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Community Health Care Association of New York State

CHCANYS’ Center for Primary Care Informatics (CPCI) High-Performance Data Warehouse Powered by Azara DRVS Supports New York’s Grant-Based Population Health Initiatives

When we connected with Lisa Perry, the Community Health Care Association of New York State’s (CHCANYS) VP of Health IT in 2013, she was building out the CHCANYS Center for Primary Care Informatics (CPCI) and commencing work on a Centers for Disease Control and Prevention (CDC) cancer screening grant.

Now in its sixth year, the CPCI, powered by Azara DRVS, has grown to be an incredibly powerful statewide data warehouse and reporting platform that helps CHCANYS and the community health centers of New York State apply for and manage grant funding to improve population health, prepare for value-based payment, and more. The CPCI also helps meet the data requirements for public health, research, payment reform, and other health network initiatives through the aggregation, processing, and sharing of information from multiple, diverse data sources. Woven into everything they do, the work of Lisa Perry and CHCANYS to secure funding to support the CPCI and technical assistance for the community health centers helps providers achieve the Quadruple AIM – better outcomes, lower costs, and improved patient and clinician experience.

Starting with the CDC cancer screening grant in 2012 and in collaboration with the NY State Department of Health, the CPCI came to life. The grant team worked with providers and clinicians at 46 community health centers representing over 400 sites to set parameters to gather the necessary data to measure performance on cancer screening, follow-up and treatment metrics. Though most centers were not new to EHR use, unforeseen data quality issues emerged and data validation moved to the forefront of the CPCI implementation plan. If CHCANYS was to continue to apply for grants to support their Health IT and performance improvement initiatives, assuring high-quality data was imperative. Azara worked with CHCANYS to create data validation and health center training tools that helped propel the success of the CPCI. 

When centers receive the support they need to achieve quality improvements, everyone wins!
- Lisa Perry, MBA, MPP Senior VP, Quality & Technology Initiatives

In 2013, CHCANYS was awarded a three-year HRSA grant to create the New York Statewide Health Center Controlled Network (NYS-HCCN). Of 50 awards nationwide, CHCANYS received the second largest amount overall and the largest amongst the Primary Care Associations. The availability of the CPCI analytics and reporting engine played a crucial role in this award process. Thirty-three FQHCs joined CHCANYS in the original application, which provides funding for training and technical assistance (T/TA) around the adoption, implementation, and utilization of health information technology. CHCANYS subsequently received another three-year HRSA grant to support forty-three health centers in 2016 to continue and expand upon the NYS-HCCN suite of T/TA support services including using DRVS to bring Health Information Exchange (HIE) data to the FQHC’s.

As word of the CPCI and its capacity spread, CHCANYS attracted new partners and new sources of funding to support its work.

In 2016, CHCANYS started two projects in partnership with The New York University School of Medicine: HealthyHeartsNYC and the Transforming Clinical Practice Initiative. The CPCI was foundational to this work, and the funding supported practice coaching to improve clinical quality and prepare health centers for value-based payment as well as further development of the CPCI. With the consent of individual health centers, NYU researchers were also able to engage in research using health-related data from Azara DRVS.

HealthyHeartsNYC, a collaboration of NYU Langone Medical Center’s Department of Population Health, CHCANYS, and the Primary Care Information Project (PCIP) of New York City’s Department of Health and Mental Hygiene (NYC DOHMH), is a 3-year AHRQ grant-funded project to help primary care practices use the latest evidence-based treatments to improve the heart health of millions of Americans. Requirements for the
New York City-based health centers to participate included the use of an EHR system and connection to the CPCI to support population health management through dashboards and registries and to improve clinical quality measures such as UDS, HEDIS, and others.

The Transforming Clinical Practice Initiative (TCPI) is a Centers for Medicare and Medicaid funded demonstration project that seeks to prepare practices to thrive under value-based payment arrangements. Funded through September of 2019, it aims to help providers improve patient health outcomes, generate cost savings and transition to Alternative Payment Models among other goals. The grant team uses the CPCI, and the DRVS risk stratification and empanelment tools to support the requirements of value-based care.

Through all of these grants, CHCANYS was able to offer training to its staff to qualify as certified practice facilitators (coaches). Today, these coaches are still in place and have helped health center providers and staff work together to leverage tools in DRVS, such as visit planning and care management, to improve care quality, efficiency, and patient outcomes.

“These combined funding sources have allowed us to build our coaching staff to assist in performance improvement efforts across the state,” comments Lisa Perry. “When centers receive the support they need to achieve quality improvements, everyone wins!”

What’s next for CHCANYS and the CPCI? CHCANYS staff is continuing their work to support health centers in achieving the Quintuple AIM, adding Addressing the Social Determinants of Health (SDOH) to the previously mentioned Quadruple AIM. Foundation funding is supporting an ongoing initiative to collect, analyze and act upon data on patients’ social determinants of health using the PRAPARE tool for patient screening. CPCI also plays a role in this work, as the PRAPARE data populates registries that can be used to understand and address the SDOHs with the greatest impact on a patient community. CHCANYS is also waiting to hear about a significant grant where the CPCI will play a vital role in the analysis and reporting to support quality improvement relating to diabetes and hypertension across the state.

“Building the CPCI with Azara and our health centers over the past five years has been a journey for all of us,” said Lisa Perry. “Together, we have created a powerful data platform that positions our health centers, as they move into value-based care and payment, with a robust infrastructure to continue to serve our most vulnerable populations.”