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MBA 5401 Analyze Case Study I-4

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supporting Mobile Health Clinics: The Children’s Health Fund of New York City” (on pp. 157-165in the textbook).· Analyze the case study, and develop the conclusions, recommendations, and implications.· Consider the implementation challenges in the case and the technologies used to meet them, along with the finalquestions posed at the end of the case. (last paragraph on p. 165)· Summarize your findings in a two-page paper using proper APA formatting.

Supporting Mobile Health Clinics: TheChildren’s Health Fund of New York CityThe Children’s Health FundThe Children’s Health Fund (CHF) develops and supportsa national network of 22 programs and two affiliates in 15to 17 states in the United States and the District ofColumbia. The mission of the CHF is to provide comprehensivehealth care to the nation’s most medicallyunderserved children, from birth up to age 24. In-personprimary health care, mental health, and oral health servicesare delivered by teams of doctors, nurses, dentists,psychologists, social workers, and nutritionists at morethan 200 service sites across the United States inpartnership with pediatric departments and specialists inaffiliated academic medical centers or Federally QualifiedHealth Centers (FQHC).The CHF’s integrated approach to health care isconsistent with the concept of an “enhanced medicalhome” in which continuity of care is ensured via coordinationacross multiple healthcare providers and specialties.In the United States, the Medical Home concept is beingadopted as one aspect of health care reform to ensure ahigh quality standard of care that also seeks to increaseefficiencies and reduce costs for acute care. This type ofintegrated health care delivery is enabled by health informationtechnology (HIT)—not only computer software butalso communications networks.1The cofounder and president of the CHF, Dr. IrwinRedlener, received his M.D. from the University of Miamiin 1969. But his life mission for bringing medical care tounderserved children reportedly began when he was amedical resident in pediatrics at the Children’s Hospital ofDenver and saw a poster for VISTA (Volunteers in Serviceto America) with the words: “If you’re not part of the solution,you’re part of the problem.” Dr. Redlener’s quest tobecome part of the solution began with delivering medicalcare in Lee County, Arkansas, then working on earthquakerelief in Guatemala, followed by serving as medical directorfor USA for Africa, and this poster is hanging in hisoffice today.2An important motivation in my life has been workingwith kids whose situation makes them vulnerablefor reasons out of their control. They are desperatelyill, or living in extreme poverty, or disconnectedfrom medical care. I feel most energized by trying tohelp children who have the fewest resources.—Irwin Redlener3In 1987, Redlener cofounded the Children’s Health Fund(CHF) in New York City. Its initial focus was on pediatriccare for homeless kids, and his cofounder was singer/songwriterPaul Simon. While working for USA for Africa, hehelped solicit the help of other recognized entertainers,including Joan Baez, Harry Belafonte, Lionel Richie, andMichael Jackson. When he learned that Paul Simon wasinterested in doing something for the homeless, he reachedout to him:I was working for USA for Africa, setting up thegrant office in New York City. Paul Simon, who wason the We Are the World record, wanted to do somethingfor the homeless. We visited a number ofwelfare hotels. In the Hotel Martinique [in TimesSquare] a thousand children and their families werewarehoused. Somebody suggested that we should geta van and bring doctors there.—Irwin Redlener4That was the beginning of what would become CHF’snational network of Children’s Health Projects (CHP), inwhich health care is delivered via doctors, nurses, and Copyright © 2010 by Carol V. Brown, Distinguished Professor,and Kevin Ryan, Distinguished Associate Professor, Stevens Institute ofTechnology.1The Medical Home concept, which originated with the AmericanAcademy of Pediatrics in the 1960s, is today being considered as a meansto reinvent primary care in the United States. One of the current barriersto implementation is the fee-for-service reimbursement model within theUnited States.2As reported by Tom Callahan, “Mobilizing for Kids,” Diversion forPhysicians at Leisure (April 15, 2004): 30–32. 3 Ibid.4 Ibid. The “We Are the World” record was made to raise funds for theUSA for Africa’s famine relief efforts. For example, see: http://www.inthe80s.com/weworld.shtml.158 Part I • Information TechnologyEXHIBIT 1 CHF National NetworkCopyright © the Children’s Health Fund. Reproduced with permission. All rights reserved.other professionals in an RV-size mobile medical clinic(MMC) that is driven to locations where the people arewho need it—such as city shelters for homeless families.The flagship program with the first MMC was launched inNYC in 1987, and by 2009 the program had beenexpanded to cities and some deep rural areas withinCHF’s growing national network of clinics. The clinicsare supported by 41 state-of-the-art MMCs (32 medical, 3mental health, 5 dental, 1 public health field office, and 1health education) operating in different programs acrossthe country (see the map in Exhibit 1). By 2009, some hadbeen in service for many years and while not obsolete,lacked some of the newest features, such as modularnetwork cabling and upgraded electrical generators; 7 newMMCs were in some stage of procurement in June 2010.The payments for the medical care provided by CHFprimarily come from four sources: private individual andcorporate donation, congressional aid, and two governmenthealth insurance programs that support children living inpoverty. These programs are Medicaid and the StateChildren’s Health Insurance Program (SCHIP). Medicaidinsures kids whose parents earn little or no money; thefederal government pays part of the costs, but programs areadministered and partially funded by state governments.SCHIP, a newer federal program initiated in 1997, insureschildren in families that earn too much to qualify forMedicaid, but too little to afford private health insurance. InFebruary 2009, President Obama signed a bill thatcontinues funding for SCHIP ($32 billion over the next 4.5years).Mobile Medical Clinics at the Children’sHealth FundCHF’s Mobile Medical Clinics (MMCs) are housed in 36- to44-foot long blue vans, designed to provide a full range ofpediatric primary health care including preventive care (e.g.,childhood vaccinations), diagnosis and management of acuteand chronic diseases, mental health, dental, and health educationservices. In addition to care provided in the mobileclinics, care is provided at stationary clinical sites located inshelters, schools, and community centers, and traditionalhealth clinics (e.g., the South Bronx Health Center forChildren & Families in NYC). The mobile clinics routinelyvisit low-income neighborhoods and homeless and domesticviolence shelters to provide medical services, but MMCsSan Francisco Peninsula, CALos Angeles , CAIdaho Montrose, COArkansasChicago, ILPhiladelphia, PACHF NationalOffice, NYNew York CityProgramsLong Island , NYNew JerseyWashington D.C.West VirginiaMemphis, TNMississippiMississippi Gulf CoastOrlando, FLNew Orleans, LAPhoenix, AZSouthern Arizona, AZAustin, TXDallas, TXChildren’s Health Fund National OfficeChildren’s Health Fund ProgramsAffiliates–Special InitiativesBaton Rouge, LASouth FloridaCase Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 159have also been deployed to provide medical services inresponse to public health crises or emergencies, including the9/11 attacks on the World Trade Center, hurricanes Rita andKatrina in 2005, and the 2010 Gulf of Mexico oil spill.Two primary CHF principles are at the heart of thedesign of the MMCs:• To provide high-quality pediatric primary care aswell as mental health services, dental services, andsocial services to medically underserved populationswith children.• To operate in partnership with a high-quality localmedical institution, such as an academic medicalcenter or FQHC, to ensure access to other medicalexperts as needed as well as coordinated health carefor the local population.Access to reliable, affordable transportation is a major constraintfor those living in poverty at government-sponsoredlocations, as well as areas where there are few health careproviders, known as HPSAs (Health Professional ShortageAreas). To help remove this constraint for low-income andhomeless residents in New York and four other major areas,GlaxoSmithKlein provided a $2.3 million grant to supporttransportation funding in 2004: $35,000 on taxi rides and$20,000 on bus tickets for adults were spent by the DallasChildren’s Health Project (CHP) the prior year. In NewYork, this Referral Management Initiative had dramaticresults: specialist appointment compliance rose from 5 toabout 70 percent.5The medical home concept is based on the premisethat a returning patient will be supported by a trustedhealthcare team who knows the patient and has access todocumentation of his or her health history. Exhibit 25 Tony Hartzel, “Transportation a Vital Health Link,” The Dallas MorningNews (December 19, 2004).EXHIBIT 2 The CHF Medical Mobile Unit (MMU) ModelCopyright © the Children’s Health Fund. Reproduced with permission. All rights reserved. 160 Part I • Information Technologyshows a model of the MMC and its layout, with a separateregistration area and waiting room, a nurse’s station, andexamination rooms.The sides of the blue vans are painted (like“billboards”) to clearly signal that they are CHF units withqualified medical personnel onboard. On a given dayduring a given time period each week, the MMCs arescheduled to be at the same location with the same medicalpersonnel onboard.We don’t just show up like in an ice-cream man mode,give a shot and disappear. The protocol is that everyTuesday from X-time to Y-time the doctor is there.—Jeb Weisman, CIOProviding high-quality primary care from a mobile clinicdoes present some unique challenges for supporting thosewho are delivering the health care, such as:• Designing an environment which is consistent withand will support standard physician office and clinicprocesses. This includes providing the requiredspace and medical equipment to support high qualitydelivery of primary care, including sufficient, highqualityelectrical power.• Complying with regulatory standards such as thoseset forth by JCAHO (e.g., PC locations) and governmentlegislation (e.g., HIPAA laws for privacy andsecurity of personal health information).6• Supporting a mobile unit that operates at multiple,primarily urban, sites—each with its own uniqueenvironmental factors.• Providing computer and communications technologieswithin the MMC that are reliable anddependable, as well as off-site access to technicalsupport.Another important consideration is the overall cost foreach mobile clinic—including the initial costs for a stateof-the-artMMC as well as continuing operating costs. Themajority of the approximately $500,000 capital budget foreach MMC is allocated to the required medical equipmentand associated vehicle requirements (i.e., space, power,and transportation needs). Preventive care via a medicalhome should of course result in long-term cost savings forstate and federal payers as children receive immunizationsand regular health checkups that can avoid costly visitsto hospital emergency rooms, but these are difficult tomeasure. Given the national shortage in primary carephysicians, CHF’s association with a major medical centeralso means that MMC may be part of medical residents’formal training rotation, often in pediatrics or communitymedicine, as part of the medical team.Healthcare Information Systemsto Support Primary CareIn the United States today, it is still not unusual to findpaper-based record keeping in physician practices (referredto as ambulatory or outpatient practices). Two types offunctionality are provided in software packages developedand maintained by vendors who specialize in the healthcareindustry:• Practice Management Systems (PMS) supportadministrative tasks such as patient workflow andthe revenue cycle, with data including patient contactinformation, appointment scheduling, andpatient insurance plan information.• Electronic Medical Record (EMR) systems supportclinicians, such as patient diagnosis, treatment andphysician orders, with data including patient demographics(age, gender), family history information,allergies, medications, and clinical documentation ofdiagnoses, treatments, and outcomes for prior visitsand specialty referrals.By 2008, only 4 percent of physicians in ambulatory settingshad a fully functional EMR; 13 percent had a partiallyfunctional EMR; but 50 percent of those in larger practices(11 or more physicians) had partial or full EMR support.7Some vendors provide packaged solutions with PMSand EMR modules designed to exchange data with each other.However, since some of the clinical packages are designed tospecifically support certain types of care—such as pediatrics,OB/GYN, cardiac care, and so on—specialty practices inparticular may have purchased software from differentvendors. In addition, software that supports electronicprescription transactions to pharmacies and insurers hasrecently been widely adopted as this capability has becomerequired for reimbursements by government and otherinsurers. Investments in software packages to support clinicalprocesses in small practices (1–3 physicians) in particular willbe made at a much faster rate during the second decade of thiscentury due to financial incentives administered by Medicaidand Medicare to eligible physicians who have implemented 6JCHAO (Joint Commission on Accreditation of HealthcareOrganizations) is the accreditation body for healthcare organizations. TheHIPAA (Health Insurance Portability and Accountability Act) PrivacyRule governs all protected health information; the HIPAA Security Rulesets security standards for protected health information maintained ortransmitted in electronic form.7 2007 study by the Institute of Health Policy at Massachusetts GeneralHospital (MGH).Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 161certified electronic health record systems and reported specificmetrics for Meaningful Use beginning in 2011 under theHITECH Act.8The advantages of using computerized health informationsystems were recognized early on by the CHF. JebWeisman, the current CIO, initially joined the organizationin the late 1980s prior to the implementation of the firstMMC to lead the efforts to provide state-of-the-art supportfor the MMCs. Initially a home-grown system was developedand maintained.Given the way the transitional housing system for thehomeless worked at the time—there were enforcedmoves every 3 weeks and that sort of thing—it wasincredibly important that you had a real history.Some of these kids were being immunized half adozen times for measles, by the time they were 6 or 7because if something would show up, it is better togive them shots than not . . . . So you had as much asmedical over-neglect as under-neglect going on.Records are vitally important.—Jeb WeismanIn 1999, CHF partnered with a now defunct vendor todevelop specialized technology for the MMC environment.This system was then phased out in 2007 when CHF partneredwith another leading Electronic Health Record(EHR) software vendor: eClinicalWorks.9 Given the CHF’searly investment in custom software that supported the datacollection of detailed clinical data specifically for pediatriccare, Weisman’s team built in a similar data collectioncapability for use with the commercial software package.Having this detailed information in a standard formatenables high-quality patient–physician interactions on notonly the first but also subsequent visits, in addition to providingthe data needed for referrals. Medically underservedpopulations typically have higher levels of lead in theirbloodstreams, asthma, and other chronic conditions.10One of the record keeping challenges faced by allphysician practices is the integration of laboratory andimaging results with the rest of a patient’s health record.In a paper environment, the test results are typically faxedfrom the facilities performing and interpreting the tests tothe requesting physician, and then paper copies and film(such as x-rays or CAT scans) are filed in the patient’sfolder along with other hard-copy records. When testresults are not received in a timely manner, a nurse or otherstaff member typically makes a call to the test facility’sstaff and can receive the missing record in a relatively shorttime period. Today’s more sophisticated healthcareinformation system (HIS) solutions integrate electronicreports of test results with the patient’s record so that thephysician can quickly access all relevant data with thesame patient record interface.However, maintaining an accurate medical historyfor a patient who lives in poverty and may be residing in ahomeless shelter or other temporary housing is more complicatedthan for patients with a more permanent address.In cities and towns with CHF clinics, a patient served by aspecific clinic in a given neighborhood in the Bronx thismonth may be domiciled in a different shelter in a differentborough and show up at a permanent clinic or MMC in adifferent location in NYC the next month. To retrieve arecord from another clinic may require a phone call andfax capabilities.Both telephone and fax capabilities are therefore basicrequirements for not only retrieving missing data but alsoconsulting with other medical experts, and supporting patientreferrals to other clinicians, including specialists. Anideal solution to capture the patient data that have previouslybeen collected for the same patient—especially when thesame software package is being used at multiple clinics—would be to have it available in structured electronic form.Connectivity Needs to Support MobileMedical ClinicsThere are therefore two primary communications needsfor clinicians to deliver quality healthcare via a mobileclinic: (1) access to patient data previously captured atanother medical facility (or MMC) but not yet available inthe patient record system in the clinic and (2) access topersonnel at another medical facility for either an emergencyconsult or referral, or a more routine referral. In anideal world, all of the network requirements describedbelow for a mobile clinic environment would be satisfied.However, some unique challenges are associated withMMC service environments.• Network availability and reliability. The number 1networking requirement is that remote access to dataand people needs to be available. Yet the MMCs aredeployed mostly in dense urban areas—and sometimesin sparsely populated rural areas—that may8 The implementation of an HITECH Act, which is a portion of theAmerican Recovery and Reinvestment Act legislation signed into law byPresident Obama in February 2009, is overseen by the Office of theNational Coordinator for HIT within the U.S. Department of Health andHuman Services. An EHR is similar to an EMR, except it is designed toexchange data with other healthcare systems external to the healthcareprovider who owns it.9 Soon after this adoption date, eClinicalWorks was selected as an EHRvendor for the New York City Department of Health and MentalHygiene’s (DoHMH) Primary Care Information Project (PCIP).10 As reported in an interview of Irwin Redlener by Janice Lloyd, “‘KidsCan’t Wait’ for Health Care,” USA Today (May 21, 2009): 7D.162 Part I • Information Technologynot provide network availability or may not providereliable access to voice and data networks.• Data security. At a minimum, HIPAA requirementsfor data security must be met. User data must beencrypted at the database server level, and additionalencryption and “network tunneling” are needed forprotection of patient data at the network level.11• Easy to use with zero on-site support.Networking technologies in the MMCs are thereto support the high-quality delivery of pediatricprimary care. Since the highly trained and educatedmedical staff is not necessarily sophisticated inknowledge about networking technology andmaintenance of equipment, it is critical for the networkingsolution to be “push-button” technologyand require little infield maintenance andprovisioning.• Inexpensive to deploy and operate. The installednetworking equipment should not add significantexpense to the cost of an MMC. The network solutionsshould also be readily available and easy toacquire plus easy to install in the MMC.• Network throughput (data rate) and latency.The data rate must support the transfer of textbasedfiles (medical health records and patientreferrals). The transmission of high-density medicalimages (e.g., digital X-rays) requires muchhigher throughput rates and therefore provides adifferent challenge. Another critical requirementis to minimize network latency; large latencyresults in inefficiencies and possible confusion onthe part of the MMC staff (e.g., “Is the networkconnection still active or not? Why is it taking solong to load?”).Connectivity Solutions:What Workedand What Didn’tSince the launch of the first MMC in the 1987, severalnetworking solutions have been tried and newer technologieshave become available and affordable. Two differentwireless network solutions were tried, with mixed results.Satellite-Based AccessIn 2005, a number of MMCs were equipped withrooftop-mounted satellite antenna systems. These antennasystems were equipped with a setup function whichautomatically unfolds the antenna and raises the antennafrom a horizontal (“flat”) position to a position where theantenna is facing the sky. The antenna then performs ascanning operation to detect the strongest available satellitesignal and begins establishing a communications link withthe satellite. When the system is powered down, the antennafolds back into the original horizontal position. Althoughthese systems were expensive and designed for mobileoperation, they proved to be mechanically unreliable.You have these structural limitations to the system.Every day it goes up and down but unlike mom-andpopcasual use, we’re dealing with vital health careinformation and communications. Invariably, themechanical system breaks down—a gear strips, aconnector fails, or a circuit fries. We have had doctorsand nurses climbing on the roof to manuallylower the antenna system, and these are high-end,sophisticated devices . . . . Well, that is not good onmany levels, not the least of which alienates userstowards the technology.—Jeb WeismanThey also posed structural problems for the MMCs (due totheir weight). In some situations, the satellite communicationsalso had unacceptably large latency due to the natureand design of satellite communication systems.It is interesting how expectations get managed inthese kinds of environments. In terms of throughput orcapacity in a perfect world, most of the data that youare moving is simple structured textual data. So actuallyyou need very little bandwidth, but you needbandwidth without significant latency . . . . A 1.5Megabit satellite connection is way different from 1.5Megabit connections on a wired line or even inWimax, or whatever the flavor of the month is, in atraditional Ethernet-based system. The latency is akiller. It is deceptive for the end user: even if thethroughput is okay to move that image down, or tomove those data up, they don’t trust it—because ittakes longer to refresh than we are used to today athome or in the office. Do they step away and hopetheir data are refreshed when they are taking care ofthe patient, or do they stand there for twice as longwaiting for something to happen? Very often wirelesscommunication at the satellite level can make thingsworse than just going with the flow—which is to say‘we are here, we are in a box in the middle ofnowhere, and we just have got to manually write itdown and deal with it later.’—Jeb Weisman11 Tunneling is a networking technique that encrypts user data for securetransport over the public Internet.Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 163Cellular Wireless Networks—WirelessModem SolutionFirst piloted in 2004 and formally entered into service in2007, the MMC was equipped with a Sierra WirelessAirLink PinPoint X wireless modem that provided ThirdGeneration (3G) wireless service with a “fall-back” capabilityto 2.5G wireless service in areas where 3G servicewas not available. The advantage of this specific wirelessmodem was that it supported both 3G standards widelydeployed in the United States: both Universal MobileTelecommunications Service (UMTS) and cdma2000. Thepotential for 3G rates is in the range of several Mbps, sothis wireless solution provided the MMC with a high datarate to and from the Internet. However, the transmission ofpatient data requires cellular coverage and reliability at a“mission-critical” or “professional” level, but today’s generalpurpose wireless networks are designed for “consumer”levels. If the wireless coverage is not available andreliable, this solution can only be used to support MMCcommunications that are not mission critical.For the clinicians working in the mobile clinics,dependable and predictable wireless access to the Internetis more critical than achieving higher data rates. 3G andthe emerging 4G networks do have the required throughput(4G wireless networks are promising 100 Mbps) for transmittingmore than text-based data. However, what thesenetworks do not deliver is reliable and dependable coverage(i.e., network access) at the level required.A hybrid alternative that has been tried is to delaydata transmission from the MMC until there is access fromthe van to a wired broadband solution, such as in a communitycenter or school.Delayed Broadband Wired AccessIn this mode of operation, the MMC operates as a “storeand-forward”device: patient records, medical referrals, anddigital images are stored on an MMC server until wiredbroadband Internet access is available. A typical configurationis to have a wireless LAN (WiFi) connection via awireless router from the MMC to the broadband accesspoint into the other facility. The obvious disadvantages ofthis approach are the delay in accessing and transferringinformation, and the security of the wireless LAN link. Inaddition, the MMC is not always able to use a nearby thirdparty’swired network due to local restrictions on accessto its wired broadband connection or HIPAA securityconcerns.Many of these organizations or institutions, particularlyones that are city based, won’t allow you toinstall your own telecom infrastructure in their buildings.So we can go to shelters where they even oftenhave an Internet or network-based infrastructure andwe are not allowed to connect to it. Plus then we havesome problems around what I will generically refer toas a HIPAA Issue–we can’t just go through any oldnetwork . . . HIPAA rules are actually changing substantially—becomingmuch more restrictive, muchbetter prescribed and set out, and much more painfulif you violate them . . . . So when we look at the solutions,we have to make sure we can tunnel.—Jeb WeismanAsynchronous Multi-Master DatabaseReplication (AMMR)In the absence of a reliable, high-speed networking solutionto enable patient data transfers from the MMCs to thecentral server at the headquarters of the New York CHP inthe Bronx, a more hands-on solution has been adopted toenable (1) the integration of patient record data collected atmultiple sites and (2) provide a backup capability. But italso requires physical proximity of the servers in theMMCs to the CHP offices.Banks figured out years ago that if you could put ateller machine in a town in Montana, people would useit and you would make money on every transaction.But do you think there was telecommunications out tothat town? There was not. So how did it work? AMMR.At some point the cash machine could dial up in themiddle of the night, when rates were low, and send thedata up to Wells Fargo. It all got merged together, businessrules were applied, and then it sent back downinserts to the [ATM] database. [The ATM] knows whatit needs to know and makes it through another day,without real-time high bandwidth telecom.What happens here is that all the servers fromthe vans are physically brought in to a central locationso that there are X number of what we call thelaptop servers connected to the master or primaryserver. We press the button and it goes through akind of round robin, moves the data up to the masterfrom each one, applies business rules, aggregates thedata, and then copies the identical data set to everysingle one of those [servers]. We do it throughinserts; we are not actually copying 10 gigs of datadown to each one, so it is a very efficient process.And when you are done, each one of those devices isan exact working copy of the entire data set. It’s anelegant solution to an inelegant problem.—Jeb Weisman164 Part I • Information TechnologyOther Support Challenges and SolutionsThe IT infrastructure on the mobile unit includes a serverbuilt from a Panasonic ToughBook laptop (CF30) and anumber of client computers which are a lighter-dutyToughBook. They support a wireless Ethernet capability,but the recommended MMC solution is wired—because ofgreater throughput and more reliability:These generators—anywhere between 5 and 20 kilowatts—areunderneath the mobile units, and theyproduce electromagnetic radiations. You don’t get alot of wireless connectivity when you have got 20kilowatt generators standing under your feet . . . . It isa 36 foot van, and you are 20 feet (or 15 feet) fromthe server and you cannot make a wireless connectionthat is reliable—the power is too dirty . . . . Even thebest regulated generator will produce increasinglydirty power with a lot of harmonics and a lot ofbrownouts. Brownouts are the danger. In a spike, thething explodes, melts . . . you just buy a new one. Buta brownout slowly degrades the electronics in delicatemedical equipment. You don’t know that it isdying, and it begins to create false data or fails at anunexpected time. Plus you have got air conditionersand air filtration in the mobile unit, which have thesebig startup power needs. So what you have to do is toput at least a real time UPS in front of these thingsand preferably something like a line conditioner voltageregulator that pre-cleans it and then gets it to theUPS, because the UPS is for the most part not builtfor this degree of dirty power.Jeb WeismanInkjet printers also have to be used instead of laser printers—because laser printers can’t generally be used with a UPS thatfits in the mobile environment. Unfortunately, the operatingcost of an inkjet printer is higher.The CHF’s NYC office provides the initial on-site ITsetup and training for new MMC programs and ongoingremote help desk support. Most of the MMC teams supportedby CHF have gone 100 percent live with electronic recordkeeping for all of their patients within the first week. One ofthe reasons for the fast start-up is that the training team nowincludes a clinician who is an experienced user of the EMR:Our training team typically consists of me, another personon our staff—kind of an application specialist—and we typically take either a medical director or ahigh-level clinical provider from one of our projectswithin the network who has been using eClinicalWorksout in the field. That actually makes a huge difference.We always have members of the training team staywith [the MMC team], on-site, in clinic support.Usually they are there for the first afternoon of seeingpatients live with the system, and then also for the nextmorning. We try to split it that way so that we go tomore than one site—covering as many sites as possiblein case there are any technical or clinic process problems.One of the great things that has really worked sowell for us in our training is not separating outaccording to role during the training: we are not trainingall of our providers in a room by themselves, nottraining the registrar alone, or the nurses. They aredeveloping [their own] built-in tech support; they arelearning each other’s jobs and how to help each other.This is how a clinic really works and the trainingsimulates this.—Jennifer Pruitt, Director,Clinical Information SystemsMobile Health Clinics for Crisis ResponseIn 2003, Dr. Redlener also became the first director of theNational Center for Disaster Preparedness withinColumbia University’s Mailman School of Public Health.One of the goals of this center is to deal with the aftermathof major disasters and assess the impacts on high risk, vulnerablechildren and communities. Prior to that date, CHFhad already sent its MMCs to respond to crises related toHurricane Andrew (1992) and the 9/11 World TradeCenter attack in New York City (2001).The best choice for communications technologyfollowing a natural disaster is highly dependent on thecrisis situation. If cell towers and base stations previouslyavailable in the region have not been lost, theexisting commercially available cellular network can beutilized. However, this is the same network available forpublic cell-phone service, and following a disaster therecan be network overload due to an increase in calldemands by the public. Most wireless providers do notimplement a call-priority capability, so a mobile clinic’susage of the network will typically compete with callsfrom the public at large. In worse scenarios, there maybe no cellular network access available in the emergencyrelief area. The same may be said during otherpublic disruptions such as blackouts. In 2003, a largeportion of the United States lost electrical power.Within hours virtually all cell phone communications inNew York City had failed as uninterruptible powersupply batteries were depleted and generators failed orCase Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 165were inadequately sized for the scale of the outage. Apossible alternative, of course, is to use the MMC vansequipped with their own generators and with satelliteantennas.Just days after Hurricane Katrina hit New Orleans in2005, Redlener personally accompanied two mobilehealthcare units with a team of medics to provide vaccinationsand treat infections in the Gulf coast region. In theinitial weeks, they had treated more than 7,000 patientswhose doctors’ offices had been wiped out—either washedaway or flooded. The following year, a study by the centerreported that one in three children that were housed intrailers sponsored by the Federal Emergency ManagementAgency (FEMA) had at least one chronic illness, and thenumber of children housed in trailers in the Baton Rougearea were twice as likely to be anemic than children inNYC’s homeless shelters. The need for more ongoinghealth support for children was clear, and CHF helped toestablish and finance new mobile clinics in the Gulf port(Biloxi, Mississippi) and in the New Orleans and BatonRouge, Louisiana, areas.12The FutureBy early 2009, Dr. Redlener was on another quest: to buildawareness about the long-term health impacts on childrenfrom economic recessions. His “Kids Can’t Wait” campaignemphasized that missed immunizations and earlyhealth assessments have long-term impacts that can behard to recover from.By mid-2010, the need for mobile clinics in theUnited States was even more widespread, and the televisioncoverage of the 2009 earthquake devastation in Haitihad greatly increased public awareness about the need forquick, mobile healthcare solutions. Installing technologyon a new MMC, training the staff on-site, and providingremote support for the first weeks of operation was now awell-honed capability among the NYC-based CHF staff.However, CIO Weisman wonders how even bettersupport could be provided for the mobile clinics and whatnew support challenges lie ahead. Are there newer moreaffordable network communications solutions that shouldbe tried? Will the federal government’s HITECH stimulusfunds and Meaningful Use standards lead to better softwareintegration solutions? Will the increase in softwareadoptions at physician offices make it more difficult forhim to retain his staff? What combination of conditionscould emerge that render the mobile medical clinic modelobsolete?

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supporting Mobile Health Clinics: The Children’s Health Fund of New York City” (on pp. 157-165in the textbook).· Analyze the case study, and develop the conclusions, recommendations, and implications.· Consider the implementation challenges in the case and the technologies used to meet them, along with the finalquestions posed at the end of the case. (last paragraph on p. 165)· Summarize your findings in a two-page paper using proper APA formatting.

Supporting Mobile Health Clinics: TheChildren’s Health Fund of New York CityThe Children’s Health FundThe Children’s Health Fund (CHF) develops and supportsa national network of 22 programs and two affiliates in 15to 17 states in the United States and the District ofColumbia. The mission of the CHF is to provide comprehensivehealth care to the nation’s most medicallyunderserved children, from birth up to age 24. In-personprimary health care, mental health, and oral health servicesare delivered by teams of doctors, nurses, dentists,psychologists, social workers, and nutritionists at morethan 200 service sites across the United States inpartnership with pediatric departments and specialists inaffiliated academic medical centers or Federally QualifiedHealth Centers (FQHC).The CHF’s integrated approach to health care isconsistent with the concept of an “enhanced medicalhome” in which continuity of care is ensured via coordinationacross multiple healthcare providers and specialties.In the United States, the Medical Home concept is beingadopted as one aspect of health care reform to ensure ahigh quality standard of care that also seeks to increaseefficiencies and reduce costs for acute care. This type ofintegrated health care delivery is enabled by health informationtechnology (HIT)—not only computer software butalso communications networks.1The cofounder and president of the CHF, Dr. IrwinRedlener, received his M.D. from the University of Miamiin 1969. But his life mission for bringing medical care tounderserved children reportedly began when he was amedical resident in pediatrics at the Children’s Hospital ofDenver and saw a poster for VISTA (Volunteers in Serviceto America) with the words: “If you’re not part of the solution,you’re part of the problem.” Dr. Redlener’s quest tobecome part of the solution began with delivering medicalcare in Lee County, Arkansas, then working on earthquakerelief in Guatemala, followed by serving as medical directorfor USA for Africa, and this poster is hanging in hisoffice today.2An important motivation in my life has been workingwith kids whose situation makes them vulnerablefor reasons out of their control. They are desperatelyill, or living in extreme poverty, or disconnectedfrom medical care. I feel most energized by trying tohelp children who have the fewest resources.—Irwin Redlener3In 1987, Redlener cofounded the Children’s Health Fund(CHF) in New York City. Its initial focus was on pediatriccare for homeless kids, and his cofounder was singer/songwriterPaul Simon. While working for USA for Africa, hehelped solicit the help of other recognized entertainers,including Joan Baez, Harry Belafonte, Lionel Richie, andMichael Jackson. When he learned that Paul Simon wasinterested in doing something for the homeless, he reachedout to him:I was working for USA for Africa, setting up thegrant office in New York City. Paul Simon, who wason the We Are the World record, wanted to do somethingfor the homeless. We visited a number ofwelfare hotels. In the Hotel Martinique [in TimesSquare] a thousand children and their families werewarehoused. Somebody suggested that we should geta van and bring doctors there.—Irwin Redlener4That was the beginning of what would become CHF’snational network of Children’s Health Projects (CHP), inwhich health care is delivered via doctors, nurses, and Copyright © 2010 by Carol V. Brown, Distinguished Professor,and Kevin Ryan, Distinguished Associate Professor, Stevens Institute ofTechnology.1The Medical Home concept, which originated with the AmericanAcademy of Pediatrics in the 1960s, is today being considered as a meansto reinvent primary care in the United States. One of the current barriersto implementation is the fee-for-service reimbursement model within theUnited States.2As reported by Tom Callahan, “Mobilizing for Kids,” Diversion forPhysicians at Leisure (April 15, 2004): 30–32. 3 Ibid.4 Ibid. The “We Are the World” record was made to raise funds for theUSA for Africa’s famine relief efforts. For example, see: http://www.inthe80s.com/weworld.shtml.158 Part I • Information TechnologyEXHIBIT 1 CHF National NetworkCopyright © the Children’s Health Fund. Reproduced with permission. All rights reserved.other professionals in an RV-size mobile medical clinic(MMC) that is driven to locations where the people arewho need it—such as city shelters for homeless families.The flagship program with the first MMC was launched inNYC in 1987, and by 2009 the program had beenexpanded to cities and some deep rural areas withinCHF’s growing national network of clinics. The clinicsare supported by 41 state-of-the-art MMCs (32 medical, 3mental health, 5 dental, 1 public health field office, and 1health education) operating in different programs acrossthe country (see the map in Exhibit 1). By 2009, some hadbeen in service for many years and while not obsolete,lacked some of the newest features, such as modularnetwork cabling and upgraded electrical generators; 7 newMMCs were in some stage of procurement in June 2010.The payments for the medical care provided by CHFprimarily come from four sources: private individual andcorporate donation, congressional aid, and two governmenthealth insurance programs that support children living inpoverty. These programs are Medicaid and the StateChildren’s Health Insurance Program (SCHIP). Medicaidinsures kids whose parents earn little or no money; thefederal government pays part of the costs, but programs areadministered and partially funded by state governments.SCHIP, a newer federal program initiated in 1997, insureschildren in families that earn too much to qualify forMedicaid, but too little to afford private health insurance. InFebruary 2009, President Obama signed a bill thatcontinues funding for SCHIP ($32 billion over the next 4.5years).Mobile Medical Clinics at the Children’sHealth FundCHF’s Mobile Medical Clinics (MMCs) are housed in 36- to44-foot long blue vans, designed to provide a full range ofpediatric primary health care including preventive care (e.g.,childhood vaccinations), diagnosis and management of acuteand chronic diseases, mental health, dental, and health educationservices. In addition to care provided in the mobileclinics, care is provided at stationary clinical sites located inshelters, schools, and community centers, and traditionalhealth clinics (e.g., the South Bronx Health Center forChildren & Families in NYC). The mobile clinics routinelyvisit low-income neighborhoods and homeless and domesticviolence shelters to provide medical services, but MMCsSan Francisco Peninsula, CALos Angeles , CAIdaho Montrose, COArkansasChicago, ILPhiladelphia, PACHF NationalOffice, NYNew York CityProgramsLong Island , NYNew JerseyWashington D.C.West VirginiaMemphis, TNMississippiMississippi Gulf CoastOrlando, FLNew Orleans, LAPhoenix, AZSouthern Arizona, AZAustin, TXDallas, TXChildren’s Health Fund National OfficeChildren’s Health Fund ProgramsAffiliates–Special InitiativesBaton Rouge, LASouth FloridaCase Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 159have also been deployed to provide medical services inresponse to public health crises or emergencies, including the9/11 attacks on the World Trade Center, hurricanes Rita andKatrina in 2005, and the 2010 Gulf of Mexico oil spill.Two primary CHF principles are at the heart of thedesign of the MMCs:• To provide high-quality pediatric primary care aswell as mental health services, dental services, andsocial services to medically underserved populationswith children.• To operate in partnership with a high-quality localmedical institution, such as an academic medicalcenter or FQHC, to ensure access to other medicalexperts as needed as well as coordinated health carefor the local population.Access to reliable, affordable transportation is a major constraintfor those living in poverty at government-sponsoredlocations, as well as areas where there are few health careproviders, known as HPSAs (Health Professional ShortageAreas). To help remove this constraint for low-income andhomeless residents in New York and four other major areas,GlaxoSmithKlein provided a $2.3 million grant to supporttransportation funding in 2004: $35,000 on taxi rides and$20,000 on bus tickets for adults were spent by the DallasChildren’s Health Project (CHP) the prior year. In NewYork, this Referral Management Initiative had dramaticresults: specialist appointment compliance rose from 5 toabout 70 percent.5The medical home concept is based on the premisethat a returning patient will be supported by a trustedhealthcare team who knows the patient and has access todocumentation of his or her health history. Exhibit 25 Tony Hartzel, “Transportation a Vital Health Link,” The Dallas MorningNews (December 19, 2004).EXHIBIT 2 The CHF Medical Mobile Unit (MMU) ModelCopyright © the Children’s Health Fund. Reproduced with permission. All rights reserved. 160 Part I • Information Technologyshows a model of the MMC and its layout, with a separateregistration area and waiting room, a nurse’s station, andexamination rooms.The sides of the blue vans are painted (like“billboards”) to clearly signal that they are CHF units withqualified medical personnel onboard. On a given dayduring a given time period each week, the MMCs arescheduled to be at the same location with the same medicalpersonnel onboard.We don’t just show up like in an ice-cream man mode,give a shot and disappear. The protocol is that everyTuesday from X-time to Y-time the doctor is there.—Jeb Weisman, CIOProviding high-quality primary care from a mobile clinicdoes present some unique challenges for supporting thosewho are delivering the health care, such as:• Designing an environment which is consistent withand will support standard physician office and clinicprocesses. This includes providing the requiredspace and medical equipment to support high qualitydelivery of primary care, including sufficient, highqualityelectrical power.• Complying with regulatory standards such as thoseset forth by JCAHO (e.g., PC locations) and governmentlegislation (e.g., HIPAA laws for privacy andsecurity of personal health information).6• Supporting a mobile unit that operates at multiple,primarily urban, sites—each with its own uniqueenvironmental factors.• Providing computer and communications technologieswithin the MMC that are reliable anddependable, as well as off-site access to technicalsupport.Another important consideration is the overall cost foreach mobile clinic—including the initial costs for a stateof-the-artMMC as well as continuing operating costs. Themajority of the approximately $500,000 capital budget foreach MMC is allocated to the required medical equipmentand associated vehicle requirements (i.e., space, power,and transportation needs). Preventive care via a medicalhome should of course result in long-term cost savings forstate and federal payers as children receive immunizationsand regular health checkups that can avoid costly visitsto hospital emergency rooms, but these are difficult tomeasure. Given the national shortage in primary carephysicians, CHF’s association with a major medical centeralso means that MMC may be part of medical residents’formal training rotation, often in pediatrics or communitymedicine, as part of the medical team.Healthcare Information Systemsto Support Primary CareIn the United States today, it is still not unusual to findpaper-based record keeping in physician practices (referredto as ambulatory or outpatient practices). Two types offunctionality are provided in software packages developedand maintained by vendors who specialize in the healthcareindustry:• Practice Management Systems (PMS) supportadministrative tasks such as patient workflow andthe revenue cycle, with data including patient contactinformation, appointment scheduling, andpatient insurance plan information.• Electronic Medical Record (EMR) systems supportclinicians, such as patient diagnosis, treatment andphysician orders, with data including patient demographics(age, gender), family history information,allergies, medications, and clinical documentation ofdiagnoses, treatments, and outcomes for prior visitsand specialty referrals.By 2008, only 4 percent of physicians in ambulatory settingshad a fully functional EMR; 13 percent had a partiallyfunctional EMR; but 50 percent of those in larger practices(11 or more physicians) had partial or full EMR support.7Some vendors provide packaged solutions with PMSand EMR modules designed to exchange data with each other.However, since some of the clinical packages are designed tospecifically support certain types of care—such as pediatrics,OB/GYN, cardiac care, and so on—specialty practices inparticular may have purchased software from differentvendors. In addition, software that supports electronicprescription transactions to pharmacies and insurers hasrecently been widely adopted as this capability has becomerequired for reimbursements by government and otherinsurers. Investments in software packages to support clinicalprocesses in small practices (1–3 physicians) in particular willbe made at a much faster rate during the second decade of thiscentury due to financial incentives administered by Medicaidand Medicare to eligible physicians who have implemented 6JCHAO (Joint Commission on Accreditation of HealthcareOrganizations) is the accreditation body for healthcare organizations. TheHIPAA (Health Insurance Portability and Accountability Act) PrivacyRule governs all protected health information; the HIPAA Security Rulesets security standards for protected health information maintained ortransmitted in electronic form.7 2007 study by the Institute of Health Policy at Massachusetts GeneralHospital (MGH).Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 161certified electronic health record systems and reported specificmetrics for Meaningful Use beginning in 2011 under theHITECH Act.8The advantages of using computerized health informationsystems were recognized early on by the CHF. JebWeisman, the current CIO, initially joined the organizationin the late 1980s prior to the implementation of the firstMMC to lead the efforts to provide state-of-the-art supportfor the MMCs. Initially a home-grown system was developedand maintained.Given the way the transitional housing system for thehomeless worked at the time—there were enforcedmoves every 3 weeks and that sort of thing—it wasincredibly important that you had a real history.Some of these kids were being immunized half adozen times for measles, by the time they were 6 or 7because if something would show up, it is better togive them shots than not . . . . So you had as much asmedical over-neglect as under-neglect going on.Records are vitally important.—Jeb WeismanIn 1999, CHF partnered with a now defunct vendor todevelop specialized technology for the MMC environment.This system was then phased out in 2007 when CHF partneredwith another leading Electronic Health Record(EHR) software vendor: eClinicalWorks.9 Given the CHF’searly investment in custom software that supported the datacollection of detailed clinical data specifically for pediatriccare, Weisman’s team built in a similar data collectioncapability for use with the commercial software package.Having this detailed information in a standard formatenables high-quality patient–physician interactions on notonly the first but also subsequent visits, in addition to providingthe data needed for referrals. Medically underservedpopulations typically have higher levels of lead in theirbloodstreams, asthma, and other chronic conditions.10One of the record keeping challenges faced by allphysician practices is the integration of laboratory andimaging results with the rest of a patient’s health record.In a paper environment, the test results are typically faxedfrom the facilities performing and interpreting the tests tothe requesting physician, and then paper copies and film(such as x-rays or CAT scans) are filed in the patient’sfolder along with other hard-copy records. When testresults are not received in a timely manner, a nurse or otherstaff member typically makes a call to the test facility’sstaff and can receive the missing record in a relatively shorttime period. Today’s more sophisticated healthcareinformation system (HIS) solutions integrate electronicreports of test results with the patient’s record so that thephysician can quickly access all relevant data with thesame patient record interface.However, maintaining an accurate medical historyfor a patient who lives in poverty and may be residing in ahomeless shelter or other temporary housing is more complicatedthan for patients with a more permanent address.In cities and towns with CHF clinics, a patient served by aspecific clinic in a given neighborhood in the Bronx thismonth may be domiciled in a different shelter in a differentborough and show up at a permanent clinic or MMC in adifferent location in NYC the next month. To retrieve arecord from another clinic may require a phone call andfax capabilities.Both telephone and fax capabilities are therefore basicrequirements for not only retrieving missing data but alsoconsulting with other medical experts, and supporting patientreferrals to other clinicians, including specialists. Anideal solution to capture the patient data that have previouslybeen collected for the same patient—especially when thesame software package is being used at multiple clinics—would be to have it available in structured electronic form.Connectivity Needs to Support MobileMedical ClinicsThere are therefore two primary communications needsfor clinicians to deliver quality healthcare via a mobileclinic: (1) access to patient data previously captured atanother medical facility (or MMC) but not yet available inthe patient record system in the clinic and (2) access topersonnel at another medical facility for either an emergencyconsult or referral, or a more routine referral. In anideal world, all of the network requirements describedbelow for a mobile clinic environment would be satisfied.However, some unique challenges are associated withMMC service environments.• Network availability and reliability. The number 1networking requirement is that remote access to dataand people needs to be available. Yet the MMCs aredeployed mostly in dense urban areas—and sometimesin sparsely populated rural areas—that may8 The implementation of an HITECH Act, which is a portion of theAmerican Recovery and Reinvestment Act legislation signed into law byPresident Obama in February 2009, is overseen by the Office of theNational Coordinator for HIT within the U.S. Department of Health andHuman Services. An EHR is similar to an EMR, except it is designed toexchange data with other healthcare systems external to the healthcareprovider who owns it.9 Soon after this adoption date, eClinicalWorks was selected as an EHRvendor for the New York City Department of Health and MentalHygiene’s (DoHMH) Primary Care Information Project (PCIP).10 As reported in an interview of Irwin Redlener by Janice Lloyd, “‘KidsCan’t Wait’ for Health Care,” USA Today (May 21, 2009): 7D.162 Part I • Information Technologynot provide network availability or may not providereliable access to voice and data networks.• Data security. At a minimum, HIPAA requirementsfor data security must be met. User data must beencrypted at the database server level, and additionalencryption and “network tunneling” are needed forprotection of patient data at the network level.11• Easy to use with zero on-site support.Networking technologies in the MMCs are thereto support the high-quality delivery of pediatricprimary care. Since the highly trained and educatedmedical staff is not necessarily sophisticated inknowledge about networking technology andmaintenance of equipment, it is critical for the networkingsolution to be “push-button” technologyand require little infield maintenance andprovisioning.• Inexpensive to deploy and operate. The installednetworking equipment should not add significantexpense to the cost of an MMC. The network solutionsshould also be readily available and easy toacquire plus easy to install in the MMC.• Network throughput (data rate) and latency.The data rate must support the transfer of textbasedfiles (medical health records and patientreferrals). The transmission of high-density medicalimages (e.g., digital X-rays) requires muchhigher throughput rates and therefore provides adifferent challenge. Another critical requirementis to minimize network latency; large latencyresults in inefficiencies and possible confusion onthe part of the MMC staff (e.g., “Is the networkconnection still active or not? Why is it taking solong to load?”).Connectivity Solutions:What Workedand What Didn’tSince the launch of the first MMC in the 1987, severalnetworking solutions have been tried and newer technologieshave become available and affordable. Two differentwireless network solutions were tried, with mixed results.Satellite-Based AccessIn 2005, a number of MMCs were equipped withrooftop-mounted satellite antenna systems. These antennasystems were equipped with a setup function whichautomatically unfolds the antenna and raises the antennafrom a horizontal (“flat”) position to a position where theantenna is facing the sky. The antenna then performs ascanning operation to detect the strongest available satellitesignal and begins establishing a communications link withthe satellite. When the system is powered down, the antennafolds back into the original horizontal position. Althoughthese systems were expensive and designed for mobileoperation, they proved to be mechanically unreliable.You have these structural limitations to the system.Every day it goes up and down but unlike mom-andpopcasual use, we’re dealing with vital health careinformation and communications. Invariably, themechanical system breaks down—a gear strips, aconnector fails, or a circuit fries. We have had doctorsand nurses climbing on the roof to manuallylower the antenna system, and these are high-end,sophisticated devices . . . . Well, that is not good onmany levels, not the least of which alienates userstowards the technology.—Jeb WeismanThey also posed structural problems for the MMCs (due totheir weight). In some situations, the satellite communicationsalso had unacceptably large latency due to the natureand design of satellite communication systems.It is interesting how expectations get managed inthese kinds of environments. In terms of throughput orcapacity in a perfect world, most of the data that youare moving is simple structured textual data. So actuallyyou need very little bandwidth, but you needbandwidth without significant latency . . . . A 1.5Megabit satellite connection is way different from 1.5Megabit connections on a wired line or even inWimax, or whatever the flavor of the month is, in atraditional Ethernet-based system. The latency is akiller. It is deceptive for the end user: even if thethroughput is okay to move that image down, or tomove those data up, they don’t trust it—because ittakes longer to refresh than we are used to today athome or in the office. Do they step away and hopetheir data are refreshed when they are taking care ofthe patient, or do they stand there for twice as longwaiting for something to happen? Very often wirelesscommunication at the satellite level can make thingsworse than just going with the flow—which is to say‘we are here, we are in a box in the middle ofnowhere, and we just have got to manually write itdown and deal with it later.’—Jeb Weisman11 Tunneling is a networking technique that encrypts user data for securetransport over the public Internet.Case Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 163Cellular Wireless Networks—WirelessModem SolutionFirst piloted in 2004 and formally entered into service in2007, the MMC was equipped with a Sierra WirelessAirLink PinPoint X wireless modem that provided ThirdGeneration (3G) wireless service with a “fall-back” capabilityto 2.5G wireless service in areas where 3G servicewas not available. The advantage of this specific wirelessmodem was that it supported both 3G standards widelydeployed in the United States: both Universal MobileTelecommunications Service (UMTS) and cdma2000. Thepotential for 3G rates is in the range of several Mbps, sothis wireless solution provided the MMC with a high datarate to and from the Internet. However, the transmission ofpatient data requires cellular coverage and reliability at a“mission-critical” or “professional” level, but today’s generalpurpose wireless networks are designed for “consumer”levels. If the wireless coverage is not available andreliable, this solution can only be used to support MMCcommunications that are not mission critical.For the clinicians working in the mobile clinics,dependable and predictable wireless access to the Internetis more critical than achieving higher data rates. 3G andthe emerging 4G networks do have the required throughput(4G wireless networks are promising 100 Mbps) for transmittingmore than text-based data. However, what thesenetworks do not deliver is reliable and dependable coverage(i.e., network access) at the level required.A hybrid alternative that has been tried is to delaydata transmission from the MMC until there is access fromthe van to a wired broadband solution, such as in a communitycenter or school.Delayed Broadband Wired AccessIn this mode of operation, the MMC operates as a “storeand-forward”device: patient records, medical referrals, anddigital images are stored on an MMC server until wiredbroadband Internet access is available. A typical configurationis to have a wireless LAN (WiFi) connection via awireless router from the MMC to the broadband accesspoint into the other facility. The obvious disadvantages ofthis approach are the delay in accessing and transferringinformation, and the security of the wireless LAN link. Inaddition, the MMC is not always able to use a nearby thirdparty’swired network due to local restrictions on accessto its wired broadband connection or HIPAA securityconcerns.Many of these organizations or institutions, particularlyones that are city based, won’t allow you toinstall your own telecom infrastructure in their buildings.So we can go to shelters where they even oftenhave an Internet or network-based infrastructure andwe are not allowed to connect to it. Plus then we havesome problems around what I will generically refer toas a HIPAA Issue–we can’t just go through any oldnetwork . . . HIPAA rules are actually changing substantially—becomingmuch more restrictive, muchbetter prescribed and set out, and much more painfulif you violate them . . . . So when we look at the solutions,we have to make sure we can tunnel.—Jeb WeismanAsynchronous Multi-Master DatabaseReplication (AMMR)In the absence of a reliable, high-speed networking solutionto enable patient data transfers from the MMCs to thecentral server at the headquarters of the New York CHP inthe Bronx, a more hands-on solution has been adopted toenable (1) the integration of patient record data collected atmultiple sites and (2) provide a backup capability. But italso requires physical proximity of the servers in theMMCs to the CHP offices.Banks figured out years ago that if you could put ateller machine in a town in Montana, people would useit and you would make money on every transaction.But do you think there was telecommunications out tothat town? There was not. So how did it work? AMMR.At some point the cash machine could dial up in themiddle of the night, when rates were low, and send thedata up to Wells Fargo. It all got merged together, businessrules were applied, and then it sent back downinserts to the [ATM] database. [The ATM] knows whatit needs to know and makes it through another day,without real-time high bandwidth telecom.What happens here is that all the servers fromthe vans are physically brought in to a central locationso that there are X number of what we call thelaptop servers connected to the master or primaryserver. We press the button and it goes through akind of round robin, moves the data up to the masterfrom each one, applies business rules, aggregates thedata, and then copies the identical data set to everysingle one of those [servers]. We do it throughinserts; we are not actually copying 10 gigs of datadown to each one, so it is a very efficient process.And when you are done, each one of those devices isan exact working copy of the entire data set. It’s anelegant solution to an inelegant problem.—Jeb Weisman164 Part I • Information TechnologyOther Support Challenges and SolutionsThe IT infrastructure on the mobile unit includes a serverbuilt from a Panasonic ToughBook laptop (CF30) and anumber of client computers which are a lighter-dutyToughBook. They support a wireless Ethernet capability,but the recommended MMC solution is wired—because ofgreater throughput and more reliability:These generators—anywhere between 5 and 20 kilowatts—areunderneath the mobile units, and theyproduce electromagnetic radiations. You don’t get alot of wireless connectivity when you have got 20kilowatt generators standing under your feet . . . . It isa 36 foot van, and you are 20 feet (or 15 feet) fromthe server and you cannot make a wireless connectionthat is reliable—the power is too dirty . . . . Even thebest regulated generator will produce increasinglydirty power with a lot of harmonics and a lot ofbrownouts. Brownouts are the danger. In a spike, thething explodes, melts . . . you just buy a new one. Buta brownout slowly degrades the electronics in delicatemedical equipment. You don’t know that it isdying, and it begins to create false data or fails at anunexpected time. Plus you have got air conditionersand air filtration in the mobile unit, which have thesebig startup power needs. So what you have to do is toput at least a real time UPS in front of these thingsand preferably something like a line conditioner voltageregulator that pre-cleans it and then gets it to theUPS, because the UPS is for the most part not builtfor this degree of dirty power.Jeb WeismanInkjet printers also have to be used instead of laser printers—because laser printers can’t generally be used with a UPS thatfits in the mobile environment. Unfortunately, the operatingcost of an inkjet printer is higher.The CHF’s NYC office provides the initial on-site ITsetup and training for new MMC programs and ongoingremote help desk support. Most of the MMC teams supportedby CHF have gone 100 percent live with electronic recordkeeping for all of their patients within the first week. One ofthe reasons for the fast start-up is that the training team nowincludes a clinician who is an experienced user of the EMR:Our training team typically consists of me, another personon our staff—kind of an application specialist—and we typically take either a medical director or ahigh-level clinical provider from one of our projectswithin the network who has been using eClinicalWorksout in the field. That actually makes a huge difference.We always have members of the training team staywith [the MMC team], on-site, in clinic support.Usually they are there for the first afternoon of seeingpatients live with the system, and then also for the nextmorning. We try to split it that way so that we go tomore than one site—covering as many sites as possiblein case there are any technical or clinic process problems.One of the great things that has really worked sowell for us in our training is not separating outaccording to role during the training: we are not trainingall of our providers in a room by themselves, nottraining the registrar alone, or the nurses. They aredeveloping [their own] built-in tech support; they arelearning each other’s jobs and how to help each other.This is how a clinic really works and the trainingsimulates this.—Jennifer Pruitt, Director,Clinical Information SystemsMobile Health Clinics for Crisis ResponseIn 2003, Dr. Redlener also became the first director of theNational Center for Disaster Preparedness withinColumbia University’s Mailman School of Public Health.One of the goals of this center is to deal with the aftermathof major disasters and assess the impacts on high risk, vulnerablechildren and communities. Prior to that date, CHFhad already sent its MMCs to respond to crises related toHurricane Andrew (1992) and the 9/11 World TradeCenter attack in New York City (2001).The best choice for communications technologyfollowing a natural disaster is highly dependent on thecrisis situation. If cell towers and base stations previouslyavailable in the region have not been lost, theexisting commercially available cellular network can beutilized. However, this is the same network available forpublic cell-phone service, and following a disaster therecan be network overload due to an increase in calldemands by the public. Most wireless providers do notimplement a call-priority capability, so a mobile clinic’susage of the network will typically compete with callsfrom the public at large. In worse scenarios, there maybe no cellular network access available in the emergencyrelief area. The same may be said during otherpublic disruptions such as blackouts. In 2003, a largeportion of the United States lost electrical power.Within hours virtually all cell phone communications inNew York City had failed as uninterruptible powersupply batteries were depleted and generators failed orCase Study I-4 • Supporting Mobile Health Clinics: The Children’s Health Fund of New York City 165were inadequately sized for the scale of the outage. Apossible alternative, of course, is to use the MMC vansequipped with their own generators and with satelliteantennas.Just days after Hurricane Katrina hit New Orleans in2005, Redlener personally accompanied two mobilehealthcare units with a team of medics to provide vaccinationsand treat infections in the Gulf coast region. In theinitial weeks, they had treated more than 7,000 patientswhose doctors’ offices had been wiped out—either washedaway or flooded. The following year, a study by the centerreported that one in three children that were housed intrailers sponsored by the Federal Emergency ManagementAgency (FEMA) had at least one chronic illness, and thenumber of children housed in trailers in the Baton Rougearea were twice as likely to be anemic than children inNYC’s homeless shelters. The need for more ongoinghealth support for children was clear, and CHF helped toestablish and finance new mobile clinics in the Gulf port(Biloxi, Mississippi) and in the New Orleans and BatonRouge, Louisiana, areas.12The FutureBy early 2009, Dr. Redlener was on another quest: to buildawareness about the long-term health impacts on childrenfrom economic recessions. His “Kids Can’t Wait” campaignemphasized that missed immunizations and earlyhealth assessments have long-term impacts that can behard to recover from.By mid-2010, the need for mobile clinics in theUnited States was even more widespread, and the televisioncoverage of the 2009 earthquake devastation in Haitihad greatly increased public awareness about the need forquick, mobile healthcare solutions. Installing technologyon a new MMC, training the staff on-site, and providingremote support for the first weeks of operation was now awell-honed capability among the NYC-based CHF staff.However, CIO Weisman wonders how even bettersupport could be provided for the mobile clinics and whatnew support challenges lie ahead. Are there newer moreaffordable network communications solutions that shouldbe tried? Will the federal government’s HITECH stimulusfunds and Meaningful Use standards lead to better softwareintegration solutions? Will the increase in softwareadoptions at physician offices make it more difficult forhim to retain his staff? What combination of conditionscould emerge that render the mobile medical clinic modelobsolete?