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.