Community Health Centers and HIT
Driving Innovation in the Patient-Centered
Medical Home
Alliance for Health Reform Briefing:
Medicaid and Health IT
Presented by:
Judith Featherstone MD, FAAFP
Medical Director
August 1, 2011
Health Centers Today
Today, Health Centers serve as the health care home for more
than 20 million patients nationally, including:
• 1 in 7 Medicaid beneficiaries
• 1 in 7 uninsured persons
• 1 in 3 individuals in poverty
• 1 in 7 rural Americans
*Includes patients of federally-funded health centers, non-federally funded health centers or “Look-Alikes”
HealthPoint: Your Community Health Center
HealthPoint is the largest CHC in the 14th largest
county in the US.
 12 Clinics: 7 medical, 4 dental, 1 school-based
 Patients = 62,542, Visits = 210,865
 Medicaid, Medicare and Public Insurance- 55%
 Uninsured – 37%
 In addition to primary medical and dental care, services
 Prenatal care and delivery
 Complementary and alternative medicine including naturopathic
medicine, acupuncture and nutrition counseling
 Behavioral health
 Pharmacies in all clinics
HealthPoint Patients
Patient race/ethnicity
Other, 4%
Patient income by Federal Poverty Level
Black / African
Amercian, 12%
201% +, 4%
Islander, 13%
101 - 200%,
0 - 100%, 58%
Patient by insurance
Patients, 37%
Medicaid, Basic
Health, 55%
Insurance, 8%
Health Centers and HIT: National Perspective
Nationally, three quarters of all health centers are now on the road to
adopting integrated health information technology systems.
HealthPoint Perspective
2005 Electronic Health Record/ Practice Management Adoption
2007 Quality of Care Outcomes Reports
2007 Immunization Data Interface with the State Registry
2008 Population Recall Reports
2008-11 Templates for Behavioral Health, MSS, Homeless care
2008 Electronic Prescribing
2010 Internal Pharmacy System Integrates with EHR,
2010 Electronic Dental Record Integrates with EHR,
2011 Billing from EHR
2011 Future: Patient Portal, HIE, Enhanced Reporting and Decision
Challenges to Adopting Health IT
• Equipment
• Staff training
• Provider use
• Reassignment of
Medicaid HIT Incentive
Opportunities for Health IT Support
• Medicaid HIT Incentive
• Health Center
Controlled Networks
• Primary Care
• Regional Extension
Health Centers and HIT: National Perspective
Health centers use Health IT in varied ways to meet the needs of their
patients, for example…
Telehealth: patients, including those in rural or remote areas, can
“see” a provider for screenings, behavioral health encounters,
remote eye exams, and chronic disease management.
Referral Tracking: the record, patient history, medication and Rx plan
follows the patient across health center sites and other health care
Personal Chronic Care Management: electronic records notify
providers and patients when it’s time for a check up or check in.
Innovations at HealthPoint
• Specialist guidelines for
referrals built into EHR.
• Coordination of EDR and
• Tracking referral completion
• Managing for quality of care
• Reports on health disparities
to target community
• Video interpretation
• Mobile phones for health
• Website with links to
mobile applications for
healthy living.
• Telepharmacies
Health IT: Improving the PCMH
Patient Experience
Time of visit activities
Invite in for individual visit or
group with cohort.
Coordinate with specialists, ER
and hospital, decrease
redundant work.
Decision support built in for
referral appropriateness,
referral preparation, evidence
based testing.
Population Care
Outreach to patients due for
health maintenance services
Outreach to patients with chronic
diseases which are uncontrolled
or due for monitoring.
Reports can guide us in setting up
appropriate systems such as
community health workers for
new immigrant populations.
Develop interventions targeting
obesity based on our reports
including language and
Health IT: Improving the PCMH
Patient-Centered Medical Home
Six standards align with the core components of primary care
1)Enhance Access and Continuity
2)Identify and Manage Patient Populations
3)Plan and Manage Care
4)Provide Self-Carte Support and Community Resources
5)Track and Coordinate Care
6)Measure and Improve Performance
Health IT is vital to meet these standards.

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