Urban Health Plan in New York Uses Its EHR Meaningfully to Improve Care Coordination

Dan Figueras, South Bronx, New York
Portrait and quote; "'We were already using the EHR for care coordination and just needed to tweak some of our processes to meet the Meaningful Use measures.' -Dan Figueras"


Urban Health Plan in the South Bronx, New York delivers care to 48,000 patients each year through a network of facilities including a state-of-the-art 37,000 square foot health center, seven satellite health centers, seven school-based health centers, and two homeless shelters. The 39 primary care physicians, 25 specialists, and 42 physician assistants and nurse practitioners provide services to a diverse low-income population. Urban Health Plan was recognized as a level 3 Patient-Centered Medical Home by the National Committee for Quality Assurance and as a top-performing community health center by the Federal Health Resources and Services Administration. The health center also received the 2009 Nicholas E. Davies Award from the Healthcare Information and Management Systems Society.

Meaningful Use Attestation

Urban Health Plan began the attestation process for Meaningful Use in 2012. Eligible professionals in their first year of New York’s Medicaid EHR incentive program can register and adopt, implement, or upgrade (AIU) to a certified EHR to receive incentive payments. Twenty-six physicians and dentists at Urban Health Plan attested to AIU in March 2012 and received their first incentive payment in May 2012. Several providers have met Meaningful Use Stage 1 measures and will begin attestation in the fall 2012 when New York State opens its Web site.

  • Care Coordination Measures – Several providers have met the following MU care coordination measures.
  • Exchanging Key Clinical Information – The providers performed at least one test of the certified EHR technology’s capacity to electronically exchange key clinical information. Urban Health Plan providers exchange key clinical information with other health care providers and specialists in the plan’s referral network using the peer-to-peer feature in the EHR system, eClinicalWorks. A limitation of this feature is that the center doesn’t always know who the provider will be when they refer to large city hospitals. “This process would be more useful if we could send the information to a specific practice site such as Bronx Lebanon Ear Nose Throat,” said Alison Connelly-Flores.
  • Medication Reconciliation – The providers performed medication reconciliation for more than 50 percent of patients transitioned into their care. Urban Health Plan has documented and reported on their providers’ progress in achieving this measure for over a year. All medical providers are required to perform medication reconciliation each time they see a patient. A medical assistant or patient service representative checks the transition of care box to indicate that the patient has seen another doctor since the last visit. The provider verifies the medications the patient is taking and checks a medication reconciliation box in the patient’s EHR. The corporate MU dashboard records the checked boxes and generates reports that are distributed to providers who may need to improve their performance.
  • Summary of Care when Transitioning or Referring – Summaries of care are provided more than 50 percent of the time for patients they transition or refer to other care providers or care settings. The provider sends a care summary attached to the referral in the EHR. If patients are referred by the health center to the Emergency Department, the provider includes progress notes with the clinical summary. Depending on the patient, the provider may also include the results of laboratory tests or diagnostic imaging tests with the care summary.

Care Coordination Initiatives

In early 2012, the health center developed a program for patients with chronic medical or behavioral health conditions and/or significant psychosocial issues to stabilize and engage them in primary care, improve their health status, and reduce preventable Emergency Department visits and hospitalizations. Through a partnership with the Bronx Lebanon Hospital and its Community Physician Referral program, the number of hospital admissions has been reduced. Urban Health Plan’s referral department schedules the appointments electronically with the hospital’s specialists, which has improved timely access to needed specialists and referrals at the hospital.

Using the EHR Meaningfully

The EHR’s ability to collect and generate data on providers’ performance led Urban Health Plan to create an incentive program. When Urban Health Plan decided to achieve Meaningful Use, it realigned its incentive payment program with the MU measures. The health center receives monthly data on Stage 1 measures for all providers including those who have attested to MU AIU from the Regional Extension Center for New York City (REACH), and from eClinicalWorks’ MU Adoption Quality (MAQ) dashboard. Providers who don’t meet a MU measure’s requirement receive reports, and performance improvement projects are initiated. For example, many providers forget to print clinical summaries and give them to their patients. “To remind providers to do this, we used technology to create a popup reminder box in the EHR, changed our reporting from monthly to weekly, and increased the target from 50 percent to 60 percent,” said Dan Figueras. After 2 months of weekly reporting, nearly all providers met the target.

Urban Health Plan provides incentives to providers based on their productivity, quality, patient satisfaction, and organizational participation. The integration of identified process and outcome measures into provider templates enabled data to be captured at the point of care for the performance improvement teams. Reporting such information is facilitated by using structured data and forms that ask for and collect data in a structured format, with some answers triggering additional questions such as “Do you smoke? If yes, how many packs?” These structured forms also can calculate the severity of conditions including asthma, depression, and alcohol abuse and can summarize the data in the progress note. The EHR system also facilitates mining historical data for trends. For example, the health center’s colon cancer screening rates were historically low. “We improved our rates by generating daily lists of patients with orders for Fecal Occult Blood Tests. The case manager proactively calls these patients, answers any collection questions they have, and encourages them to complete the ordered test,” said Samuel DeLeon, MD.

Working with NYC REACH

NYC REACH is a program from the NYC Department of Health and Mental Hygiene's Primary Care Information Project that assists local practices with implementing EHRs and achieving Meaningful Use measures. As an early EHR adopter, Urban Health Plan began collaborating with the NYC Department of Health in 2008, giving presentations on best practices and serving as a model for other practices. The health center joined NYC REACH in 2010 and co-hosted seminars on the MU proposed rules and participated in educational seminars on MU Registration and Attestation. NYC REACH also receives the health center’s monthly MU data from its MAQ dashboard and sends the center an email flagging any items that need attention. “I may include suggestions on how certain providers can improve or offer to set up a meeting with them to review the data,” said Anne Rapin, MPH, Clinical Quality Specialist with NYC REACH.


  • MU attestation – Urban Health Plan adjusted some workflows after implementing the certified upgrade of the EHR. For example, one MU measure requires providers to document each patient’s smoking status in the vitals section of the EHR. However, when the documentation location changed in the upgraded EHR, many providers didn’t provide documentation resulting in lower numbers than before. “To improve our performance, we trained our medical assistants to document the smoking status in the EHR,” said Connelly-Flores. If they were smokers, providers documented the related intervention. This initiative resulted in a significant increase in documentation.
  • Health Information Exchange (HIE) Connection/ Implementation – Urban Health Plan participated in a brief pilot program operated by the Bronx Regional Health Information Organization (RHIO) in 2009. For a few months, one of the center’s satellite sites was connected to the RHIO and had access to patient information at local hospitals. However, the interoperability product the Bronx RHIO selected did not meet usability requirements and was discontinued. The RHIO has since selected a new interoperability product that it is being tested. “We’re now waiting for technical issues to be resolved between eClinicalWorks and the new product before going live, hopefully this year,” said Figueras.


Since implementing the EHR in 2006, the following improvements have occurred:

  • The EHR has eliminated paper charts and an average of 75 lost paper charts per month. Lost charts required 0.6 full time employees (FTE) monthly and cost about $21,000 annually.
  • The health center is better managed through an electronic corporate dashboard that reflects the organizational goals and extracts data from the EHR system based on key financial, access, operational, and clinical performance indicators.
  • The EHR enabled the health center to roll out its reliable and cost-effective incentive program for providers and helped improve provider productivity.
  • The EHR has transformed how information is captured and knowledge is managed for performance improvement projects.

Lessons Learned

While achieving MU, Urban Health Plan learned to measure its progress from baseline, generate weekly or monthly reports, and monitor improvements until it met or exceeded its goals. By making the reporting process transparent to all providers, the health center could see its status on the MU measures. This transparency also created a sense of competition and peer pressure among providers. The health center also learned that factors beyond its control can delay completion of MU attestation and HIE connection. When Urban Health plan joined the Bronx RHIO, it learned that it was not connected with other RHIOs, which limits providers’ abilities to exchange clinical information with providers outside of the Bronx. Gaining access to a broader provider network will require statewide interoperability to connect the RHIOs and meet future MU HIE requirements. New York State is developing a statewide eHealth Collaborative that is working to connect the RHIOs statewide in the future.

Case Studies Category
Meaningful Use
Care Coordination