As healthcare provider organizations increasingly move forward on population health management initiatives, care coordination, powered through technology, is a vital component in improving the delivery of patient-centered healthcare and social services.
In Southern Colorado, Community Health Partnership (CHP), a coalition of more than 25 provider organizations, has a reputation for adopting state-of-the-art technology to support its vision of higher quality, better coordinated care for individuals living in the Pikes Peak region. In the past few years, CHP has been making strides to provide integrated care for high-risk populations in its communities, with a focus on collaboration and whole-person care coordination, through the adoption of innovative technology solutions. The goal, according to CHP officials, is to connect healthcare providers, payers and agencies together in a seamless way.
Based in Colorado Springs, CHP was formed in 1992, founded by Aspen Pointe, the El Paso County Medical Society, El Paso County Public Health, Memorial Health System, Peak Vista Community Health Centers, and Penrose-St. Francis Health Services. The membership has grown to more than 25 organizations and individuals representing a variety of areas in healthcare.
Within CHP, Community Care of Central Colorado is the regional collaborative care organization (RCCO) designated by the state to coordinate care and the delivery of services for members of Health First Colorado (Colorado’s Medicaid Program) in four Colorado counties—El Paso, Teller, Park and Elbert counties. Community Care began enrolling members in July 2011 and currently serves 180,000 Medicaid clients in the four-county region.
For two years, Jim Calanni served as chief technology officer at CHP, where he led the design and development of a comprehensive, data-sharing infrastructure linking primary care, mental health and social services providers across Southern Colorado (Calanni left CHP at the beginning of 2018).
With an eye towards advancing forward on its mission of improving access and controlling cost for the Health First program, last summer CHP began working with technology solutions provider Eccovia Solutions to implement its ClientTrack coordination platform across its entire provider network. Eccovia Solutions provides its platform to state Medicaid agencies, accountable care organizations, Medicaid Waiver programs, and community-based providers to help case workers and care providers collaborate to address the physical, behavioral, and economic factors that drive population health.
According to Calanni, the ClientTrack platform, which is powered by the Microsoft Azure Government cloud, by using this technology, CHP and its partner organizations have created a true community care program as opposed to the more typical solution revolving around historical charting of past medical issues. He adds that the platform allows organizations to enhance workflow efficiency, collaborate across multiple agencies, measure and report outcomes, and meet complex regulatory compliance requirements.
“Using the Fast Healthcare Interoperability Resources (FHIR) data exchange standards, ClientTrack integrates with CHP’s robust data warehouse, ALLURData (a Colorado-based technology company), and the CORHIO (Colorado Regional Health Information Organization) health information exchange (HIE). This integration enables 25 providers to collaborate and share encounter data in order to refer people for assistance and care from the most appropriate agency for their unique needs, and measure and report on their outcomes,” he says.
Building a Data-Sharing Infrastructure
This technology initiative represents just the latest step in CHP’s ongoing journey to improve collaboration and care coordination in its communities through the use of technology and health IT. When Calanni joined CHP in March 2015, one of his first orders of business was to lead a technology initiative to build a data-sharing infrastructure across the community.
Calanni and his colleagues at CHP began a pilot program, working with CORHIO, to connect three organizations—Peak Vista Community Health Centers (a Federally Qualified Health Center), Aspen Pointe, a mental and behavioral health care provider, and Colorado Springs Health Partners, a large healthcare practice in Colorado Springs (now owned by DaVita Medical Group).
“We wanted to show that those three organizations with three very different EHRs (electronic health records) could communicate. So, instead of a getting an off-the-shelf software solution and becoming an IT shop and managing our own HIE, we worked with CORHIO to connect providers to the HIE,” he says, adding that, at the time, there were no ambulatory providers connected to CORHIO.
Later in 2015 and continuing in 2016, CHP began expanding the program to connect its provider network to the Colorado HIE, which entailed the process of connecting its members’ disparate EHR systems to the CORHIO network. “In our community, of the 40 main primary care providers, there are 38 different EHR systems. We partnered with them and contributed significant financial and human resources, and now we’ve built the bridges to all 38 of those different EHR systems,” he says.
By connecting CHP members to the statewide HIE network, which includes bi-directional data exchange, health care providers participating in the coalition now have faster and more complete access to their patients’ most critical health information. The enhanced information access will improve patients’ care coordination, reduce treatment delays, eliminate unnecessary testing and allow care providers to make more targeted diagnoses and treatment recommendations.
“We now have about 80 percent of our primary care practices connected now into CORHIO, which is pretty awesome, and on a daily basis, automatically, they are sending clinical documents to the HIE,” he says.
At the time, Morgan Honea, chief executive officer at CORHIO, said of CHP: “CHP is among the most ambitious health care coalitions in the state — they are implementing state-of-the-art technology that will significantly improve collaboration among providers in their area. Ultimately, this will improve patient outcomes and reduce overall health care costs for everyone.”
Connecting to CORHIO was an important step in the ongoing data-sharing journey, Calanni says. “Previously, we had access to all of the Medicaid claims data, and there would be a three-month lag before we would get it, so that was a very reactive attempt to try to impact things. And, now we’re getting real-time clinical data. The next piece of this is how do we actually get this to our care coordinators so that they can see that Jane or John Doe was at the ER last night? And then they can notify the primary care provider to make sure they have transportation and to make sure they don’t fall off the grid,” he says, adding, “A lot of times, with super utilizers, they could have been to the ER seven times in three months and we would never know until we got the first claim.”
The next step in the journey was the implementation of the ClientTrack care coordination platform this past year to connect healthcare providers, care coordinators and social services, he notes. “So, we have all this claims historical data and real-time clinical data in one spot, and now we want to push that out to something that not only the healthcare providers and our care coordinators could look at and take action on, but also the final piece was, how do we get this into the hands of social determinants people,” he says.
“An example, the soup kitchens have a great deal of data that we wanted to connect the dots on that you would never really get because they don’t have much technology. And, now they are able to have portal access [to the platform]. If somebody comes into the soup kitchen, they can type in their name and immediately it brings up the information, then automatically notifies our care coordinator that John Doe is now at the soup kitchen. And, so, what happened, did John Doe lose his job? And, now the care coordinators can try to get in front of this thing with someone that might be have some social determinants that are impacting their life, and eventually their health,” Calanni says.
And, he adds that the platform provides the flexibility to define what information is accessible to each user. “It’s all rules and privilege access-based. For example, the soup kitchen is just going to see the patient’s name, their Medicaid ID and who their care coordinator is. So, it’s the same record, but just different views for different people.”
For healthcare providers, the platform enables a single sign-on to provide real-time access to a consolidated virtual community health record of each patient. “If a Medicaid patient comes into a hospital and this patient has been working with one of our care coordinators then the provider will see that Jane Doe is in a substance abuse program, getting food stamps, and has a child in foster care, has transportation issues. And, we also would know about the event, so we could arrange transportation to a respite center for a few days for rehabilitation. Also, for people who come out of the criminal justice system, there is no record. This platform offers a single-entry point to a patient’s history,” he says, adding, “It’s not perfect, but we’re really trying to fill in the gaps in this patient’s health journey.”
There were a number of technology challenges involved with all of this work, Calanni says, particularly in the areas of data consolidation and reconciliation. “The most difficult challenge was the behavioral health piece, and that’s just a thorn in everybody’s side, especially the protected data. We found that most providers, if not all, have fallen into the position of we’re not going to send the record, at all, because, let’s say, it has Thorazine mentioned.”
He continues, “We’ve had some challenges, and we’re making our way through it pretty effectively, of redacting out the things that come in that record. So, you have a CCD (continuity of care document) that is submitted from a mental health center, and it’s about literally going down to the data element level and saying, ‘These are the data fields in this CCD that have to be redacted, but everything else is fine.’ And then we have to prove that out arduously to these organizations to ask them to submit it. Without that information, and this is common everywhere, an ER doctor has no idea what medication a patient might be taking, such as psychotropic medication, because that information is blocked. That has been the biggest challenge, having to go down to the data element level.”
And, Calanni emphasizes that it has been a coordinated effort by multiple stakeholders—CORHIO, CHP, the state Medicaid agency, and the vendors—to accomplish the data integration. “There are heroes on every one of those circles. We work together to look at, what’s the lightest lift, what makes the most sense, how do we prioritize what data needs to get out—is it allergies, medications, mental health issues? It’s been a very organic, fluid technology drive and we’re still in the middle of it,” he says.