HCCN Objectives:
Objective A1: Patient Access
Description: Increase the percentage of PHCs using health IT to facilitate patients’ access to their personal health information (e.g., patient history, test results, shared electronic care plans, self-management tools).
Numerator: Number of PHCs with at least 50 percent of patients having accessed their patient portal accounts within the last 12 months
Resources:
- Patient Question Builder App
- Health Literacy- A Guide for Simplifying the User Experience
- Patient Access Information for Individuals: Get it, Check it, Use it!
- Achieving Meaningful Use
Objective A2: Patient Engagement
Description: Increase the percentage of PHCs improving patient engagement with their health care team by advancing health IT and training (e.g., patient use of remote monitoring devices, better medication adherence with text reminders).
Numerator: Number of PHCs with at least 30 percent of patients who have used a digital tool (e.g., electronic messages sent through the patient portal to providers, remote monitoring) between visits to communicate health information with the PHC within the last 12 months.
Resources:
- Patient Engagement Playbook- Health IT.Gov
- Patient Engagement and Education – One-Stop Shopping for AHRQ Health Literacy Tools
- Viewing Patients as Partners: Patient Portal Implementation and Adoption
- Community Health Center Adoption Framework for Electronic Patient Engagement
Objective A3: Provider Burden
Description: Increase the percentage of PHCs that improve health IT usability to minimize provider burden (e.g., align EHRs with clinical workflows, improve structured data capture in and/or outside of EHRs).
Numerator: Number of PHCs that have improved provider satisfaction (e.g. survey results) through implementation of at least one HIT facilitated intervention (e.g. improved CDS, EHR template customization/optimization, telehealth, eConsults, mobile health, dashboards, other reporting tools) within the last 12 months.
Resources:
Objective B1: Data Protection
Description: Increase the percentage of PHCs that have completed a security risk analysis and have a breach mitigation and response plan.
Numerator: Number of PHCs that have implemented a breach mitigation and response plan based on their annual security risk assessment.
Resources:
- Cybersecurity Checklist for health center staff working remotely
- HIPAA Security Rule Toolkit
- Security Risk Assessment Tool
- Health Center Defense Against the Dark Web PPT
- Cybersecurity HITEQ Power point
Objective B2: Health Information Exchange
Description: Increase the percentage of PHCs that leverage HIE to meet Health Level Seven International (HL7) standards or national standards as specified in the ONC Interoperability Standards Advisory and share information securely with other key providers and health systems.
Numerator: Number of PHCs that transmitted summary of care record to at least 3 external health care providers and/or health systems in the last 12 months using certified EHR technology through platforms that align with HL7 or national standards specified in the ONC Interoperability Standards Advisory.
Resources:
- Evidence of HIE impact for Health Centers
- Should Health Centers Participate in Health Information Exchange
- Vendors and Communities Working Together: A Catalyst for Interoperability and Exchange
- Glossary of HIE terms and links to related sites
- HITEQ Highlights: Using Health Information Technology to Facilitate SBIRT Service Delivery in Health Centers Webinar
Objective B3: Data Integration
Description: Increase the percentage of PHCs that consolidate clinical data with data from multiple clinical and non-clinical sources across the health care continuum (e.g., specialty providers, departments of health, care coordinators, social service/housing organizations) to optimize care coordination and workflows.
Numerator: In the last 12 months, the number of PHCs that have integrated data into structured EHR fields (i.e., not free text or attachments) from at least 3 external clinical and/or non-clinical sources.
Resources:
- HITEQ Highlights: Managing Data as a Strategic Asset: Data Governance Webinar
- Integrating Internal and External Data into a Health Center’s Primary Care Services
- Utilizing and Integrating Behavioral Health Data into a Health Center’s Primary Care Services
- Connecting Health and Care for the Nation
Objective C1: Data Analysis
Description: Increase the percentage of PHCs that improve capacity for data standardization, management, and analysis to support value-based care activities (e.g., improve clinical quality, achieve efficiencies, reduce costs).
Numerator: Number of PHCs using a dashboard and/or standard reports to present useful data to inform value-based care activities (e.g., improve clinical quality, achieve efficiencies, reduce costs) in the last 12 months.
Resources:
- Building Data Teams and Skills: Maximizing Data Literacy and Data Governance for a Data Driven Culture
- HITEQ Highlights: Managing Data as a Strategic Asset: Data Governance Fundamentals Webinar
- Demystifying Predictive Analytics Factsheet on Predictive Analytics for Health Centers
Objective C2: Social Risk Factor Intervention
Description: Increase the percentage of PHCs that use both aggregate and patient-level data on social risk factors to support coordinated, effective interventions.
Numerator: Number of PHCs that use health IT to collect or share social risk factor data with care teams and use this data to inform care plan development on at least 50 percent of patients identified as having a risk factor (e.g. care teams use patient reported data on food insecurity or other social risk factors to better tailor care plans/interventions and community referrals to improve chronic disease management and outcomes) in the last 12 months.
Resources:
- Using Social Determinants of Health Data & New Technology Tools to Connect with Appropriate Community Resources
- Panel Management in the Age of Value-Based Care
- Developing a Data Dashboard for PRAPARE Data Webinar
- Population Health Management, Social Determinants of Health and How These Fit
Objective C3: Applicant Choice
Description: Applicants will develop an objective and outcome measure to address an emerging issue based on the needs of the PHCs in their network (e.g., addressing substance use disorder, improving interoperability with Prescription Drug Monitoring Programs, utilizing telemedicine to improve access, participating in precision medicine initiatives).
Numerator: N/A
Resources:
- HIPAA and Telehealth-A Stepwise Guide to Compliance Factsheet
- Telehealth and Telephone Visits in the Time of COVID-19: FQHC Workflows and Guides
- COVID-19 Telehealth Toolkit
- Telehealth 101
- HIPAA and Telehealth
