
alcohol abuse) and a summary of the data appears in the progress note.
One particular area of concern for us was our asthma data. We had made significant and sustained
improvements in the health outcomes of our asthmatic patients prior to EHR implementation. Our ability to create
reports following initial implementation was slowed down compared to the Access registries. Creating the structured
data that was missing in the initial implementation allowed for continuity in our reporting.
Our ability to run reports, such as tests ordered but not received, has created the opportunity to reach out to
patients in real time. For instance, colon cancer screening levels have historically been low. We have had some
success in improving our rates by generating daily lists of patients with an FOBT ordered. The case manager is then
able to proactively call patients, answering any collection questions they have and encouraging compliance with
completing the test. This has resulted in a 4% increase in screening rates over the past 6 months.
9. Process: Implementation and Transition to EHR
Strategy, Workflow, Communication: Our overall implementation plan focused on the Project Team’s
intimate involvement in all phases of the project. Senior leadership’s involvement was vital and they were the catalysts
for encouraging adoption and managing change. Because of their involvement in our performance improvement work,
they understood that the role of adoption was to transform the organization in terms of its workflow and use of
technology and data. They understood that adoption was not about adding to the status quo but about transforming the
status quo into a more efficient and effective system.
The idea of health information technology becoming a permanent part of UHP was reinforced by promoting
the technology at every available opportunity. Staff at all levels of the organization were involved in the adoption of
the EHR. Senior leadership developed a strategy for involving providers in the development and deployment phases of
adoption. Recognition and rewards were redirected towards successful use of the EHR. Additionally, clinical template
development was delegated to provider groups and to specialists that led to a proactive approach to improving the
product and facilitating “buy-in”.
Rolling out the integrated EHR at sites in successive, two-week bursts created a record of demonstrated
successes, as did communicating the proposed workflow plan to all staff. A thorough workflow analysis of all
processes was conducted by holding meetings with each department. As a result of the meetings, a flowchart of all
direct and indirect processes that occurred within the organization was developed. The Project Manager evaluated how
well workflow and other changes required for EHR implementation were working and made needed adjustments. Our
successes were communicated to staff via newsletters, emails, and town hall meetings. This strategy allowed for all
staff to be recognized for their efforts, encouraged participation in the adoption phase, and reinforced senior leadership
support.
Workflow: When we began to adopt the technology, it was essential that each affected process be mapped so
that it could be clearly understood. The new technology clearly highlighted areas for improvement regarding
efficiency – mandating that the PM re-design workflows. Three years later we continue to re-evaluate workflows and
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focus on individual tangential but important processes. For example, by monitoring cycle times we learned that a
bottleneck was being created by the discharge process. As a result, we created additional discharge rooms and
improved cycle time.
Configuration/Templates: The PM worked closely with the CMO, the super user primary care providers,
and the specialists to assure that the system was properly configured and that templates were well designed to capture
the required documentation. The individual providers had input into the design of templates. Attention was given to
the existing performance improvement teams to assure that specific registry information was built into the system as
structured data elements for reporting purposes. Retaining the “uniqueness” of individual provider notes was a
priority, so rather than having answers default to “normal”, we configured the templates to default to “I didn’t ask” or
“not examined.” (See Appendix 9 Screenshot 1 for an example).
Education/Training: UHP has a Learning Center for Professional Development that prides itself on our
uncanny ability to acquire, transfer, and manage knowledge. We believe that the foundation of our ability to quickly
adapt to the changing health care environment lies within our workforces’ ability to learn. UHP has a well developed
New Employee Orientation and Annual Employee Orientation program designed around providing the necessary tools
that each staff position needs in order to carry out our Mission. As such, a computer training center was created to
serve this purpose. This didactic training together with the “hot seat” concept previously introduced proved quite
successful in managing this new knowledge.
After implementation, it was decided that a new provider or staff member could not be put on the floor
without EHR training. This caused us to change our New Employee orientation program in its entirety. It gave us an
opportunity to evaluate the program’s effectiveness and to make the appropriate changes. As a result, our new
employee orientation now consists of a five day training program, a good portion of which is dedicated to EHR.
Ongoing training sessions intended to optimize system use are integrated into regularly scheduled Medical Staff
meetings with providers from satellite locations joining via video conferencing, thus creating savings by reducing
providers’ travel time and assuring that providers are present to see patients.
Information exchange: The flow of information has been facilitated because the practice management,
scheduling, decision support, billing and reporting functions are all integrated in one product. This eliminated the time
that it took to transfer information from one system to another. In addition, associated clinical services such as
laboratory, radiology, imaging and electronic prescribing are also integrated. A unified system supports connectivity
between providers and staff, improves efficiency, rationalizes workflow, reduces cost and supports efficacy of
treatment. A bidirectional interface allows lab orders and results to be electronically exchanged. The use of equipment
that interfaces with our EHR has been invaluable in eliminating the risk of human error. All vitals, EKG, and
spirometry equipment interfaces with our system so that as a patient’s blood pressure, pulse and temperature are
obtained, they are electronically transferred into the EHR. Although a bit more expensive, UHP’s senior leadership
was convinced that this was a much more efficient way of working.
As previously mentioned, pre EHR, we maintained independent disease registries. Today we have integrated
the captured elements of these registries into eCW’s clinical templates or SMART forms. This has eliminated the need
for independent registries. We have interoperability capabilities with the NYC DOHMH through the transfer of
syndromic surveillance data, the exchange of immunization data to their CIR, and with their Take Care NY indicators
through quality measure reporting. Interoperability has also been established with the NYS Medicaid system whereby
UHP providers can access prescription data. This assists with our medication reconciliation process and allows us to
have access to information that often the patient cannot express on their own. Lastly we are a board member of the
Bronx Regional Health Information Organization (RHIO) which was founded to create interoperability between all
Bronx County hospitals and health centers. Although in it is initial phase, UHP is able to retrieve several valuable
pieces of information from one of the borough hospitals.
Hardware/Networks: UHP already had a solid IT infrastructure. For optimal system performance, the CTO
re-designed the hardware/network infrastructure using in-house expertise and his prior experience in creating and
maintaining an IT system. Scalability and reliability were critical metrics of the design. Additional bandwidth was
allocated for the optimal performance of the radiology and imaging systems. This proved to be a successful choice.
Historical Data: Patient demographics, immunizations, medications, insurance information, and
appointments were electronically migrated from one system to the next. Migration from the paper chart to the EHR
system began with the decision that there would be no scanning on a massive scale. No historical records were
scanned. Until the entire organization was “live,” progress notes were printed and placed into the paper medical record
to maintain the integrity of the chart. As each area/site/ department went live, they were instructed to begin
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documenting in the EHR system. This process was followed until all departments in the organization went “live” (six
months). Once all departments went “live,” the providers were informed the paper record would be available for one
year but nothing could be added to the paper chart. Providers were instructed to extract any data needed from the paper
record and document it in eCW, e.g., the last mammogram results. After using the system for six months, the average
provider no longer requested paper charts.
Document Management: Scanning occurs at various points during the patient visit. When a patient first
presents at one of our facilities, their intake forms including insurance cards, identification cards, and consent forms are
scanned into the electronic record. This is performed at the point of care. An “out-guide” then follows the patient
through the visit. This is true for both new and existing patients. Any paper documents generated during the visit
(forms that need to be completed, documentation brought by the patient) are placed into the out-guide which is directed
to a “To Be Scanned” bin at the nurse’s station. Out-guides are collected throughout the day, and papers contained in
them are scanned into the system. This scanning is centralized and each page is quality checked by another staff
member. Additionally all consults received from outside referral sources are scanned into the appropriate patient chart
by our Referral Center and are assigned to the patient’s primary care provider for review. The Project Team defined
each filing point as a scanning point and used this as a guiding principle regarding document management.
Continuity of Care: UHP, its management, and Board have created a service that has the patient as its heart,
around which all other systems operate. The patient-centered information system allows for documentation of all
activities, by all providers, at all sites within the UHP system. The system ensures that the health care team has the
most current and complete information, and allows for real-time access by providers in a network of services sites and
walk in clinics. UHP’s medical team creates lab orders, prescriptions, receives electronic test results, and facilitates bidirectional communications to and from referring clinicians. All of these connectors have enhanced the lines of
communication through timely, legible and accessible patient information. This allows the point of care to be extended
across the continuum of care to any site/service because access to the medical chart is unhindered. A paper chart no
longer delays care, instead an electronic record facilitates care. Patient identity is verified using biometrics, specifically
iris-recognition technology.
EHR Support: UHP has established a successful hierarchical approach to support the EHR system that
ensures a prompt organizational resolution to issues as they arise and provides technical assistance as needed for the
end user. This success has been built on a strong training component that encouraged staff acceptance and provided a
baseline of knowledge and competency. From go live to present, all questions within a department are channeled first
to the departmental super-user. If the super-user cannot answer the question, the question is sent to the PM / IT staff.
If internal resources are unable to resolve the issue, a support ticket is opened with eCW. Our support staff has grown
from one to three, with varying levels of knowledge. The need for this staff has grown out of an understanding of what
was needed and the level of skill needed to respond. Staff members have been re-deployed to serve in this function.
This was a result of our internal promotion culture, where we are constantly looking for interested, qualified staff
members to fill existing vacant positions.
EHR Maintenance and Optimization: The PM’s role was revisited once full implementation occurred. Her
title was changed to Clinical Systems Administrator (CSA) and her main function is to maintain the EHR system,
customize templates as needed, perform upgrades, redesign work processes, and optimize the functionality of the
system. The value of reporting cannot be overstated as a function of the EHR system. As a result, enhanced reporting
is one of the functions that the CSA oversees. In the spirit of performance improvement, the CSA is responsible for
improving the performance of the EHR system while upgrading the expectations of the staff. Our EHR system is
extremely powerful and must be continuously monitored to assure maximum performance. On the technical side, the
CTO and IT staff monitor the health of the servers and the specific parameters set for the application levels (Tomcat
servers) and the backend (MySQL records locks). Slow query logs are used to ensure that the network and
applications continue to run properly. Email alerts are sent by the application when the results are outside of the
predefined limits so UHP can proactively avert any system problems/down-time. (See Appendix 9 Screenshot 2).
10. Progress/Impact: Value, Outcomes, and Lessons Learned
Strategic Alignment: The objectives of this project were well aligned with our strategic plan. Our strategic
plan focuses on six pillars: service, people, community, finance, quality, and growth. Service specifically focuses on
operational efficiencies and the use of technology. People focuses on retaining members of the workforce.
Community focuses on identifying community needs and assuring that we are meeting them. Finance focuses on
remaining financially viable. Quality refers to improving the quality of care by continuously striving to improve our
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performance. Growth focuses on continuing to serve and capturing increased market share. Clearly, this initiative was
well aligned with the organizational strategic plan.
Achievement of Objectives/Anticipated Impact: The specific EHR objectives that were identified in Section
1 were also accomplished. Their progress is delineated below.
Objective 1: Improve Health Outcomes by expanding Clinical Decision Support Tools: eCW’s clinical
decision support is integrated into the product and developed from evidenced based national quality standards and
NYC public health priorities. To ensure a best-practices environment within the organization, the CSA has augmented
these protocols with the appropriate professional organization specialty protocols received from UHP’s specialists.
Standing orders, specialty protocols, medication formularies, unacceptable abbreviations are examples of other
supports now used. The flexibility and ease of developing structured data and decision support was demonstrated with
the “Swine Flu” threat. The CSA developed a template based on the CDC’s protocol and built an order set into eCW.
Treatment guidelines (tests/education/medication) specific to Swine Flu would appear on the provider’s monitor if, for
example, a provider entered the diagnosis, “viral infection NOS.”
In addition, evidence based protocols specific to our performance improvement work were built into the
system and our results show that care has been improved in many areas. Outcome measures are monitored by reports,
rather than time consuming chart reviews. As a result, UHP has been able to take on new performance improvement
projects and is able to address areas of care not typically the focus of an FQHC or other public clinic.
In Appendix 10 Tables 1-4, outcome data is provided for four of our performance improvement projects to
demonstrate that the EHR has led to improved patient outcomes. In the asthma collaborative (Table 1), the percentage
of persons who received annual influenza vaccinations improved from 9% in 2006 to 29% in December 2008. For a
cancer screening process measure for mammograms (Table 2), in 2006, 19% of eligible women received a
mammogram in the prior two years, whereas, in December 2008, 50% of eligible women did. For the childhood
obesity project (Table 3), before the EHR, 32% of parents of children ages birth to two years received nutrition
education compared to 85% of parents in December 2008. For the HIV project (Tables 4a-4c), from 2006 to
December 2008, the percentage of patients reporting practicing safer behaviors increased from 39% to 88%, patients
reporting condom use increased from 50% to 88%, and patients receiving Mental Status Examinations increased from
43% to 82%.
Additionally, as a result of being able to improve asthma care through up-to-date protocols, by being able to
send automatic reminders of follow-up and missed appointments, and by being able to track asthma patient adherence
to treatment plans, it was revealed through a NYC DOHMH project that UHP’s costs for one of the larger managed
care plan, Affinity Health Plan, was 22% less for adult asthmatic patients when comparing UHP to Affinity’s entire
provider network and 39% less for pediatric asthmatic patients using the same comparison. These cost reductions were
found to occur in a period after EHR implementation, 2006-2007.
Objective 2: Improve Care Coordination: The objective was to enrich care coordination by: 1) enhancing
patient access, 2) upgrading the flow of laboratory and test data for greater availability, 3) linking UHP sites
electronically to remove the need to transport records and 4) improve the referral process
Access to care has been improved by facilitating the production and utilization of scheduling and “no show”
reports that permit easier tracking and rescheduling of patients. Through interfaces, the EHR ties in patients’
laboratory, radiology and other test results so that they can be viewed together. The records of patients treated at any
UHP clinic can be accessed at any other UHP site eliminating the need to move records around form one location to
another. Coordinating referrals to specialists has improved: 1) providers transmit electronic requests to the referral
office eliminating paper and the loss of any requests, 2) providers use the EHR to select only the specific patient data
that needs to be sent to the specialist, and 3) visits to specialists are tracked to determine patients who need follow-up
due to missed appointments and to determine the location of specialists’ test results. Telephone case managers are
better able to track large numbers of patients for compliance. We have been able stratify patient data as with our
diabetics so that we can improve our ability to track the right patients at the right time. We can also determine how
quickly laboratory and other testing results are reviewed by the provider and can intervene as needed.
Objective 3: Improve Patient/Family Satisfaction: Pre-EHR, patient survey results were collected over
several weeks and, rather than focusing on the current visit, staff were concerned about collecting enough surveys to
have statistically meaningful results. In a highly innovative use of EHR capabilities, UHP combined the power of
EHR with the services of an independent management company (Crossroads) to create a valid method of collecting
patient satisfaction data daily called “Rapid-Response” reporting. Crossroads receives patient visit information on a
daily basis to call and elicit responses in English and Spanish to twenty questions on topics including waiting time,
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privacy of protected health information, and provider treatment. Crossroads compiles monthly reports, analyzed by
site, department, and new/returning patient, and feeds the results back to management and staff to make close to “real
time” changes that lead to performance improvement. In Appendix 10 Graphs, the average scores across the
organization for the twenty areas studied are shown for the first month (July 2007) and the last available month (March
2009). For each month, approximately 150 patients were surveyed. Overall patient satisfaction has risen by 3% from
84% in 2007 to 87% in 2009. In 2007, three scores exceeded 90% compared to eight scores in 2009.
The results demonstrate that patients experience a high level of satisfaction in almost all areas. As part of its
process to continuously improve, UHP learned from the patient satisfaction data that patient cycle time was an issue.
As a result, our quality unit, the IACH, intervened and formed a performance improvement team to focus on this issue.
Changes were tested and several improvements were made that reduced cycle time from 72 to 49 minutes (32%). All
three patient waiting time satisfaction measures have improved from 2007 to 2009.
Objective 4: Improve Reporting: Our original objectives were to expand the use of reports to: 1) Enable the
IACH to create specific reports to address more focused issues; 2) to eliminate time-consuming paper chart reviews so
that more time could be spent in providing care; 3) to meet Federal, State, and City reporting requirements and to
expand communicable diseases reporting; and 4) to better integrate fiscal and clinical information for reporting as
recommended by the strategic plan. With the EHR, performance improvement efforts have improved dramatically.
Not only are Joint Commission activities easier to track, but monitoring and sampling patient care outcomes through
computer generated reports has eliminated paper chart review. While UHP utilizes numerous standard financial,
clinical and administrative reports, we are capable of capturing any data elements defined through structured data.
Data reports are created by departments to track various elements required for internal and external reporting, e.g., birth
weights, needed for the UDS and all internal collaborative data.
Not anticipated prior to the EHR, but very valuable, is the ability to create reports with targeted data for
outside reviewers and auditors. As a result, time is saved in providing information to third parties and it becomes
easier to prepare for the audit. Both fiscal and program audits use much less program management and fiscal
department time than before the EHR was in place. Also, reports used to monitor clinical related activities such as
unlocked notes, unreviewed laboratory results, documented referrals (appointments yet to be made), and abnormal
laboratory results or patients to be recalled, are sent to the CEO, CMO, CTO, CSA and department heads on a daily
basis. Any provider whose numbers are above pre-established threshold values receive an email alerting them about
the issue. (See Appendix 10 Screenshot) The organizational dashboard could not have been accomplished had it not
been for the ease of collecting the required data through eCW. We have now begun to push down the dashboard so
that eventually every program, department and site can see their individual results.
Objective 5: Improve Efficiency by increasing Staff and Provider Productivity:
Staff productivity: The EHR automates and streamlines staff workflow at all levels of the organization
allowing for efficiencies and increased staff satisfaction. While supporting patient care and clinical processes, the
system facilitates the practice management and other fundamental business management functions including
registration, scheduling, and billing among others which improve efficiencies and thus improves staff satisfaction.
First, UHP has achieved a paperless chart and the only paper processed for a patient visit is from an outside source.
Incoming paper documents are scanned and reviewed to ensure quality. Second, many functions formerly conducted
by Medical Records staff have become unnecessary, for example, searching for “lost charts.” Eliminating this activity
has reduced friction among staff members and the anxiety of patients who cannot be seen until the chart is “found.”
Making new charts and pulling charts for each session and moving charts through hallways using special carts is no
longer necessary. The electronic transmission of lab results has ended the need to sort laboratory reports and give
providers stacks of laboratory results to review, and file in the charts. Third, the Medical Records Department has been
transformed into the Health Information Department. Because so many time-consuming activities have become
extinct, Medical Records Department staff were re-deployed. This was a deliberate action that over the course of the
year when paper records were still being supplied to the providers, the Medical Records staff were given the option to
apply for new positions within the organization. Of the 12 original staff members, six have been retrained and the
other six left through attrition. Of the remaining ones, morale is high as they have been given new skill sets and new
roles and responsibilities and they continue to work at the organization 3 years later.
Provider Productivity: Through the EHR, UHP gained operational efficiency and saved time and effort by
computerizing and rationalizing the clinicians’ workflow and has helped improve the quality of care to patients through
clinical alerts and decision support. The EHR has also assisted in the development of a provider incentive
compensation program, before which scoring quality and productivity would have been nearly impossible. Through
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this program, provider satisfaction has greatly improved as they can literally make more money based on their
performance. Enhancing this is their own ability to monitor their specific performance since it is all accessible in the
EHR system. The NYC DOHMH analyzed UHP’s encounter data and noted that productivity did not appear to be
negatively impacted by the implementation. Taking seasonal cycles into account, one can observe a slow, steady
increase in total productivity that continues today (See Appendix 10 Line Graphs). Many templates, lists, alerts,
checks and protocols added to the system have reduced many quality and compliance issues. Providers now have the
opportunity to spend less time completing billing and other administrative paperwork and increase time spent on
clinical activities.
Objective 6: Enhance Revenue and Decrease Expense: The objectives included 1) To reduce or eliminate
direct expenses related to the Medical Records, to convert Medical Records spaces into areas for patients, revenue
generation, or both, 2) To increase provider and staff efficiency and productivity evidenced by an increased number of
patients, visits and higher revenues, and 3) To connect clinical and practice management functions resulting in fewer
coding/billing errors. Management and the Board of UHP subscribe to a business philosophy that seeks to maximize
revenue while containing cost in order to ensure the long-term viability of the organization. Thus UHP sought to
implement an EHR system not only to improve patient care but also to seek efficiencies, productivity of providers, and
to reduce costs wherever possible. Substantial decreases in expenses have been realized as previously noted. We
experienced a decrease in annual costs of $476,516. Additionally, from the table in Appendix10 Table 10, one can see
that from 2005 to 2008, the number of UHP users increased by 19% and the number of claims filed with insurance
companies increased by 23%. In addition, in 2008 there were 15,000 more patient visits than projected. For more
details on sustainability, refer to the “Financial” section under “PROOF.”
Critical Success Factors: Among the most important critical success factors is the culture of continuous
performance improvement. UHP’s foundation is rooted in a true culture of excellence, strengthened by UHP’s
leadership and the strategic partnership that has been formed with the vendor. Senior leadership pushed the envelope
with all aspects of the installation. Not only did UHP implement eCW, but the Project Team worked with eCW to
further advance their product by increasing their functionality with the creation of the disease registries and their
upgrading of the Referral process, to name a few. A combination of our leadership, vision, and commitment to
excellence were our critical success factors.
Technical Infrastructure Measurements: A software product that monitors application servers has been
incorporated to enable the CTO and his staff to detect trends in response time down to parts of a second. Alerts are
sent automatically to the CTO and Network Manager when slowdowns hit threshold values. The MIS department by
tracking and using infrastructure measurements can determine and resolve issues leading to slowdowns before larger
problems occur.
Help Desk Support: Although eCW is intuitive, we constantly monitor various aspects of the system to
ensure it is being used as UHP defined it should be. Problems, such as coding, are identified and additional training is
provided. UHP uses a hierarchical support tree to resolve issues locally and moves them up the tree only if needed.
About 95% of all issues are handled in-house right away, and the issues referred to eCW through a “problem ticket,”
are minimal. UHP/eCW tracks the issues and resolution times.
Lessons Learned Throughout Implementation: The most important lesson is that executive level
commitment to the project is key. Without the CEO’s commitment, the project could not have been implemented
quickly and successfully. Other lessons learned include:
• PLANNING cannot be underscored enough
• Dedicated Project Team and PM
• Orient/engage providers/staff early
• Identify in-house trainers (super-users)
• Improve provider/staff EHR skills
• Develop the parameters to choose the right vendor
• Understand the different types of EHRs
• Tailor EHR to organization by workflow
analysis/redesign
• Train the vendor on your organization / workflow
• Teach basic functionality before the “sexier”
• Design the vendor training for your health center
features
staff
• Maintain a solid IT structure
• Ensure training is ongoing
• Maintain a “crash cart” of required paper forms for • Recognize and address newly discovered
inefficiencies/deficiencies uncovered by the EHR.
times when the system goes down.
Next Steps: UHP is working with NYC DOHMH / Verizon to pilot a text messaging system to determine if
sending health reminders via text will prompt them to scheduled needed appointments. Reminders will be sent to
Urban Health Plan, Inc.
14
patients due for preventive vaccinations and cardiovascular checks. The primary goal of this pilot is to conduct a oneyear study, starting in July 2009, to create a proof of concept around immunizations for both adults and children. A
secondary goal of this pilot is to investigate which other text alerts physicians find helpful. These alerts could include
reminders about future appointments, filling and taking prescribed medications, and following-up on laboratory or test
results.
UHP is continuing its collaboration with NYC DOHMH/eCW to improve public health functionality
and with eCW to improve its software product that they will distribute nationally.
Unique Partnership with Canyon Ranch Institute (CRI). UHP’s CEO and CMO worked with the former
U.S. Surgeon General, Dr. Richard Carmona, to develop a partnership between CRI and UHP. CRI leadership
believed that the CRI program, which is usually accessible only to the highly privileged, could be adapted for use in
inner-city communities. UHP and CRI staff worked together to identify core program elements that captured the spirit
and intention of the LEP program (Life Enhancement Program). The resulting 6-week curriculum takes an integrative
approach to addressing chronic disease, inspiring and empowering patients to embrace wellness by integrating the best
practices in health care of both Canyon Ranch and Urban Health Plan. Through informative workshops, dynamic
exercise sessions, food demonstrations, stress reduction techniques and fun field trips, participants will receive the
information and support needed to create healthy self management goals and long-term positive behavior changes. By
helping participants learn tools for incorporating stress management, healthy eating, and physical activity in their daily
lives, UHP and CRI hope to help patients reduce risk factors for chronic disease and promote a vibrant, wellnesscentered community in the South Bronx. The ability to collect data in a structured format will facilitate required
reporting to the CRI.
Bronx RHIO: As a working member for more than two years, UHP has been an active participant in
improving the Bronx RHIO. This health exchange provides access to important patient information and enables UHP
providers to give better care, improve continuity of care, increase efficiency, and decrease costs associated with
ordering duplicative tests. As a pilot site in June 2008, UHP began to view laboratory results, medications, diagnoses,
procedures, encounters, and demographics from the contributing hospitals on UHP patients who gave consent. UHP is
now working with the Bronx RHIO to expand the amount of information providers are capable of viewing (discharge
summaries, radiology reports, cardiology reports, EKGs, microbiology, and pathology reports) and to also share UHP
information with the other RHIO participants. The RHIO group has grown to include 18 local independent
organizations/agencies.
Preparing for “Medical Home” Certification through the National Committee for Quality Assurance
(NCQA): UHP is preparing our application to become a Certified Medical Home. The NYC DOHMH has been
working with NCQA to establish baseline EHR functionality required to become certified and has pre-certified eCW
version 8 users to level 1. This certified functionality, coupled with our internal policies and procedures enables us to
apply for Level 3 “Medical Home” certification.
Video Conferencing: Because ongoing training is needed to optimize the EHR system, video conferencing
allows meetings to be held with all sites to ensure all clinics are involved with EHR issues and updates. Reduction in
travel to trainings ensures more time for patient care, higher attendance and reduced cost.
11.
Practice: Innovations
Innovation: Biometrics Improves Patient Safety and reduces possibility of Fraud. UHP’s EHR contains
the world’s first deployment of Eye Controls SafeMatch™ patient identification system using iris recognition. UHP
actively participated in product development as the principal alpha and beta test site, and provided significant input to
the product’s design and features from both clinician and patient perspectives. At our facilities, when a patient looks
into a small camera attached to a clinical computer, the patient is identified in seconds using their iris pattern
(essentially zero identification error rate), instantly retrieving their electronic health record. The need for positive
identification arises because patients have the same name and because patients attempt to use others’ identification
cards. UHP uses the SafeMatch® system for patient check-in and exam room ID at the clinical locations with over 35
ID stations, and is in the process of expanding the ID system to encompass every station where patient records are
accessed. This system has already demonstrated its ability to prevent duplicate records, ensure that each patient is
treated using a unique record, prevent benefits fraud, and enhance patient safety by ensuring that the right record is
used every time for diagnosis and treatment. (See Appendix 11 Photos).
Innovation: Employee Health & Wellness Program. Based on results of the strategic planning process,
UHP developed a program to improve employee health, a move that will increase staff productivity, decrease health
Urban Health Plan, Inc.
15
insurance costs and decrease unplanned time off. UHP has installed a separate eCW server to support our Employee
Wellness Program. From data extracted from the EHR (BMI, blood pressure, smoking status) combined with the
needs and interests of UHP employees gathered from a staff survey, it was found that obesity, poor nutritional habits,
and stress were negatively affecting UHP employees. Specifically, UHP queried the EHR at that time and learned that
the percentage of employees with a BMI greater than 30 was 45.63%, and the percentage with a BMI greater than
35 was 21.88%. As a result, we started a Weight Watchers group whose first 15 participants lost 61.4 pounds in
the first 6 weeks of the program. Other significant employee health and wellness programs and features include
walking clubs, health fairs, discounted gym memberships, stress reduction classes, and health snacks in vending
machines.
Due to the implementation of this program, UHP exceeded the
Employees Influenza Vaccine Rate Year
2008 CDC influenza vaccination rate of 60%, with four
15%
2007
departments having 100% participation/vaccination rates. Other
64%
2008
related data tracked which promotes health and simultaneously
fulfills regulations, includes: N-95 Fit Testing and mask size; PPD’s, and vaccination schedules.
Innovation: Patient Portal. UHP patients are beginning to learn to manage their own care through the
Patient Portal, patients can view selected laboratory tests and test results, selected diagnostic imaging tests and their
results, view prescription status, make prescription requests, and look to see if they are due for appointments already
scheduled or that are soon due to be scheduled (e.g., annual physical due by July 15). As we continue our roll out of
the Portal, patients will be able to pre-register for an appointment, export histories to a personal health record (See
Appendix 11 Screenshot).
Other: Dozens of Visitors Travel to UHP to View eCW live/Presentations. UHP has had more than 40
site visits from agencies to discuss our implementation and to observe UHP’s use of eCW. Groups from as far away as
Kazakhstan in Central Asia have visited. Pictured in Appendix 11 Table 1 and Photo are members of the Kazakhstan
Department of Ministry at their December 2007 visit to UHP. Additionally, UHP is constantly being asked about their
eCW experience. The CSA has presented numerous times and the CEO has presented as well. We are viewed as trend
setters when it comes to health information adoption.
Conclusion
In conclusion, we are both honored and privileged to be able to submit this application for the prestigious
Davies Award of Excellence. Early on, we took on the challenge of adopting health information technology because
as an organization we had already made great strides in fulfilling our mission and transforming our health care delivery
system. We had relocated our main site to a brand new state of the art primary care facility. We had grown our
network and continued to grow our patient base. We were integrating a culture of safety, performance improvement,
and patient centeredness into the fabric of our organization. We were realizing improvements in reducing health
disparities within our community. We had attained Joint Commission accreditation and were being recognized for our
work throughout the country.
Our decision to adopt health information technology was a natural decision for us. We recognized that in
order to continue to transform our organization and the work that we were engaged in, the use of technology was
required as an accelerator. Urban Health Plan was successful in our adoption because we understood the importance of
senior leadership and the value of taking on calculated risks and not waiting for others to lead so that we could follow.
From an organizational development perspective, we were ready to take on the challenge. Today, our organization is
at a totally different level than we were just three years ago. Our agility in adapting to change, our ability to acquire
and manage new knowledge, and our ability to adopt new technologies continues to transform who we are and how we
do things.
Our experiences have made our organization much wiser, stronger, and viable than where we were when we
began. Today, we stand ready to assist other providers get to where we are. Our transformation, although challenging
at times, has taken us to a place we could not have even imagined when we began.
Urban Health Plan, Inc.
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Appendix 1 Table 1-1
Appendix 1 Table 1-2
Demographic of Service Area
Poverty Rate (Highest of
Congressional Districts in U.S.)
“Extreme” poverty, defined as
living at or below 50% of FPL
Children Below Poverty Level
Single Women Household
Percentage
(Census)
37.7%
33.3%
Disease
Mental Health Issues
Hospitalization Rate
Adult Diabetes
Obesity
HIV/AIDS
Bronx
20%
NYC
1%
17%
29%
3.15%
8%
12%
50.3%
30%
Appendix 1 Table 1-3. UHP Patient Encounter Statistics 2005 Through 2008
Service Profile
Medical
Dental
Mental Health
Other Professional Services
Other Enabling Services
Total
Urban Health Plan, Inc.
Encounters Encounters Encounters Encounters
2005
2006
2007
2008
125,658
125,775
127,457
133,284
8,769
7,822
8,883
10,845
6,609
8,688
10,837
14,429
3,941
3,250
6,300
12,339
4,572
6,831
21,258
30,709
149,549
152,366
174,735
201,606
2009 Project
based on Q1
----------219,456
17
Appendix 2 Table 2-2. Descriptions of Performance Improvement Teams
Aim Statement for all Collaborative Teams: Urban Health Plan is committed to ensuring that our patients with
asthma obtain healthcare to improve their quality of life. Consistent with the mission of the organization to provide
high quality services in a culturally competent and barrier-free environment, we will use the six components of the
chronic care model to assure an interdisciplinary approach.
Asthma Program
Aim Statement: In 2001, Urban Health Plan Participated in the BPHC Asthma II Collaborative to improve health
outcomes for the high prevalence of asthma in our community. The Asthma Program provides comprehensive
evaluations by a provider and comprehensive education by highly qualified asthma educators with years of experience.
The Main Objectives of the Asthma Program are: 1) preventive measures, 2) on-going care, and 3) asthma education.
Cancer Core Team
Aim Statement: Consistent with Urban Health Plan’s mission to provide high quality healthcare in a culturally
proficient manner, the Cancer Collaborative strives to ensure that all adult patients receive age and gender appropriate
screening tests for breast, cervical and colon cancer as well as timely follow-up in accordance with established
standards and evidence based guidelines. The Care Model will be used to assure a comprehensive interdisciplinary
approach. Population of Focus: All female patients age 21 and over, and male patients age 51 and older at El Nuevo
San Juan Health Center, Bella Vista Health Center and Plaza Del Castillo Health Center seen by their primary care
provider within the last 24 months.
Fit for Life Team
Aim Statement: The Fit 4 Life program will continue the UHP tradition of providing high-quality services through
nutrition education and fitness guidance. Our ultimate goal is to minimize risk of Type 2 diabetes and promote a
healthy lifestyle. We are targeting parents of 0-36 month old children with the objective of achieving or maintaining a
healthy BMI between the 5th and 84th percentiles. We will use the care model to assure a comprehensive interdisciplinary approach. Population of Focus: All of Dr. Ally’s patients from Birth to Thirty-Six months
Las Mariposas (Depression Collaborative)
Aim Statement: Urban Health Plan, Inc. is committed to improve the quality of Mental Health Care provided to our
patients. This will initially be accomplished by developing an effective treatment for depression. We will teach and
promote self management behavior to ameliorate depressive symptoms and employ creative methods to improve
mental health. Consistent with the mission of our organization to improve high quality services in a culturally
competent and barrier free environment, we will use the collaborative care model to assure an interdisciplinary
approach.
Appendix 2 Table 2-3: NYC DOHMH Representation of Bio-Surveillance Data Received from UHP
Respiratory Disease (7 day moving average)
RESP_DX
7 per. Mov. Avg. (RESP_DX)
45
40
35
30
25
20
15
10
5
1/
2/
20
08
1/
9/
20
08
1/
16
/2
00
8
1/
23
/2
00
8
1/
30
/2
00
8
2/
6/
20
08
2/
13
/2
00
8
2/
20
/2
00
8
2/
27
/2
00
8
3/
5/
20
08
3/
12
/2
00
8
3/
19
/2
00
8
3/
26
/2
00
8
4/
2/
20
08
4/
9/
20
08
4/
16
/2
00
8
4/
23
/2
00
8
4/
30
/2
00
8
5/
7/
20
08
5/
14
/2
00
8
5/
21
/2
00
8
5/
28
/2
00
8
6/
4/
20
08
0
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Appendix 3: Biographical Sketch of Implementation Team
PALOMA IZQUIERDO-HERNANDEZ
Paloma Izquierdo-Hernandez is the President and Chief Executive Officer of Urban Health Plan. She was
raised in the Bronx, New York and attended Boston College for her undergraduate studies. She holds two master
degrees, an MS and an MPH, from Teachers College, Columbia University and the School of Public Health,
Columbia University, respectively.
Ms. Izquierdo-Hernandez has been involved with Urban Health Plan since 1980 and has risen to the top of
the organization by dedicating over 25 years as the organization’s Administrator, Executive Director, and currently
as its President and Chief Executive Officer.
Led by her efforts, Urban Health Plan has grown from a one site facility to a network of three federally
qualified community health centers, five school health programs, four sites at facilities for at risk populations, and
two administrative facilities that house multiple grant funded programs including a growing WIC program and
several of the organization’s administrative functions. All of the sites are supported by an Urban Health Plan
transportation system and are all accredited by the Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO). Today over 26,000 community residents are provided with top quality health care and in
the past year over 145,000 primary and specialty care visits were rendered at Urban Health Plan.
SAMUEL DeLEON, M.D.
Dr. Samuel DeLeon is the Vice President of Medical Affairs and Chief Medical Officer at Urban Health
Plan where he is responsible for the oversight of all clinical services provided at the Center as well as the Quality
Improvement program.
Dr. DeLeon has been affiliated with UHP since 1994 following his training in the Department of Pulmonary
Medicine at Westchester County Medical Center. Dr. DeLeon is a graduate of the Universidad Catolica Madre Y
Maestra Medical School, Santiago D.R. and is a Diplomat of both the American Board of Internal Medicine and the
American Board of Medical Management.
Dr. DeLeon holds admitting privileges at Columbia Presbyterian Hospital, Bronx Lebanon Hospital Center
and Our Lady of Mercy Medical Center. He holds memberships in and actively participates in the activities of the
American Thoracic Society, the American College of Physicians, the Bronx County Medical Society and the
National Hispanic Medical Association.
ALISON CONNELLY-FLORES
Alison Connelly-Flores served as Implementation Manager and is Clinical Systems Administrator (CSA) and
Physician Assistant at Urban Health Plan, Inc. for nearly 10 years. Having successfully implemented eClinicalWorks
at UHP and its satellite clinics, her main focus is building public health functionality into the system with the NYC
DOHMH and on various other system interfaces, including an Iris Recognition program. She serves as a provider in
the Infectious Diseases clinic. Alison received her PA certification from St. Vincent’s Catholic Medical Center where
she graduated first in her class. She earned a Bachelor’s degree from Villanova University.
DANIEL FIGUERAS
Daniel Figueras joined Urban Health Plan in July 2000 as Chief Technology Officer. He oversees the Information
Technology, telecom and clinical systems operations at all sites as well as the billing and Medical Records
Departments. Before moving to Urban Health Plan, he was Director of IT for Americhoice. Mr. Figueras has 12 years
of experience in the health sector and 25 years of experience in IT operations. For 13 years he developed systems and
applications for finance in a property/casualty insurance company, and was Assistant Vice-President there for 6 years.
Mr. Figueras received a bachelor’s degree in Electrical Engineering from The City College of New York. He
is a member of the College of Healthcare Information Management Executives (CHIME) and is a Certified
Professional in Healthcare Information and Management Systems (CPHIMS) from The Healthcare Information and
Management Systems Society (HIMSS).
Urban Health Plan, Inc.
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Appendix 4: Thank You Letters from NYC DOHMH and eClinicalWorks
Urban Health Plan, Inc.
20
Urban Health Plan, Inc.
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Appendix 5 – Rollout of eCW
Appendix 7: Hardware Diagram Showing Load-Balanced N-Train Architecture
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Appendix 8 Table 8-1: Number of “Lost” Charts by Month in for Months Prior to EHR Installation
Charts "Lost" in 2006 Prior to EHR
(Scheduled Appointments Only)
Quarter
2006
Q1
Q2
Q3
Q4
Appts
Scheduled
33,231
33,713
33,428
33,208
Records
Not Found
82
91
234
584
Percentage
.25%
.27%
.70%
1.8%
Appendix 8 Table 8-2. UHP Patient Encounter Statistics 2005 Through 2008
Service Profile
Medical
Dental
Mental Health
Other Professional
Services
Other Enabling
Services
Total
Encounters
2005
125,658
8,769
6,609
3,941
Encounters
2006
125,775
7,822
8,688
3,250
Encounters
2007
127,457
8,883
10,837
6,300
Encounters
2008
133,284
10,845
14,429
12,339
2009 Proj
based on Q1
---------
4,572
6,831
21,258
30,709
---
149,549
152,366
174,735
201,606
219,456
Appendix 8 Graph 1: Organizational Dash Board
Ratio DASH BOARD AVG 2008
ORGANIZA1 Current
TIONAL
29 Pediatrics: Immunizations Rates
130.00%
2 Days In Account Receivable
28 Adolescent Care: %of Behavioral Risk Assessments
3 Days In Account Payable
110.00%
27 Prenatal Care: Post Partum Visits Rate
4 Days cash on hand
109.67%
26 Prenatal Care: Entry into Prenatal Care: 1st Trimester
86.34%
77.00%
90.00%
70.59%
86.40%
71.42%
5 Actual Visits
109.15%
70.00%
25 Cancer Screening: M /F 51+ With An FOBT Done In The Past 2 Yrs
50.00%
30.00%
24 Cancer Screening: 21+ With A Pap Smear Done In The Past 2 Yrs
56.67%
23 Cancer Screening: 42+ With A M ammogram Done In The Past 2 Yrs
7 Staff Turn Over Rate
32.44%
85.26%
10.00%
94.15%
71.99%
22 Diabetes- Average A1C
70.62%
6 R ate of Change
130.00%
74.53%
8 New Patient Satisfaction
-10.00%
96.13%
94.70%
87.08%
9 Existing Patient Satisfaction
107.97%
21 Depression 50%Reduction In PHQ
10 Pt Cnts: Patient Contacted w/in 48hrs
98.68%
105.80%
20 Asthma Avg Symptoms Free Days
84.80%
11 Patient Complaints per 1000
72.20%
74.07%
72.10%
19 Primary Provider Panel Size
100.00%
12 Provider Changes: Unacceptable x1000
89.34%
18 Average Cycle Time
13 Third Available Appointment Initial
97.97%
17 %of Reschedule Appointments due to Vacation
130.00%
16 M edical Team Productivity
Urban Health Plan, Inc.
14 Third Available Appointment F/U
15 Show Rate
23
Appendix 8 Table 8-3: Spider Graph Indicators
2008 Indicators
16 Medical Team Productivity
17 % of Reschedule Appointments due to Vacation
18 Average Cycle Time
19 Primary Provider Panel Size
20 Asthma Avg Symptoms Free Days
1
2
3
4
5
Current Ratio
Days In Account Receivable
Days In Account Payable
Days cash on hand
Actual Visits
6
Rate of Change
21
Depression 50% Reduction In PHQ
7
Staff Turn Over Rate
22
Diabetes- Average A1C
8
New Patient Satisfaction
23
9
Existing Patient Satisfaction
24
10
Patient Complaints: Patient Contacted w/in 48hrs
25
Cancer Screening: 42+ With A Mammogram Done
In The Past 2 Yrs
Cancer Screening: 21+ With A Pap Smear Done In
The Past 2 Yrs
Cancer Screening: M/F 51+ With An FOBT Done
In The Past 2 Yrs
11
Patient Complaints per 1000
26
12
Provider Changes: Unacceptable
27
Prenatal Care: Entry into Prenatal Care: 1st
Trimester
Prenatal Care: Post Partum Visits Rate
13
Third Available Appointment Initial
28
Adolescent Care: % of Behavioral Risk Assessments
14
Third Available Appointment F/U
29
Pediatrics: Immunizations Rates
15
Show Rate
30
Primary Provider Score Card Index
Appendix 9 Screenshot 1: Example of a template with defaults “didn’t ask” and “not examined”
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Appendix 9 Screenshot 2: Maintenance and Optimization
This is a auto generated e-mail triggered because of the following entities being monitored :
Monitor
ecw-app4.urbanhealthplan.org_Tomcat-server [IF-ecwapp4.urbanhealthplan.org_Tomcat-server_8080]
Attribute
Average Response Time
Reasons
Average Response Time - Clear
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Appendix 10 : Health Disparity Collaborative Outcomes for 1) Asthmatics receiving influenza vaccine, 2)
Mammograms, 3) Obesity, and several HIV items measured.
1.
Asthma Collaborative: Percentage of patients receiving influenza vaccine
Percent of Asthm a Patients w ith an Influenza Vaccine w ithin the past 12m os
28.5%
30%
Percent
25%
20%
8.6%
15%
10%
5%
0%
Mar 06
2.
Dec 08
Cancer Collaborative: Women age 42 or greater receiving mammograms within
recommended protocol timeframe
Percent of Fem ale Patients Ages 42+ w ith a Mam m ogram Done w ithin the past
24m os
49.4%
50%
24.5%
Percent
40%
30%
20%
10%
0%
Mar 06
3.
Dec 08
“Fit for Life” (Obesity Prevention) Collaborative
Pe rce nt of Patie nts Age s 0-23m os Re ce iving Nutrition Education
85.1%
100%
Percent
80%
60%
32.5%
40%
20%
0%
Mar 06
Urban Health Plan, Inc.
Dec 08
26
4a.
Project Sunrise (HIV) Collaborative: Patient Survey Measures of Safer Practices
Percent of HIV Patients Practicing Safe Behaviors
88.0%
100%
Percent
80%
39.1%
60%
40%
20%
0%
Jul 06
4b.
Dec 08
Project Sunrise (HIV) Collaborative: Patient Survey Measures of Condom Use
Percent of Sexually Active HIV Patients Using Condom s
87.7%
100%
50.0%
Percent
80%
60%
40%
20%
0%
Jul 06
4c.
Dec 08
Project Sunrise (HIV Collaborative): Provider Measures of Mental Status for HIV Patients
Percent of HIV Patients w ith a Mental Status Assessm ent
82.4%
100%
Percent
80%
43.3%
60%
40%
20%
0%
Jun 07
Urban Health Plan, Inc.
Dec 08
27
Appendix 10:
Showing Patient Satisfaction Results 10 B. Showing Patient Satisfaction Report Results, Jan
2009
A.
Patient Satisfaction Ranking and Percentages of 20 Factors, March 2009
B.
Patient Satisfaction Ranking and Percentages of 20 Factors, September 2007
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Appendix 10:
Appendix 10:
Example of Daily Email Automatically Sent to Providers who have Work Overdue
DOHMH Line graphs of provider productivity.
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29
Appendix 10 Table 10: Comparison of UHP User and Claims Data 2005 and 2008. Note that the number of
billing staff remained the same despite the growth in each of the figures.
CLAIMS
USERS
Appendix 11:
2005
139,151
26,035
2008
171,264
31,045
Variance
32,113
5,010
% Growth
23%
19%
Innovation--Biometrics innovation improves patient safety.
Original Iris Scanner
Urban Health Plan, Inc.
New/Improved Iris Scanner
30
Appendix 11:
Note:
Visits to UHP by other agencies to observe ECW
The Department of Ministry from the Republic of Kazakstan in Central Asia visited UHP on December
10, 2007
Visits to UHP by Other Agencies to Observe ECW
06/08/06 NYCDOHMH/Corrections
06/29/06 Whitney Young, Jr. Health Center
11/06/06 NYC Department of Health & Mental
Hygiene (DOHMH) Visit
11/30/06 Lutheran Hospital
01/02/07 Primary Care Development Corporation
(PCDC)
01/10/07 Open Door
01/16/07 Medical and Health Research Associates
(MHRA)
02/21/07 Hawaii PCA
03/08/07
03/15/07
03/28/07
04/10/07
04/11/07
05/10/07
05/31/07
06/21/07
06/28/07
NYC Health Commissioner, Dr. Frieden
Open Door
Washington, DC Primary Care Association
Salud Family Health Center (conf call)
Southwestern Medical Clinic
Soundview Health Center
Redwood Community Health Center
Planned Parenthood
Montgomery County DOH, Ohio
07/12/07 AHRC
07/24/07 Thundermidst Health Center
07/26/07 Multimedic
08/21/07 Betances Health Center
09/06/07 Salud Health Center
10/11/07 Diagnostic & Treatment Center, Brooklyn
11/01/07 Lutheran Hospital
11/08/07 ODA – Institute for Community Living /
Bronx Women’s Health Pavillion
11/15/07 Henry J. Austin Community Health Center
12/10/07 Department of Ministry, Kazakstan
12/20/07 Rufuah Health Center
01/17/08 AHRC
01/24/08 AHRC
02/07/08 Young Adult Institute (YAI)
04/03/08 YAI
04/10/08 Tri-County Medical
04/24/08 Newark Community Health Center
Visitors from the Kazakhstan Department of Ministry and Project Team in 2007
Urban Health Plan, Inc.
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