MBA 5401 Analyze Case Study I-4
upporting Mobile Health Clinics: The Children’s Health Fund of New Analyze the case study, and·York City” (on pp. 157-165in the textbook). Consider·develop the conclusions, recommendations, and implications. the implementation challenges in the case and the technologies used to meet them, along with the finalquestions posed at the end of the case. Summarize your findings in a two-page paper·(last paragraph on p. 165) using proper APA formatting.
Supporting Mobile Health Clinics: TheChildren’s Health Fund of New York CityThe Children’s Health FundThe Children’s Health Fund (CHF) develops and supportsa national network of 22 programs and two affiliates in 15to 17 states in the United States and the District ofColumbia. The mission of the CHF is to provide comprehensivehealth care to the nation’s most medicallyunderserved children, from birth up to age 24. In-personprimary health care, mental health, and oral health servicesare delivered by teams of doctors, nurses, dentists,psychologists, social workers, and nutritionists at morethan 200 service sites across the United States inpartnership with pediatric departments and specialists inaffiliated academic medical centers or Federally QualifiedHealth Centers (FQHC).The CHF’s integrated approach to health care isconsistent with the concept of an “enhanced medicalhome” in which continuity of care is ensured via coordinationacross multiple healthcare providers and specialties.In the United States, the Medical Home concept is beingadopted as one aspect of health care reform to ensure ahigh quality standard of care that also seeks to increaseefficiencies and reduce costs for acute care. This type ofintegrated health care delivery is enabled by health informationtechnology (HIT)—not only computer software butalso communications networks.1The cofounder and president of the CHF, Dr. IrwinRedlener, received his M.D. from the University of Miamiin 1969. But his life mission for bringing medical care tounderserved children reportedly began when he was amedical resident in pediatrics at the Children’s Hospital ofDenver and saw a poster for VISTA (Volunteers in Serviceto America) with the words: “If you’re not part of the solution,you’re part of the problem.” Dr. Redlener’s quest tobecome part of the solution began with delivering medicalcare in Lee County, Arkansas, then working on earthquakerelief in Guatemala, followed by serving as medical directorfor USA for Africa, and this poster is hanging in hisoffice today.2An important motivation in my life has been workingwith kids whose situation makes them vulnerablefor reasons out of their control. They are desperatelyill, or living in extreme poverty, or disconnectedfrom medical care. I feel most energized by trying tohelp children who have the fewest resources.—Irwin Redlener3In 1987, Redlener cofounded the Children’s Health Fund(CHF) in New York City. Its initial focus was on pediatriccare for homeless kids, and his cofounder was singer/songwriterPaul Simon. While working for USA for Africa, hehelped solicit the help of other recognized entertainers,including Joan Baez, Harry Belafonte, Lionel Richie, andMichael Jackson. When he learned that Paul Simon wasinterested in doing something for the homeless, he reachedout to him:I was working for USA for Africa, setting up thegrant office in New York City. Paul Simon, who wason the We Are the World record, wanted to do somethingfor the homeless. We visited a number ofwelfare hotels. In the Hotel Martinique [in TimesSquare] a thousand children and their families werewarehoused. Somebody suggested that we should geta van and bring doctors there.—Irwin Redlener4That was the beginning of what would become CHF’snational network of Children’s Health Projects (CHP), inwhich health care is delivered via doctors, nurses, and Copyright © 2010 by Carol V. Brown, Distinguished Professor,and Kevin Ryan, Distinguished Associate Professor, Stevens Institute ofTechnology.1The Medical Home concept, which originated with the AmericanAcademy of Pediatrics in the 1960s, is today being considered as a meansto reinvent primary care in the United States. One of the current barriersto implementation is the fee-for-service reimbursement model within theUnited States.2As reported by Tom Callahan, “Mobilizing for Kids,” Diversion forPhysicians at Leisure (April 15, 2004): 30–32. 3 Ibid.4 Ibid. The “We Are the World” record was made to raise funds for theUSA for Africa’s famine relief efforts. For example, see: http://www.inthe80s.com/weworld.shtml.158 Part I • Information TechnologyEXHIBIT 1 CHF National NetworkCopyright © the Children’s Health Fund. Reproduced with permission. All rights reserved.other professionals in an RV-size mobile medical clinic(MMC) that is driven to locations where the people arewho need it—such as city shelters for homeless families.The flagship program with the first MMC was launched inNYC in 1987, and by 2009 the program had beenexpanded to cities and some deep rural areas withinCHF’s growing national network of clinics. The clinicsare supported by 41 state-of-the-art MMCs (32 medical, 3mental health, 5 dental, 1 public health field office, and 1health education) operating in different programs acrossthe country (see the map in Exhibit 1). By 2009, some hadbeen in service for many years and while not obsolete,lacked some of the newest features, such as modularnetwork cabling and upgraded electrical generators; 7 newMMCs were in some stage of procurement in June 2010.The payments for the medical care provided by CHFprimarily come from four sources: private individual andcorporate donation, congressional aid, and two governmenthealth insurance programs that support children living inpoverty. These programs are Medicaid and the StateChildren’s Health Insurance Program (SCHIP). Medicaidinsures kids whose parents earn little or no money; thefederal government pays part of the costs, but programs areadministered and partially funded by state governments.SCHIP, a newer federal program initiated in 1997, insureschildren in families that earn too much to qualify forMedicaid, but too little to afford private health insurance. InFebruary 2009, President Obama signed a bill thatcontinues funding for SCHIP ($32 billion over the next 4.5years).Mobile Medical Clinics at the Children’sHealth FundCHF’s Mobile Medical Clinics (MMCs) are housed in 36- to44-foot long blue vans, designed to provide a full range ofpediatric primary health care including preventive care (e.g.,childhood vaccinations), diagnosis and management of acuteand chronic diseases, mental health, dental, and health educationservices. In addition to care provided in the mobileclinics, care is provided at stationary clinical sites located inshelters, schools, and community centers, and traditionalhealth clinics (e.g., the South Bronx Health Center forChildren & Families in NYC). The mobile clinics routinelyvisit low-income neighborhoods and homeless and domesticviolence shelters to provide medical services, but MMCsSan Francisco Peninsula, CALos Angeles , CAIdaho Montrose, COArkansasChicago, ILPhiladelphia, PACHF NationalOffice, NYNew York CityProgramsLong Island , NYNew JerseyWashington D.C.West VirginiaMemphis, TNMississippiMississippi Gulf CoastOrlando, FLNew Orleans, LAPhoenix, AZSouthern Arizona, AZAustin, TXDallas, TXChildren’s Health Fund National OfficeChildren’s Health Fund ProgramsAffiliates–Special InitiativesBaton Rouge, LASouth FloridaCase Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 159have also been deployed to provide medical services inresponse to public health crises or emergencies, including the9/11 attacks on the World Trade Center, hurricanes Rita andKatrina in 2005, and the 2010 Gulf of Mexico oil spill.Two primary CHF principles are at the heart of thedesign of the MMCs:• To provide high-quality pediatric primary care aswell as mental health services, dental services, andsocial services to medically underserved populationswith children.• To operate in partnership with a high-quality localmedical institution, such as an academic medicalcenter or FQHC, to ensure access to other medicalexperts as needed as well as coordinated health carefor the local population.Access to reliable, affordable transportation is a major constraintfor those living in poverty at government-sponsoredlocations, as well as areas where there are few health careproviders, known as HPSAs (Health Professional ShortageAreas). To help remove this constraint for low-income andhomeless residents in New York and four other major areas,GlaxoSmithKlein provided a $2.3 million grant to supporttransportation funding in 2004: $35,000 on taxi rides and$20,000 on bus tickets for adults were spent by the DallasChildren’s Health Project (CHP) the prior year. In NewYork, this Referral Management Initiative had dramaticresults: specialist appointment compliance rose from 5 toabout 70 percent.5The medical home concept is based on the premisethat a returning patient will be supported by a trustedhealthcare team who knows the patient and has access todocumentation of his or her health history. Exhibit 25 Tony Hartzel, “Transportation a Vital Health Link,” The Dallas MorningNews (December 19, 2004).EXHIBIT 2 The CHF Medical Mobile Unit (MMU) ModelCopyright © the Children’s Health Fund. Reproduced with permission. All rights reserved. 160 Part I • Information Technologyshows a model of the MMC and its layout, with a separateregistration area and waiting room, a nurse’s station, andexamination rooms.The sides of the blue vans are painted (like“billboards”) to clearly signal that they are CHF units withqualified medical personnel onboard. On a given dayduring a given time period each week, the MMCs arescheduled to be at the same location with the same medicalpersonnel onboard.We don’t just show up like in an ice-cream man mode,give a shot and disappear. The protocol is that everyTuesday from X-time to Y-time the doctor is there.—Jeb Weisman, CIOProviding high-quality primary care from a mobile clinicdoes present some unique challenges for supporting thosewho are delivering the health care, such as:• Designing an environment which is consistent withand will support standard physician office and clinicprocesses. This includes providing the requiredspace and medical equipment to support high qualitydelivery of primary care, including sufficient, highqualityelectrical power.• Complying with regulatory standards such as thoseset forth by JCAHO (e.g., PC locations) and governmentlegislation (e.g., HIPAA laws for privacy andsecurity of personal health information).6• Supporting a mobile unit that operates at multiple,primarily urban, sites—each with its own uniqueenvironmental factors.• Providing computer and communications technologieswithin the MMC that are reliable anddependable, as well as off-site access to technicalsupport.Another important consideration is the overall cost foreach mobile clinic—including the initial costs for a stateof-the-artMMC as well as continuing operating costs. Themajority of the approximately $500,000 capital budget foreach MMC is allocated to the required medical equipmentand associated vehicle requirements (i.e., space, power,and transportation needs). Preventive care via a medicalhome should of course result in long-term cost savings forstate and federal payers as children receive immunizationsand regular health checkups that can avoid costly visitsto hospital emergency rooms, but these are difficult tomeasure. Given the national shortage in primary carephysicians, CHF’s association with a major medical centeralso means that MMC may be part of medical residents’formal training rotation, often in pediatrics or communitymedicine, as part of the medical team.Healthcare Information Systemsto Support Primary CareIn the United States today, it is still not unusual to findpaper-based record keeping in physician practices (referredto as ambulatory or outpatient practices). Two types offunctionality are provided in software packages developedand maintained by vendors who specialize in the healthcareindustry:• Practice Management Systems (PMS) supportadministrative tasks such as patient workflow andthe revenue cycle, with data including patient contactinformation, appointment scheduling, andpatient insurance plan information.• Electronic Medical Record (EMR) systems supportclinicians, such as patient diagnosis, treatment andphysician orders, with data including patient demographics(age, gender), family history information,allergies, medications, and clinical documentation ofdiagnoses, treatments, and outcomes for prior visitsand specialty referrals.By 2008, only 4 percent of physicians in ambulatory settingshad a fully functional EMR; 13 percent had a partiallyfunctional EMR; but 50 percent of those in larger practices(11 or more physicians) had partial or full EMR support.7Some vendors provide packaged solutions with PMSand EMR modules designed to exchange data with each other.However, since some of the clinical packages are designed tospecifically support certain types of care—such as pediatrics,OB/GYN, cardiac care, and so on—specialty practices inparticular may have purchased software from differentvendors. In addition, software that supports electronicprescription transactions to pharmacies and insurers hasrecently been widely adopted as this capability has becomerequired for reimbursements by government and otherinsurers. Investments in software packages to support clinicalprocesses in small practices (1–3 physicians) in particular willbe made at a much faster rate during the second decade of thiscentury due to financial incentives administered by Medicaidand Medicare to eligible physicians who have implemented 6JCHAO (Joint Commission on Accreditation of HealthcareOrganizations) is the accreditation body for healthcare organizations. TheHIPAA (Health Insurance Portability and Accountability Act) PrivacyRule governs all protected health information; the HIPAA Security Rulesets security standards for protected health information maintained ortransmitted in electronic form.7 2007 study by the Institute of Health Policy at Massachusetts GeneralHospital (MGH).Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 161certified electronic health record systems and reported specificmetrics for Meaningful Use beginning in 2011 under theHITECH Act.8The advantages of using computerized health informationsystems were recognized early on by the CHF. JebWeisman, the current CIO, initially joined the organizationin the late 1980s prior to the implementation of the firstMMC to lead the efforts to provide state-of-the-art supportfor the MMCs. Initially a home-grown system was developedand maintained.Given the way the transitional housing system for thehomeless worked at the time—there were enforcedmoves every 3 weeks and that sort of thing—it wasincredibly important that you had a real history.Some of these kids were being immunized half adozen times for measles, by the time they were 6 or 7because if something would show up, it is better togive them shots than not . . . . So you had as much asmedical over-neglect as under-neglect going on.Records are vitally important.—Jeb WeismanIn 1999, CHF partnered with a now defunct vendor todevelop specialized technology for the MMC environment.This system was then phased out in 2007 when CHF partneredwith another leading Electronic Health Record(EHR) software vendor: eClinicalWorks.9 Given the CHF’searly investment in custom software that supported the datacollection of detailed clinical data specifically for pediatriccare, Weisman’s team built in a similar data collectioncapability for use with the commercial software package.Having this detailed information in a standard formatenables high-quality patient–physician interactions on notonly the first but also subsequent visits, in addition to providingthe data needed for referrals. Medically underservedpopulations typically have higher levels of lead in theirbloodstreams, asthma, and other chronic conditions.10One of the record keeping challenges faced by allphysician practices is the integration of laboratory andimaging results with the rest of a patient’s health record.In a paper environment, the test results are typically faxedfrom the facilities performing and interpreting the tests tothe requesting physician, and then paper copies and film(such as x-rays or CAT scans) are filed in the patient’sfolder along with other hard-copy records. When testresults are not received in a timely manner, a nurse or otherstaff member typically makes a call to the test facility’sstaff and can receive the missing record in a relatively shorttime period. Today’s more sophisticated healthcareinformation system (HIS) solutions integrate electronicreports of test results with the patient’s record so that thephysician can quickly access all relevant data with thesame patient record interface.However, maintaining an accurate medical historyfor a patient who lives in poverty and may be residing in ahomeless shelter or other temporary housing is more complicatedthan for patients with a more permanent address.In cities and towns with CHF clinics, a patient served by aspecific clinic in a given neighborhood in the Bronx thi