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ACCEL (Access El Dorado). El Dorado County Wide Health Initiative April 16, 2008 Greg Bergner, M.D. & Sandra Dunn, MSc. Briefing Topics. History & Evolution of Goals Health Information Technology (HIT) Programs Care Pathways Privacy Practice EMPI 2008 ACCEL Focus. Background.

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accel access el dorado

ACCEL(Access El Dorado)

El Dorado County Wide Health Initiative

April 16, 2008

Greg Bergner, M.D. & Sandra Dunn, MSc

briefing topics
Briefing Topics
  • History & Evolution of Goals
  • Health Information Technology (HIT) Programs
  • Care Pathways
  • Privacy Practice
  • EMPI
  • 2008 ACCEL Focus
    • ACCEL (Access El Dorado) is a county wide health collaborative serving the uninsured,
    • underinsured and residents of El Dorado County, approximately 178,000 people
    • Situated in east central CA, 1,805 square miles of rolling hills, mountainous terrain
    • (the Sierra Nevada range), topographically divided into two zones, Lake Tahoe Basin and
    • the Western Slope
    • ACCEL Participants
    • Hospitals: Barton Memorial & Marshall Medical
    • Clinics: Tribal - Shingle Springs Tribal Health
        • Rural Clinics - Divide Wellness & Barton Community Clinic
        • FQHC - El Dorado County Community Health Center
  • County: Department of Public Health & Department of Mental Health
  • Private Providers
        • Marshall Physician Services
        • Tahoe Family Physicians
accel history













  • New areas of collaboration between hospitals and small businesses
  • Joined CalRHIO
  • Mounted technology vendor RFI for CP
  • Community clinics share best practices
  • Regional Healthy Kids insurance
  • 1st Care Pathways implemented WS
  • Community needs assessment
  • Recommend health initiatives to improve access
  • ACCEL formed to improve EDC health
  • Outreach, enrollment program started to increase access
  • Provider network development
  • Education & practice management
  • Com. Clinics improved
  • Barton rural clinic expanded
  • FQHC opened
  • Care Pathways (CP) introduced
  • California Kids (Gap) insurance
  • HIT plan identified
  • EMPI & Health Info Exchange investigated
  • HRA employee screening
  • HIE business case developed
  • Formal governance established
  • Care Pathways implemented SLT
  • Vendor agreement
  • Technology Bs.Rules for Care Pathways & EMPI
  • Privacy & Security Policies/Procedures
  • Health Alliance convened by Board of Superv.


Tobacco Master Settlement (TMS)

  • AHRQ
  • Blue Shield Found.
  • Planning for future funding



TMS, HCAP,AHRQ (multi-yr) techn. Implem. grant



Blue Shield Found.

ACCEL History


AHRQ Planning Grant


HCAP Grant to PHD

evolution of goals and objectives
Improve access to medical care for individuals, particularly children and the uninsured, in El Dorado County by:

Developing an outreach, enrollment and retention program to assist individuals enroll in low and no cost public health insurance

Securing a ‘Gap’ insurance product for children up to 300% of FPL who did not qualify for public insurance

Reduce the barriers to care for the publicly insured by:

Increasing clinic capacity through clinic redesign

Expanding rural clinics

Establishing a new FQHC

Developing public network utilizing private physicians

Improve the quality of health care and administrative efficiency in El Dorado County by:

Continuing to improve access to medical care through ongoing program nurturance and the development of enabling technology

Creating county-wide shared patient records across institutions (EMPI & 1st Gen HIE)

Establishing standardized processes with measurable outcomes (Care Pathways) to coordinate care at critical entry junctures

Building community trust and program linkages

Enhance health surveillance through the monitoring of aggregate data

Public health early casefinding

Chronic disease monitoring

Identify long-term strategic goals

Implement personal health record accessible to providers

Create a county-wide Health Information Exchange which can link to CalRHIO

Evolution of Goals And Objectives

2002 - 2005 Goals

2006 - 2009 Goals

health information technology programs

ACCEL emphasizes implementation:

Staged technology enabled programs: 1. Care Pathways, 2. EMPI, 3. HIE

  • Formal governance established
  • Privacy & Security Policies & Procedures
  • Long-term financial sustainability pursued
  • 2. EMPI:
  • Notification of Privacy Practices (NPP)
  • Initial ‘demographic’ data sharing
  • 1. Care Pathways:
  • Cross Agency Multiple Pathways 1st implemented (via paper process)
  • Vendor procured, business rules defined, IT specs, configuration & test, training dev, end user training, Go-Live Feb 2008
  • NPP implemented simultaneously
  • 3. Health Information Exchange (HIE):
  • Business Case completed
  • High level clinical data Identified
  • EMPI is foundational to goal achievement
  • Technology vendor alternatives explored
  • 1st Gen demonstration project explored
Health Information Technology Programs
care pathway background
Care Pathways Constructs

Adapted from Ohio CHAPs program

Definition: Outcome focused Cross Agency patient case management with standardized processes (mimics industrial production line concept)

Requires clear Identification of the Problem to solve and Outcome to achieve

Uses a ‘coach’ (Community Health Worker) as the patient navigator

Captures barriers, issues that stall patient progress and /or prevent Outcome completion

Common language, patient eligibility criteria, cross agency work steps & user responsibilities defined

Care Pathway Development Realities

Focuses currently on children at or below 300% of FPL

Takes 6-9 months to define & test

Requires substantial time commitment from multiple Agency representatives

Development / implementation time line is dependent upon Participant agencies level of engagement

Problem selection should take into account the incidence of problem occurrence, more numerous problems support quantified value proposition more readily

Current reimbursement policies are based upon payment for activities versus outcomes; without change sustainability may be jeopardized

Care Pathway Background
care pathway background1
ACCEL Care Pathways

Securing Health Care Coverage

(Newborns) Securing Health Care Coverage

Obtaining a Medical Home

Utilizing a Medical Home

Pediatric Mental Health Consults

Annual (insurance) Eligibility Review

Defined Care Pathway Problem & Outcome

Problem- no health insurance; Outcome - enrollment of child in public or privately funded health insurance

Problem- no health insurance; Outcome- newborn enrollment in health insurance

Problem- non urgent child presenting at ER for primary care; Outcome- child has one visit in new medical home

Problem- no newborn medical home; Outcome- 4 well baby visits + IZs

Problem- PCP needs consult for pediatric case w/ MH issues; Outcome- expedited MH visit with eval to PCP

Problem- Insurance at term; Outcome- renewal supported, eligibility extended

Care Pathway Background
care pathway status
Care Pathway Status

Care Pathways Web software is live! Participant technology implementation has been staged to support training / QA, on-site testing and the simultaneous activation of NPP

Barton Hospital is ACCEL’s technology hub. Barton’s Director of Technology is ACCEL’s Chief Technology Officer

Public Health Department is ACCEL’s hub for Community Health Workers who educate, coach patients

2 of 6 Care Pathways are in use electronically. All should be in use by early summer.

securing a medical home results
‘Securing a Medical Home’ Results

Demo Start August 2006

Client Criteria Pediatric ( >1 yr / age at or below 300% FPL) non urgent patient presenting at ER w/out PCP

Referral Source Marshall ER

# of Clients 252

Outcome Medical Home secured w/ 1 visit with PCP post ER

% Success 202 kids ((80%)

Pending 9 kids (4%)

Barriers no parent follow thru, moved out of county, no shows at clinic

PCP assignment 60 % FQHC, 6% Tribal, 34% Private Providers

process taken to address privacy practices
Process Taken to Address Privacy Practices
  • Guidance from key sources: Connecting for Health Framework
  • (, Tennessee MidSouth eHEALTH
  • Alliance (, outside legal counsel, HIPAA, California State law
  • Workshop educated multi-disciplinary stakeholders on Privacy topics
  • Steering Committee adopted overarching principles
    • Notification of Privacy Practices NPP
    • Privacy & Security Policies are the driver for Technology not the other way around
    • Security addressed separately from privacy
  • Chartered Privacy & Security workgroup to recommend policy language to Steering
  • Committee
  • Participant Memorandum of Understanding, governance agreement was
  • Developed, adopted
  • Participant Operations Cost to implement ACCEL NPP were defined, e.g. changes to existing
  • privacy forms, printing, distribution and training with staff to implement, programming
  • of registration systems to capture/track ACCEL patient NPP status


notification privacy practice npp principles
Notification Privacy Practice (NPP) Principles
  • Definitions

inclusive NPP process assumes patients confirms sharing of information to ACCEL Participant

unless they specifically decline or “opt out”

common language means that the wording for ACCEL NPP is identical across all

network Participants regardless of registration process

applies to all network Participants indicates that patient verified NPP outcome at any location applies

to all ACCEL network Participants (“global vs.. local”)


Maximum acceptance, simplicity and comparative ease of implementation outweigh potential risk

of inadequate patient understanding


Participants insure their internal policies and procedures are current, apply to access to ACCEL

System and use of ACCEL services

Process for withdrawal of NPP must be developed across all Participants with cross agency

communication process established

Patient education and notification efforts should be consistent across all network Participants

Participants will apply ‘consent, Opt-in’ for special patient categories

notification privacy practice npp status
Notification Privacy Practice (NPP) Status
  • ACCEL NPP common language, Fact Sheet & Talking Points (for end users interface with patients)
  • Were created for use by Participants. Materials are in English and Spanish.
  • ACCEL NPP and Care Pathways technology have gone live in a staged manner. By April 21, 2008
  • All Participants will be administering the NPP
  • Evaluation of NPP Opt-outs frequency will be viewed in total and by registration site 120 days
  • from April 21st by the Steering Committee
  • EMPI demonstration project is between Department of Public Health, Barton
  • Hospital, Barton Community Clinic and Tahoe Family Physicians
  • Objective for EMPI with NPP is that it will support pre populating patient demographic information into the Care Pathways technology and ultimately support a more efficient patient registration experience. A future objective is that ultimately the EMPI will serve as master patient rolodex for both the Care Pathways and HIE.
  • Tracking patient NPP status will be handled in the EMPI. Assuring that this occurs accurately and timely, requires thorough review of NPP patient scenarios to clarify business rules, that the rules are compliant with ACCEL NPP policy, and clear definition of technology programming specifications
  • Patient Data into EMPI will be from Participant NPP Go-Live date
  • Demonstration project sites have reviewed their patient types for any special
  • Patient carve outs
  • Data interface feeds will take 2 different formats (XML, HL7) given different Participant patient technology, in-house IT bench strength, etc.
  • EMPI Console, Participant specific repository will capture patient NPP changes and as well as inaccurate patient data to be amended in Participant MPI
2008 accel focus
2008 ACCEL Focus
  • Complete implementation of Care Pathway’s technology at all Participant sites
  • Complete EMPI implementation demonstration pilot
  • Extend important foundational HIE work
  • Extend specialty referral network / patient access program,improving quality of referrals and confidence in primary care work up and treatment
  • Embark upon expanded community engagement with ACCEL
  • Revisit Governance Agreements and Policies, amend as needed
  • Define and commit to a long term Sustainability Plan

Thank you!ACCEL Bergner, M.D. bergner@sbcglobal.netSandra Dunn, MSc, (916-939-7039)

This project was supported by grant funds from Blue Shield of California Foundation.

And, the project was supported by grant number UC1HS016129 from the Agency for Healthcare Research and Quality.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the

Agency for Healthcare Research and Quality.